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Peaceman AM, Mele L, Rouse DJ, Leveno KJ, Mercer BM, Varner MW, Reddy UM, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, O’Sullivan MJ, Dudley DJ, Caritis SN. Prediction of Cerebral Palsy or Death among Preterm Infants Who Survive the Neonatal Period. Am J Perinatol 2024; 41:783-789. [PMID: 35253117 PMCID: PMC9440945 DOI: 10.1055/a-1788-6281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess whether neonatal morbidities evident by the time of hospital discharge are associated with subsequent cerebral palsy (CP) or death. STUDY DESIGN This is a secondary analysis of data from a multicenter placebo-controlled trial of magnesium sulfate for the prevention of CP. The association between prespecified intermediate neonatal outcomes (n = 11) and demographic and clinical factors (n = 10) evident by the time of discharge among surviving infants (n = 1889) and the primary outcome of death or moderate/severe CP at age 2 (n = 73) was estimated, and a prediction model was created. RESULTS Gestational age in weeks at delivery (odds ratio [OR]: 0.74, 95% confidence interval [CI]: 0.67-0.83), grade III or IV intraventricular hemorrhage (IVH) (OR: 5.3, CI: 2.1-13.1), periventricular leukomalacia (PVL) (OR: 46.4, CI: 20.6-104.6), and male gender (OR: 2.5, CI: 1.4-4.5) were associated with death or moderate/severe CP by age 2. Outcomes not significantly associated with the primary outcome included respiratory distress syndrome, bronchopulmonary dysplasia, seizure, necrotizing enterocolitis, neonatal hypotension, 5-minute Apgar score, sepsis, and retinopathy of prematurity. Using all patients, the receiver operating characteristic curve for the final prediction model had an area under the curve of 0.84 (CI: 0.78-0.89). Using these data, the risk of death or developing CP by age 2 can be calculated for individual surviving infants. CONCLUSION IVH and PVL were the only neonatal complications evident at discharge that contributed to an individual infant's risk of the long-term outcomes of death or CP by age 2. A model that includes these morbidities, gestational age at delivery, and gender is predictive of subsequent neurologic sequelae. KEY POINTS · Factors known at hospital discharge are identified which are independently associated with death or CP by age 2.. · A model was created and validated using these findings to counsel parents.. · The risk of death or CP can be calculated at the time of hospital discharge..
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Affiliation(s)
- Alan M. Peaceman
- Departments of Obstetrics and Gynecology of: Northwestern University, Chicago, IL
| | - Lisa Mele
- George Washington University Biostatistics Center, Washington, DC
| | | | | | - Brian M. Mercer
- Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, and University of Tennessee, Memphis, TN
| | | | - Uma M. Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Ronald J. Wapner
- Thomas Jefferson University and Drexel University, Philadelphia, PA
| | | | - John M. Thorp
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Susan M. Ramin
- University of Texas Health Science Center at Houston-Children’s Memorial Hermann Hospital, Houston, TX
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Abstract
OBJECTIVE This study aimed to evaluate the rate and impact of episiotomy on maternal and newborn outcomes before and after restricted use of episiotomy. STUDY DESIGN This population-based observational study used an obstetric database of all deliveries since 1990 that has been maintained with quality checks. Inclusion criteria were vaginal deliveries at ≥37 weeks. Exclusion criteria included fetal malformations, multifetal gestations, or fetal deaths known on arrival to Labor and Delivery. The primary outcomes of interest were episiotomy, perineal lacerations, and newborn outcomes. To evaluate the impact of restrictive episiotomy, data from 1990 to 1997 (35% overall episiotomy rate) were compared with data from 2010 to 2017 (2.5% overall episiotomy rate). Univariable analysis of maternal and infant outcomes were performed comparing the two-time epochs with the Pearson's Chi-squared test. RESULTS Overall, 268,415 women met inclusion criteria and 49,089 (18.2%) had an episiotomy. The rate of episiotomy decreased from 37% of deliveries in 1990 to 2% in 2017. A total of 82,082 deliveries occurred in the 1990 to 1997 epoch and 57,183 in 2010 to 2017. Indicated use of episiotomy was associated with a significant decrease in third and fourth degree lacerations. Immediate newborn condition (5-minute Apgar's score ≤3 and umbilical artery pH <7.1) and neonatal outcomes (intraventricular hemorrhage [IVH] grade 3/4, positive culture sepsis, neonatal seizures, and neonatal demise) were not significantly different. CONCLUSION Selective, indicated use of episiotomy compared with routine was associated with lower rates of third/fourth-degree lacerations with no change in neonatal outcomes. The common obstetric practice of routinely performing episiotomy, presumably to prevent perineal trauma, proved untrue when analyzed over almost three decades. KEY POINTS · Episiotomy use decreased overtime at our institution.. · Decreased episiotomy use was associated with significant improvement in maternal outcomes.. · Neonatal outcomes were unchanged suggesting no deleterious effects with restricted episiotomy..
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Affiliation(s)
- Shena J Dillon
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
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Ambia A, Duryea E, Wyckoff MH, Tao W, McIntire DD, Seasely AR, Moussa M, Leveno KJ. A Randomized Trial of the Effects of Ambient Operating Room Temperature on Neonatal Morbidity. Am J Perinatol 2023. [PMID: 36918157 DOI: 10.1055/a-2053-7242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Newborn hypothermia has been implicated in neonatal morbidity without randomized evidence that it compromises the infant. Our objective was to determine if a difference in operating room temperature at cesarean birth impacts neonatal morbidity. METHODS Women undergoing cesarean delivery of a liveborn infant without major malformations were included. The institutional preexisting operating room temperature of 20°C (67°F) was compared with an experimental group of 24°C (75°F) by cluster randomization assigned on a weekly basis. Newborn hypothermia was defined as axillary temperature on arrival to the nursery of less than 36.5°C (<97.7°F). The primary outcome was a composite of neonatal morbidity including respiratory support, sepsis, hypoglycemia, and neonatal death. RESULTS Between November 2016 and May 2018, 5,221 women had cesarean deliveries at Parkland Hospital with 2,817 randomized to the standard care group and 2,404 to the experimental group. The rate of neonatal composite morbidity did not differ between the groups: standard care 398(14%) versus experimental 378(16%), P=0.11. This was despite a significant decrease in the rate of neonatal hypothermia: standard care 1,195(43%) versus experimental 414(18%), P<0.001. There was no difference in the composite outcome for preterm infants (<37 weeks) between the groups: standard care 194(49%) versus experimental 185(54%), P=0.25. CONCLUSIONS An 8-degree Fahrenheit increase in operating room temperature was significantly associated with a reduced rate of neonatal hypothermia, although this decrease was not associated with a significant improvement in neonatal morbidity. However, the increase in operating room temperature was met with resistance from obstetricians and operating room personnel. TRIAL REGISTRATION NUMBER NCT03008577 KEY WORDS: neonatal hypothermia, cesarean section, neonatal morbidity.
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Affiliation(s)
- Anne Ambia
- Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Texas Southwestern Medical Center, Dallas, United States
| | - Elaine Duryea
- Obstetrics & Gynecology, UT Southwestern Medical School, Dallas, United States
| | | | - Weike Tao
- Anesthesiology, University of Texas Southwestern Medical Center, Dallas, United States
| | | | - Angela Rose Seasely
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The University of Alabama at Birmingham, Birmingham, United States
| | | | - Kenneth J Leveno
- Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, United States
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Ogunkua OT, Duryea EL, Nelson DB, Eddins MM, Klucsarits SE, McIntire DD, Leveno KJ. Tranexamic Acid for Prevention of Hemorrhage in Elective Repeat Cesarean Delivery - A Randomized Study. Am J Obstet Gynecol MFM 2022; 4:100573. [PMID: 35038612 DOI: 10.1016/j.ajogmf.2022.100573] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The American College of Obstetricians and Gynecologists states that data is insufficient to recommend Tranexamic acid (TXA) prophylaxis for postpartum hemorrhage. OBJECTIVE This study's objective was to evaluate if prophylactic TXA reduces calculated blood loss versus placebo in women undergoing elective repeat cesarean delivery. STUDY DESIGN A double-blind, randomized, placebo-controlled trial, examining calculated blood loss with prophylactic doses of 1-gram of TXA given before skin incision and after placental delivery and standard uterotonics in women with singleton pregnancies at least 37 weeks' gestation, presenting for their second or third cesarean delivery under neuraxial anesthesia. The primary outcome was calculated blood loss at 24 hours. The calculation was based on the participant's height, weight, and the difference in hematocrit before the start of surgery and 24 hours after delivery. Prespecified secondary outcomes were quantification of maternal coagulation activity during the perioperative course. A sample size of 50 women per group was planned (N=100), based on a meta-analysis of mean reduction in blood loss after TXA. RESULTS 723 women were screened, and 110 women were randomized as follows: 55 to TXA and 55 to placebo. The primary outcome of mean calculated blood for TXA (2274 ± 469 mL) and the placebo group (2407 ± 388 mL), p > 0.05. In the secondary outcomes, D-dimer levels were lower in the TXA group than the placebo group 24 hours after delivery (2.1 ± 1.2 µg/mL versus 4.3 ± 2.4 µg/mL), p < 0.001. CONCLUSIONS Prophylactic tranexamic acid did not decrease mean calculated blood loss. Significantly less participants had calculated blood loss greater than 2000 mL in the tranexamic acid group compared to the placebo group with lower levels of D-dimer at 24 hours.
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Affiliation(s)
- Olutoyosi T Ogunkua
- Departments of Anesthesiology and Pain Management (Drs Ogunkua, Eddins, and Klucsarits) and Obstetrics and Gynecology (Drs Duryea, Nelson, McIntire, and Leveno), The University of Texas Southwestern Medical Center, Dallas, TX..
| | - Elaine L Duryea
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michelle M Eddins
- Departments of Anesthesiology and Pain Management (Drs Ogunkua, Eddins, and Klucsarits) and Obstetrics and Gynecology (Drs Duryea, Nelson, McIntire, and Leveno), The University of Texas Southwestern Medical Center, Dallas, TX
| | - Shannon E Klucsarits
- Departments of Anesthesiology and Pain Management (Drs Ogunkua, Eddins, and Klucsarits) and Obstetrics and Gynecology (Drs Duryea, Nelson, McIntire, and Leveno), The University of Texas Southwestern Medical Center, Dallas, TX
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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Nelson DB, McIntire DD, Leveno KJ. A chronicle of the 17-alpha hydroxyprogesterone caproate story to prevent recurrent preterm birth. Am J Obstet Gynecol 2021; 224:175-186. [PMID: 33035472 DOI: 10.1016/j.ajog.2020.09.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 09/18/2020] [Accepted: 09/21/2020] [Indexed: 12/19/2022]
Abstract
Preterm birth is a substantial public health concern. In 2019, the US preterm birth rate was 10.23%, which is the fifth straight year of increase in this rate. Moreover, preterm birth accounts for approximately 1 in 6 infant deaths, and surviving children often suffer developmental delay or long-term neurologic impairment. Although the burden of preterm birth is clear, identifying strategies to reduce preterm birth has been challenging. On October 29, 2019, a US Food and Drug Administration advisory committee voted 9 vs 7 to withdraw interim accelerated approval of 17-alpha hydroxyprogesterone caproate for preventing recurrent preterm birth because the called for a confirmatory trial, known as the Prevention of Preterm Birth in Women With a Previous Singleton Spontaneous Preterm Delivery trial, was not confirmatory. The Prevention of Preterm Birth in Women With a Previous Singleton Spontaneous Preterm Delivery trial included subjects enrolled in the United States and Canada to ensure that at least 10% of patients would be from North America; however, this trial took 9 years to complete and did not demonstrate significant treatment effects in the 2 primary outcomes of interest. Delivery before 35 weeks' gestation occurred in 122 of 1130 women (11%) given 17-alpha hydroxyprogesterone caproate compared with 66 of 578 women (11.5%) given placebo (relative risk, 0.95; 95% confidence interval, 0.71-1.26; P=.72). Similarly, the coprimary outcome neonatal composite index occurred in 61 of 1093 women (5.6%) given 17-alpha hydroxyprogesterone caproate compared with 28 of 559 women (5.0%) given placebo (relative risk, 1.12; 95% confidence interval, 0.68-1.61; P=.73). There was also a lack of efficacy for 17-alpha hydroxyprogesterone caproate treatment in the analysis of a variety of secondary outcomes. Like the Maternal-Fetal Medicine Units Network trial, the Prevention of Preterm Birth in Women With a Previous Singleton Spontaneous Preterm Delivery trial was also flawed. Importantly, the Maternal-Fetal Medicine Unit Network trial was the sole justification for treating women in the United States with 17-alpha hydroxyprogesterone caproate for nearly 2 decades. Currently, despite more than half a century, 17-alpha hydroxyprogesterone caproate still has not been found to be clearly effective. In this context, how does the advising physician dependent on scientific evidence advise a patient that 17-alpha hydroxyprogesterone caproate is effective when the evidence to support this advice has repeatedly been found to be inadequate? This clinical opinion is a critical appraisal of the 2 randomized trials examining the efficacy of 17-alpha hydroxyprogesterone caproate to prevent recurrent preterm birth and a chronicle of events in the regulatory process of drug approval to help answer this question. With this examination, these events illustrate the complexity of pharmaceutical regulations in the era of accelerated Food and Drug Administration approval and characterize the financial impact and influence in medicine. In this report, we also emphasize the value of observational studies in contemporary practice and identify other examples in medicine where accelerated Food and Drug Administration approval has been withdrawn. Importantly, the themes of the 17-alpha hydroxyprogesterone caproate story are not limited to obstetrics. It can also serve as a microcosm of issues within the US healthcare system, which ultimately contributes to the high cost of healthcare. In our opinion, the answer to the question is clear-the facts speak for themselves-and we believe 17-alpha hydroxyprogesterone caproate should not be endorsed for use to prevent recurrent preterm birth in the United States.
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Affiliation(s)
- David B Nelson
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX.
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
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Nelson DB, McIntire DD, Leveno KJ. Reply. Am J Obstet Gynecol 2020; 223:464-465. [PMID: 32275894 DOI: 10.1016/j.ajog.2020.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 11/30/2022]
Affiliation(s)
- David B Nelson
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Bld., Dallas, TX 75390-9023.
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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Nelson DB, McIntire DD, Leveno KJ. Second-stage labor: consensus versus science. Am J Obstet Gynecol 2020; 222:144-149. [PMID: 31473231 DOI: 10.1016/j.ajog.2019.08.044] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/26/2019] [Accepted: 08/26/2019] [Indexed: 11/28/2022]
Abstract
There has been a recent significant evolution in suggested practices for the management of labor because of the increased national cesarean delivery rate. One of the most significant changes was promulgated by the 2014 Obstetric Care Consensus entitled, "Safe Prevention of Primary Cesarean Delivery," which recommended reconsideration of the upper limits of the length of labor in the second stage as well as the first stage. We previously published a 2016 Clinical Opinion challenging the second-stage practice change. Over the past 2 years, there have been at least 5 reports as well as 2 national organization statements supporting revised management of second-stage labor. We now revisit the second-stage issue because we believe that it is important to carefully clarify the current status resulting from consensus statements as well as the evolving current status of scientific evidence. We structured this Clinical Opinion using questions in an effort to chronicle the story of how obstetric precepts on second-stage labor in use for more than 50 years were being replaced. How did we get here? What is the current evidence? What can be learned from this experience? Should American obstetrics now "fall back" to pre-existing obstetric precepts for the management of second-stage labor after having "sprung forward" an additional hour-namely, lengthening the duration of acceptable second-stage labor to 4 hours as recommended by the Obstetric Care Consensus? We believe that the data published since our 2016 Clinical Opinion buttress our original position that prolongation of the second stage beyond historical precepts is unsafe.
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Affiliation(s)
- David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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Varner MW, Costantine MM, Jablonski KA, Rouse DJ, Mercer BM, Leveno KJ, Reddy UM, Buhimschi C, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, Carpenter M, O’sullivan MJ, Peaceman AM, Dudley DJ, Caritis SN. Sex-Specific Genetic Susceptibility to Adverse Neurodevelopmental Outcome in Offspring of Pregnancies at Risk of Early Preterm Delivery. Am J Perinatol 2020; 37:281-290. [PMID: 30731481 PMCID: PMC6685763 DOI: 10.1055/s-0039-1678535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate sex-specific genetic susceptibility to adverse neurodevelopmental outcome (ANO, defined as cerebral palsy [CP], mental, or psychomotor delay) at risk for early preterm birth (EPTB, < 32 weeks). STUDY DESIGN Secondary case-control analysis of a trial of magnesium sulfate (MgSO4) before anticipated EPTB for CP prevention. Cases are infants who died by the age of 1 year or developed ANO. Controls, matched by maternal race and infant sex, were neurodevelopmentally normal survivors. Neonatal DNA was evaluated for 80 polymorphisms in inflammation, coagulation, vasoregulation, excitotoxicity, and oxidative stress pathways using Taqman assays. The primary outcome for this analysis was sex-specific ANO susceptibility. Conditional logistic regression estimated each polymorphism's odds ratio (OR) by sex stratum, adjusting for gestational age, maternal education, and MgSO4-corticosteroid exposures. Holm-Bonferroni corrections, adjusting for multiple comparisons (p < 7.3 × 10-4), accounted for linkage disequilibrium between markers. RESULTS Analysis included 211 cases (134 males; 77 females) and 213 controls (130 males; 83 females). An interleukin-6 (IL6) polymorphism (rs2069840) was associated with ANO in females (OR: 2.6, 95% confidence interval [CI]: 1.5-4.7; p = 0.001), but not in males (OR: 0.8, 95% CI: 0.5-1.2; p = 0.33). The sex-specific effect difference was significant (p = 7.0 × 10-4) and was unaffected by MgSO4 exposure. No other gene-sex associations were significant. CONCLUSION An IL6 gene locus may confer susceptibility to ANO in females, but not males, after EPTB.
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Affiliation(s)
- Michael W. Varner
- Department of Obstetrics and Gynecology, University of
Utah, Salt Lake City, Utah
| | - Maged M. Costantine
- Department of Obstetrics and Gynecology, University of
Texas Medical Branch, Galveston, Texas
| | - Kathleen A. Jablonski
- Department of Epidemiology and Biostatistics, George
Washington University Biostatistics Center, Washington, Disctrict of Columbia
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, University of
Alabama at Birmingham, Birmingham, Alabama
| | - Brian M. Mercer
- Department of Obstetrics and Gynecology, MetroHealth
Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Kenneth J. Leveno
- Department of Obstetrics and Gynecology, University of
Texas Southwestern Medical Center, Dallas, Texas
| | - Uma M. Reddy
- Eunice Kennedy Shriver National Institute of Child Health
and Human Development, Bethesda, Maryland
| | - Catalin Buhimschi
- Department of Obstetrics and Gynecology, The Ohio State
University, Columbus, Ohio
| | - Ronald J. Wapner
- Department of Obstetrics and Gynecology, Thomas Jefferson
University, Philadelphia, Pennsylvania
- Department of Obstetrics and Gynecology, Drexel
University, Philadelphia, Pennsylvania
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State
University, Detroit, Michigan
| | - John M. Thorp
- Department of Obstetrics and Gynecology, University of
North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Susan M. Ramin
- Department of Obstetrics and Gynecology, University of
Texas Health Science Center at Houston, Houston, Texas
| | - Fergal D. Malone
- Department of Obstetrics and Gynecology, Columbia
University, New York, New York
| | - Marshall Carpenter
- Department of Obstetrics and Gynecology, Brown
University, Providence, Rhode Island
| | - Mary J. O’sullivan
- Department of Obstetrics and Gynecology, University of
Miami, Miami, Florida
| | - Alan M. Peaceman
- Department of Obstetrics and Gynecology, Northwestern
University, Chicago, Illinois
| | - Donald J. Dudley
- Department of Obstetrics and Gynecology, University of
Texas Health Science Center, San Antonio, Texas
| | - Steve N. Caritis
- Department of Obstetrics and Gynecology, University of
Pittsburgh, Pittsburgh, Pennsylvania
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Adhikari EH, Nelson DB, Kelly MA, Moseley L, Wafford M, Cox A, McIntire DD, Leveno KJ. 31: Labor induction with combined foley bulb plus oral misoprostol versus misoprostol alone: a cluster-randomized trial. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Nelson DB, Alexander JM, McIntire DD, Leveno KJ. "New or not-so-new" labor management practices and cesarean delivery for arrest of progress. Am J Obstet Gynecol 2020; 222:71.e1-71.e6. [PMID: 31336076 DOI: 10.1016/j.ajog.2019.07.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/21/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Because nearly one-third of births in the United States are now achieved by cesarean delivery, comprising more than 1.27 million women each year, national organizations have recently published revised guidelines for the management of labor. These new guidelines stipulate that labor arrest should not be diagnosed unless ≥6 cm cervical dilatation has been reached or labor has been stimulated for at ≥6 hours. OBJECTIVE To determine the cervical dilatation and hours of labor stimulation prior to cesarean delivery for arrest of dilatation. MATERIALS AND METHODS Between January 1, 1999, andDecember 31, 2000, a prospective observational study of all primary cesarean deliveries was conducted at 13 university centers comprising the Eunice Kennedy Shriver National Institute for Child Health and Human Development, Maternal-Fetal Medicine Units Network. This secondary analysis includes all live-born, singleton, nonanomalous, cephalic gestations delivered by primary cesarean delivery at ≥37 weeks. A cesarean delivery was considered to have been performed for arrest of dilatation if the indication for the procedure was failure to progress, cephalopelvic disproportion, or failed induction. Augmentation was defined as stimulation after spontaneous labor had been previously diagnosed. Analysis included both the latent and active phases of labor. The active phase of labor was diagnosed when cervical dilatation was ≥4 cm in the presence of uterine contractions. RESULTS A total of 13,269 primary cesarean deliveries were available for analysis, 8,546 (65%) of which were performed for inadequate progress of labor with cervical dilatation recorded at the time of cesarean delivery. Of these cesarean deliveries for labor arrest, a total of 719 (8%) were performed in the latent phase of labor and 7827 (92%) were performed when cervical dilatation was ≥4 cm (active phase). Approximately two-thirds (n = =5876; 69%) received intrauterine pressure monitoring. A total of 5636 women (66% of those reaching the active phase of labor) had reached ≥6 cm cervical dilatation before cesarean delivery was performed. Moreover, 7440 (95%) of the 7827 women in active labor had ≥6 cm dilatation or had received labor stimulation ≥6 hours prior to cesarean delivery for arrest of dilatation. CONCLUSION Women undergoing primary cesarean delivery for arrest of dilatation 15 years before the recommendations of the Obstetrics Care Consensus had received bona fide efforts to achieve adequate labor consistent with the recommendations of the Consensus. Because 95% of these women had ≥6 cm dilatation or had received labor stimulation ≥6 hours prior to cesarean delivery for arrest of dilatation, these new recommendations are unlikely to change the cesarean delivery rates.
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Kho KA, Walsh TM, Schaffer JI, Mcintire DJ, Leveno KJ. 2912 Quality of Life Following Hysterectomy: A Randomized Clinical Trial of Laparoscopic vs Abdominal Hysterectomy. J Minim Invasive Gynecol 2019. [DOI: 10.1016/j.jmig.2019.09.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Affiliation(s)
- David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX.
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
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Ananth CV, Jablonski K, Myatt L, Roberts JM, Tita ATN, Leveno KJ, Reddy UM, Varner MW, Thorp JM, Mercer BM, Peaceman AM, Ramin SM, Carpenter MW, Samuels P, Sciscione A, Tolosa JE, Saade G, Sorokin Y. Risk of Ischemic Placental Disease in Relation to Family History of Preeclampsia. Am J Perinatol 2019; 36:624-631. [PMID: 30282103 PMCID: PMC6447463 DOI: 10.1055/s-0038-1672177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To assess the risk of ischemic placental disease (IPD) including preeclampsia, small for gestational age (SGA), and abruption, in relation to preeclampsia in maternal grandmother, mother, and sister(s). STUDY DESIGN We performed a secondary analysis of data from a randomized trial of vitamins C and E for preeclampsia prevention. Data on family history of preeclampsia were based on recall by the proband. The associations between family history of preeclampsia and the odds of IPD were evaluated from alternating logistic regressions. RESULTS Of the 9,686 women who delivered nonmalformed, singleton live births, 17.1% had IPD. Probands provided data on preeclampsia in 55.5% (n = 5,374) on all three family members, 26.5% (n = 2,562) in mother and sister(s) only, and 11.6% (n = 1,125) in sister(s) only. The pairwise odds ratio (pOR) of IPD was 1.16 (95% confidence interval [CI]: 1.00-1.36) if one or more of the female relatives had preeclampsia. The pORs of preeclampsia were 1.54 (95% CI: 1.12-2.13) and 1.35 (95% CI: 1.03-1.77) if the proband's mother or sister(s) had a preeclamptic pregnancy, respectively, but no associations were seen for SGA infant or abruption. CONCLUSION This study suggests that IPD may share a predisposition with preeclampsia, suggesting a familial inheritance.
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Affiliation(s)
- Cande V Ananth
- Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Joseph L. Mailman School of Public Health, Columbia University, New York, New York
- Department of Health Policy and Management, Joseph L. Mailman School of Public Health, Columbia University, New York, New York
| | - Kathleen Jablonski
- Department of Obstetrics and Gynecology, Biostatistics Center, The George Washington University, Washington, District of Columbia
| | - Leslie Myatt
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio
| | - James M Roberts
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan T N Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Alan M Peaceman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Susan M Ramin
- Department of Obstetrics and Gynecology, Children's Memorial Hermann Hospital, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Marshall W Carpenter
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Philip Samuels
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Anthony Sciscione
- Department of Obstetrics and Gynecology, Drexel University, Philadelphia, Pennsylvania
| | - Jorge E Tolosa
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - George Saade
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
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14
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Miller ES, Lai Y, Bailit J, Reddy UM, Wapner RJ, Varner MW, Thorp JM, Leveno KJ, Caritis SN, Prasad M, Tita ATN, Saade GR, Sorokin Y, Rouse DJ, Blackwell SC, Tolosa JE. Duration of Operative Vaginal Delivery and Adverse Obstetric Outcomes. Am J Perinatol 2019; 37:503-510. [PMID: 30895577 PMCID: PMC6754310 DOI: 10.1055/s-0039-1683439] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study aimed to evaluate whether the number of vacuum pop-offs, the number of forceps pulls, or the duration of operative vaginal delivery (OVD) is associated with adverse maternal and perinatal outcomes. STUDY DESIGN This is a secondary analysis of a multicenter observational cohort of women who underwent an attempted OVD. Women were stratified by the duration of OVD and the number of pop-offs (vacuum) or pulls (forceps) attempted. Severe perineal lacerations, failed OVD, and a composite adverse neonatal outcome were compared by the duration of OVD and number of pop-offs or pulls. RESULTS Of the 115,502 women in the primary cohort, 5,325 (4.6%) underwent an attempt at OVD: 3,594 (67.5%) with vacuum and 1,731 (32.5%) with forceps. After adjusting for potential confounders, an increasing number of pop-offs was associated with an increased odds of the composite adverse neonatal outcome. However, an increasing duration of vacuum exhibited a stronger association with the composite adverse neonatal outcome. Similarly, the number of forceps pulls was less strongly associated with the composite adverse neonatal outcome compared with the duration of forceps application. CONCLUSION The duration of OVD may be more associated with adverse neonatal outcomes than the number of pop-offs or pulls.
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Affiliation(s)
- Emily S. Miller
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Yinglei Lai
- Biostatistics Center, The George Washington University, Washington, District of Columbia
| | - Jennifer Bailit
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Uma M. Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Ronald J. Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Michael W. Varner
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - John M. Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kenneth J. Leveno
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, Texas
| | - Steve N. Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mona Prasad
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Alan T. N. Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - George R. Saade
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Sean C. Blackwell
- Department of Obstetrics and Gynecology, Children’s Memorial Hermann Hospital, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Jorge E. Tolosa
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
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Nelson DB, McIntire DD, Leveno KJ. Reply. Am J Obstet Gynecol 2019; 220:290-291. [PMID: 30550766 DOI: 10.1016/j.ajog.2018.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/29/2018] [Accepted: 12/05/2018] [Indexed: 11/28/2022]
Affiliation(s)
- David B Nelson
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9032.
| | - Donald D McIntire
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9032
| | - Kenneth J Leveno
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9032
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16
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Buhimschi CS, Jablonski KA, Rouse DJ, Varner MW, Reddy UM, Mercer BM, Leveno KJ, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, Carpenter MW, O'Sullivan MJ, Peaceman AM, Saade GR, Dudley D, Caritis SN, Buhimschi IA. Cord Blood Haptoglobin, Cerebral Palsy and Death in Infants of Women at Risk for Preterm Birth: A Secondary Analysis of a Randomised Controlled Trial. EClinicalMedicine 2019; 9:11-18. [PMID: 31143877 PMCID: PMC6510719 DOI: 10.1016/j.eclinm.2019.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Antenatal exposure to intra-uterine inflammation results in precocious Haptoglobin (Hp) expression (switch-on status). We investigated the relationships between foetal Hp expression at birth with newborn and childhood outcomes. METHODS We evaluated cord blood samples from 921 newborns of women at imminent risk for preterm delivery randomised to either placebo (n = 471, birth gestational age (GA) median [min-max]: 31 [24-41] weeks) or magnesium sulphate (n = 450, GA 31 [24-42] weeks]). Primary outcome was infant death by 1 year and/or cerebral palsy (CP) ≥ 2 years of corrected age. Adjusted odd ratios (aOR) for neonatal and childhood outcomes were calculated controlling for GA, birth weight, sex, and magnesium exposure. FINDINGS Primary outcome occurred in 2.8% of offspring. Newborns were classified in three pre-defined categorisation groups by cord blood Hp switch status and IL-6 levels: inflammation-nonexposed (Category 1, n = 432, 47%), inflammation-exposed haptoglobinemic (Category 2, n = 449, 49%), and inflammation-exposed anhaptoglobinemic or hypohaptoglobinemic (Category 3, n = 40, 4%). Newborns, found anhaptoglobinemic or hypohaptoglobinemic (Category 3) had increased OR for intraventricular haemorrhage (IVH) and/or death (aOR: 7.0; 95% CI: 1.4-34.6, p = 0.02) and for CP and/or death (aOR: 6.27; 95% CI: 1.7-23.5, p = 0.006) compared with Category 2. Foetal ability to respond to inflammation by haptoglobinemia resulted in aOR similar to inflammation-nonexposed newborns. Hp1-2 or Hp2-2 phenotypes protected against retinopathy of prematurity (aOR = 0.66; 95% CI 0.48-0.91, p = 0.01). INTERPRETATION Foetal ability to switch-on Hp expression in response to inflammation was associated with reduction of IVH and/or death, and CP and/or death. Foetuses unable to mount such a response had an increased risk of adverse outcomes.Trial Registration: clinicaltrials.gov Identifier: NCT00014989.
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Affiliation(s)
- Catalin S. Buhimschi
- Department of Obstetrics and Gynaecology, The Ohio State University, Columbus, OH, United States of America
- Corresponding author at: Department of Obstetrics & Gynecology, University of Illinois at Chicago, Chicago, IL 60612, United States of America.
| | - Kathleen A. Jablonski
- The George Washington University Biostatistics Center, Washington, DC, United States of America
| | - Dwight J. Rouse
- University of Alabama at Birmingham, Birmingham, AL, United States of America
| | | | - Uma M. Reddy
- the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States of America
| | - Brian M. Mercer
- Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, United States of America
- University of Tennessee, Memphis, TN, United States of America
| | | | - Ronald J. Wapner
- Thomas Jefferson University, Philadelphia, PA, United States of America
- Drexel University, Philadelphia, PA, United States of America
| | - Yoram Sorokin
- Wayne State University, Detroit, MI, United States of America
| | - John M. Thorp
- University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Susan M. Ramin
- University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | | | | | | | | | - George R. Saade
- University of Texas Medical Branch, Galveston, TX, United States of America
| | - Donald Dudley
- University of Texas at San Antonio, San Antonio, TX, United States of America
| | - Steve N. Caritis
- University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Irina A. Buhimschi
- Centre for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States of America
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17
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Ambia AM, Duryea EL, McIntire DD, Wyckoff MH, Tao W, Seasely AR, Leveno KJ. 51: The effect of operating room temperature on neonatal morbidity and mortality: a cluster- randomized trial. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Dillon SJ, Nelson DB, Spong CY, McIntire DD, Leveno KJ. 801: Episiotomy: evolution of a common obstetric practice at a single public hospital. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Dillon SJ, Nelson DB, Spong CY, McIntire DD, Leveno KJ. 985: Forceps and episiotomy: Do they go hand-in-hand or should they go their separate ways? Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.1009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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20
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Saade GR, Thom EA, Grobman WA, Iams JD, Mercer BM, Reddy UM, Tita ATN, Rouse DJ, Sorokin Y, Wapner RJ, Leveno KJ, Blackwell SC, Esplin MS, Tolosa JE, Thorp JM, Caritis SN, Vandorsten JP. Cervical funneling or intra-amniotic debris and preterm birth in nulliparous women with midtrimester cervical length less than 30 mm. Ultrasound Obstet Gynecol 2018; 52:757-762. [PMID: 29155504 PMCID: PMC5960623 DOI: 10.1002/uog.18960] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/13/2017] [Accepted: 10/20/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To evaluate whether the presence of cervical funneling or intra-amniotic debris identified in the second trimester is associated with a higher rate of preterm birth (PTB) in asymptomatic nulliparous pregnant women with a midtrimester cervical length (CL) less than 30 mm (i.e. below the 10th percentile). METHODS This was a secondary cohort analysis of data from a multicenter trial in nulliparous women between 16 and 22 weeks' gestation with a singleton gestation and CL less than 30 mm on transvaginal ultrasound, randomized to treatment with either 17-alpha-hydroxyprogesterone caproate or placebo. Sonographers were centrally certified in CL measurement, as well as in identification of intra-amniotic debris and cervical funneling. Univariable and multivariable analysis was performed to assess the associations of cervical funneling and intra-amniotic debris with PTB. RESULTS Of the 657 women randomized, 112 (17%) had cervical funneling only, 33 (5%) had intra-amniotic debris only and 45 (7%) had both on second-trimester ultrasound. Women with either of these findings had a shorter median CL than those without (21.0 mm vs 26.4 mm; P < 0.001). PTB prior to 37 weeks was more likely in women with cervical funneling (37% vs 21%; odds ratio (OR), 2.2 (95% CI, 1.5-3.3)) or intra-amniotic debris (35% vs 23%; OR, 1.7 (95% CI, 1.1-2.9)). Results were similar for PTB before 34 and before 32 weeks' gestation. After multivariable adjustment that included CL, PTB < 34 and < 32 weeks continued to be associated with the presence of intra-amniotic debris (adjusted OR (aOR), 1.85 (95% CI, 1.00-3.44) and aOR, 2.78 (95% CI, 1.42-5.45), respectively), but not cervical funneling (aOR, 1.17 (95% CI, 0.63-2.17) and aOR, 1.45 (95% CI, 0.71-2.96), respectively). CONCLUSIONS Among asymptomatic nulliparous women with midtrimester CL less than 30 mm, the presence of intra-amniotic debris, but not cervical funneling, is associated with an increased risk for PTB before 34 and 32 weeks' gestation, independently of CL. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - E A Thom
- The George Washington University Biostatistics Center, Washington, DC, USA
| | | | - J D Iams
- Ohio State University, Columbus, OH, USA
| | - B M Mercer
- MetroHealth Medical Center-Case Western Reserve University, Cleveland, OH, USA
| | - U M Reddy
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - A T N Tita
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - D J Rouse
- Brown University, Providence, RI, USA
| | - Y Sorokin
- Wayne State University, Detroit, MI, USA
| | | | - K J Leveno
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - S C Blackwell
- The University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX, USA
| | - M S Esplin
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - J E Tolosa
- Oregon Health & Science University, Portland, OR, USA
| | - J M Thorp
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S N Caritis
- University of Pittsburgh, Pittsburgh, PA, USA
| | - J P Vandorsten
- Medical University of South Carolina, Charleston, SC, USA
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21
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Randis TM, Rice MM, Myatt L, Tita ATN, Leveno KJ, Reddy UM, Varner MW, Thorp JM, Mercer BM, Dinsmoor MJ, Ramin SM, Carpenter MW, Samuels P, Sciscione A, Tolosa JE, Saade G, Sorokin Y. Incidence of early-onset sepsis in infants born to women with clinical chorioamnionitis. J Perinat Med 2018; 46:926-933. [PMID: 29791315 PMCID: PMC6177287 DOI: 10.1515/jpm-2017-0192] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 03/06/2018] [Indexed: 01/19/2023]
Abstract
Objective To determine the frequency of sepsis and other adverse neonatal outcomes in women with a clinical diagnosis of chorioamnionitis. Methods We performed a secondary analysis of a multi-center placebo-controlled trial of vitamins C/E to prevent preeclampsia in low risk nulliparous women. Clinical chorioamnionitis was defined as either the "clinical diagnosis" of chorioamnionitis or antibiotic administration during labor because of an elevated temperature or uterine tenderness in the absence of another cause. Early-onset neonatal sepsis was categorized as "suspected" or "confirmed" based on a clinical diagnosis with negative or positive blood, urine or cerebral spinal fluid cultures, respectively, within 72 h of birth. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by logistic regression. Results Data from 9391 mother-infant pairs were analyzed. The frequency of chorioamnionitis was 10.3%. Overall, 6.6% of the neonates were diagnosed with confirmed (0.2%) or suspected (6.4%) early-onset sepsis. Only 0.7% of infants born in the setting of chorioamnionitis had culture-proven early-onset sepsis versus 0.1% if chorioamnionitis was not present. Clinical chorioamnionitis was associated with both suspected [OR 4.01 (3.16-5.08)] and confirmed [OR 4.93 (1.65-14.74)] early-onset neonatal sepsis, a need for resuscitation within the first 30 min after birth [OR 2.10 (1.70-2.61)], respiratory distress [OR 3.14 (2.16-4.56)], 1 min Apgar score of ≤3 [OR 2.69 (2.01-3.60)] and 4-7 [OR 1.71 (1.43-2.04)] and 5 min Apgar score of 4-7 [OR 1.67 (1.17-2.37)] (vs. 8-10). Conclusion Clinical chorioamnionitis is common and is associated with neonatal morbidities. However, the vast majority of exposed infants (99.3%) do not have confirmed early-onset sepsis.
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Affiliation(s)
- Tara M. Randis
- Department of Pediatrics, Columbia University, New York, NewYork
| | | | - Leslie Myatt
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio
| | - Alan T. N. Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kenneth J. Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Uma M. Reddy
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Michael W. Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - John M. Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brian M. Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, Ohio
| | - Mara J Dinsmoor
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Susan M. Ramin
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, Texas
| | | | - Philip Samuels
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Anthony Sciscione
- Department of Obstetrics and Gynecology, Drexel University, Philadelphia, Pennsylvania
| | - Jorge E. Tolosa
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - George Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
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22
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Tita AT, Jablonski KA, Bailit JL, Grobman WA, Wapner RJ, Reddy UM, Varner MW, Thorp JM, Leveno KJ, Caritis SN, Iams JD, Saade G, Sorokin Y, Rouse DJ, Blackwell SC, Tolosa JE, Wallace M, Northen A, Grant J, Colquitt C, Mallett G, Ramos-Brinson M, Roy A, Stein L, Campbell P, Collins C, Jackson N, Dinsmoor M, Senka J, Paychek K, Peaceman A, Talucci M, Zylfijaj M, Reid Z, Leed R, Benson J, Forester S, Kitto C, Davis S, Falk M, Perez C, Hill K, Sowles A, Postma J, Alexander S, Andersen G, Scott V, Morby V, Jolley K, Miller J, Berg B, Dorman K, Mitchell J, Kaluta E, Clark K, Spicer K, Timlin S, Wilson K, Moseley L, Santillan M, Price J, Buentipo K, Bludau V, Thomas T, Fay L, Melton C, Kingsbery J, Benezue R, Simhan H, Bickus M, Fischer D, Kamon T, DeAngelis D, Mercer B, Milluzzi C, Dalton W, Dotson T, McDonald P, Brezine C, McGrail A, Latimer C, Guzzo L, Johnson F, Gerwig L, Fyffe S, Loux D, Frantz S, Cline D, Wylie S, Shubert P, Moss J, Salazar A, Acosta A, Hankins G, Hauff N, Palmer L, Lockhart P, Driscoll D, Wynn L, Sudz C, Dengate D, Girard C, Field S, Breault P, Smith F, Annunziata N, Allard D, Silva J, Gamage M, Hunt J, Tillinghast J, Corcoran N, Jimenez M, Ortiz F, Givens P, Rech B, Moran C, Hutchinson M, Spears Z, Carreno C, Heaps B, Zamora G, Seguin J, Rincon M, Snyder J, Farrar C, Lairson E, Bonino C, Smith W, Beach K, Van Dyke S, Butcher S, Thom E, Zhao Y, McGee P, Momirova V, Palugod R, Reamer B, Larsen M, Spong C, Tolivaisa S, VanDorsten J. Neonatal outcomes of elective early-term births after demonstrated fetal lung maturity. Am J Obstet Gynecol 2018; 219:296.e1-296.e8. [PMID: 29800541 DOI: 10.1016/j.ajog.2018.05.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 11/09/2016] [Accepted: 05/14/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Studies of early-term birth after demonstrated fetal lung maturity show that respiratory and other outcomes are worse with early-term birth (370-386 weeks) even after demonstrated fetal lung maturity when compared with full-term birth (390-406 weeks). However, these studies included medically indicated births and are therefore potentially limited by confounding by the indication for delivery. Thus, the increase in adverse outcomes might be due to the indication for early-term birth rather than the early-term birth itself. OBJECTIVE We examined the prevalence and risks of adverse neonatal outcomes associated with early-term birth after confirmed fetal lung maturity as compared with full-term birth in the absence of indications for early delivery. STUDY DESIGN This is a secondary analysis of an observational study of births to 115,502 women in 25 hospitals in the United States from 2008 through 2011. Singleton nonanomalous births at 37-40 weeks with no identifiable indication for delivery were included; early-term births after positive fetal lung maturity testing were compared with full-term births. The primary outcome was a composite of death, ventilator for ≥2 days, continuous positive airway pressure, proven sepsis, pneumonia or meningitis, treated hypoglycemia, hyperbilirubinemia (phototherapy), and 5-minute Apgar <7. Logistic regression and propensity score matching (both 1:1 and 1:2) were used. RESULTS In all, 48,137 births met inclusion criteria; the prevalence of fetal lung maturity testing in the absence of medical or obstetric indications for early delivery was 0.52% (n = 249). There were 180 (0.37%) early-term births after confirmed pulmonary maturity and 47,957 full-term births. Women in the former group were more likely to be non-Hispanic white, smoke, have received antenatal steroids, have induction, and have a cesarean. Risks of the composite (16.1% vs 5.4%; adjusted odds ratio, 3.2; 95% confidence interval, 2.1-4.8 from logistic regression) were more frequent with elective early-term birth. Propensity scores matching confirmed the increased primary composite in elective early-term births: adjusted odds ratios, 4.3 (95% confidence interval, 1.8-10.5) for 1:1 and 3.5 (95% confidence interval, 1.8-6.5) for 1:2 matching. Among components of the primary outcome, CPAP use and hyperbilirubinemia requiring phototherapy were significantly increased. Transient tachypnea of the newborn, neonatal intensive care unit admission, and prolonged neonatal intensive care unit stay (>2 days) were also increased with early-term birth. CONCLUSION Even with confirmed pulmonary maturity, early-term birth in the absence of medical or obstetric indications is associated with worse neonatal respiratory and hepatic outcomes compared with full-term birth, suggesting relative immaturity of these organ systems in early-term births.
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Tita AT, Doherty L, Roberts JM, Myatt L, Leveno KJ, Varner MW, Wapner RJ, Thorp JM, Mercer BM, Peaceman A, Ramin SM, Carpenter MW, Iams J, Sciscione A, Harper M, Tolosa JE, Saade GR, Sorokin Y. Adverse Maternal and Neonatal Outcomes in Indicated Compared with Spontaneous Preterm Birth in Healthy Nulliparas: A Secondary Analysis of a Randomized Trial. Am J Perinatol 2018; 35:624-631. [PMID: 29190847 PMCID: PMC5948166 DOI: 10.1055/s-0037-1608787] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To compare the risks of adverse maternal and neonatal outcomes associated with spontaneous (SPTB) versus indicated preterm births (IPTB). METHODS A secondary analysis of a multicenter trial of vitamin C and E supplementation in healthy low-risk nulliparous women. Outcomes were compared between women with SPTB (due to spontaneous membrane rupture or labor) and those with IPTB (due to medical or obstetric complications). A primary maternal composite outcome included: death, pulmonary edema, blood transfusion, adult respiratory distress syndrome (RDS), cerebrovascular accident, acute tubular necrosis, disseminated intravascular coagulopathy, or liver rupture. A neonatal composite outcome included: neonatal death, RDS, grades III or IV intraventricular hemorrhage (IVH), sepsis, necrotizing enterocolitis (NEC), or retinopathy of prematurity. RESULTS Of 9,867 women, 10.4% (N = 1,038) were PTBs; 32.7% (n = 340) IPTBs and 67.3% (n = 698) SPTBs. Compared with SPTB, the composite maternal outcome was more frequent in IPTB-4.4% versus 0.9% (adjusted odds ratio [aOR], 4.0; 95% confidence interval [CI], 1.4-11.8), as were blood transfusion and prolonged hospital stay (3.2 and 3.7 times, respectively). The frequency of composite neonatal outcome was higher in IPTBs (aOR, 1.8; 95% CI, 1.1-3.0), as were RDS (1.7 times), small for gestational age (SGA) < 5th percentile (7.9 times), and neonatal intensive care unit (NICU) admission (1.8 times). CONCLUSION Adverse maternal and neonatal outcomes were significantly more likely with IPTB than with SPTB.
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Affiliation(s)
- Alan T Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lindsay Doherty
- The Biostatistics Center, The George Washington University, Washington, District of Columbia
| | - Jim M Roberts
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leslie Myatt
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, Ohio
| | - Alan Peaceman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Susan M Ramin
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas
| | - Marshall W Carpenter
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Jay Iams
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Anthony Sciscione
- Department of Obstetrics and Gynecology, Drexel University, Philadelphia, Pennsylvania
| | - Margaret Harper
- Department of Obstetrics and Gynecology, Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Jorge E Tolosa
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
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Affiliation(s)
- David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX.
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
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Grobman WA, Bailit J, Lai Y, Reddy UM, Wapner RJ, Varner MW, Thorp JM, Leveno KJ, Caritis SN, Prasad M, Tita ATN, Saade G, Sorokin Y, Rouse DJ, Blackwell SC, Tolosa JE. Defining failed induction of labor. Am J Obstet Gynecol 2018; 218:122.e1-122.e8. [PMID: 29138035 PMCID: PMC5819749 DOI: 10.1016/j.ajog.2017.11.556] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 10/27/2017] [Accepted: 11/06/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND While there are well-accepted standards for the diagnosis of arrested active-phase labor, the definition of a "failed" induction of labor remains less certain. One approach to diagnosing a failed induction is based on the duration of the latent phase. However, a standard for the minimum duration that the latent phase of a labor induction should continue, absent acute maternal or fetal indications for cesarean delivery, remains lacking. OBJECTIVE The objective of this study was to determine the frequency of adverse maternal and perinatal outcomes as a function of the duration of the latent phase among nulliparous women undergoing labor induction. STUDY DESIGN This study is based on data from an obstetric cohort of women delivering at 25 US hospitals from 2008 through 2011. Nulliparous women who had a term singleton gestation in the cephalic presentation were eligible for this analysis if they underwent a labor induction. Consistent with prior studies, the latent phase was determined to begin once cervical ripening had ended, oxytocin was initiated, and rupture of membranes had occurred, and was determined to end once 5-cm dilation was achieved. The frequencies of cesarean delivery, as well as of adverse maternal (eg, postpartum hemorrhage, chorioamnionitis) and perinatal (eg, a composite frequency of seizures, sepsis, bone or nerve injury, encephalopathy, or death) outcomes, were compared as a function of the duration of the latent phase (analyzed with time both as a continuous measure and categorized in 3-hour increments). RESULTS A total of 10,677 women were available for analysis. In the vast majority (96.4%) of women, the active phase had been reached by 15 hours. The longer the duration of a woman's latent phase, the greater her chance of ultimately undergoing a cesarean delivery (P < .001, for time both as a continuous and categorical independent variable), although >40% of women whose latent phase lasted ≥18 hours still had a vaginal delivery. Several maternal morbidities, such as postpartum hemorrhage (P < .001) and chorioamnionitis (P < .001), increased in frequency as the length of latent phase increased. Conversely, the frequencies of most adverse perinatal outcomes were statistically stable over time. CONCLUSION The large majority of women undergoing labor induction will have entered the active phase by 15 hours after oxytocin has started and rupture of membranes has occurred. Maternal adverse outcomes become statistically more frequent with greater time in the latent phase, although the absolute increase in frequency is relatively small. These data suggest that cesarean delivery should not be undertaken during the latent phase prior to at least 15 hours after oxytocin and rupture of membranes have occurred. The decision to continue labor beyond this point should be individualized, and may take into account factors such as other evidence of labor progress.
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Affiliation(s)
- William A Grobman
- Departments of Obstetrics and Gynecology of Northwestern University, Chicago, IL.
| | - Jennifer Bailit
- MetroHealth Medical Center-Case Western Reserve University, Cleveland, OH
| | - Yinglei Lai
- George Washington University Biostatistics Center, Washington, DC
| | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | | | | | - John M Thorp
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | | | - George Saade
- University of Texas Medical Branch, Galveston, TX
| | | | | | - Sean C Blackwell
- University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX
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Affiliation(s)
- David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX.
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
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Nelson DB, McIntire DD, McDonald J, Gard J, Turrichi P, Leveno KJ. 17-alpha Hydroxyprogesterone caproate did not reduce the rate of recurrent preterm birth in a prospective cohort study. Am J Obstet Gynecol 2017; 216:600.e1-600.e9. [PMID: 28223163 DOI: 10.1016/j.ajog.2017.02.025] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/10/2017] [Accepted: 02/13/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND 17-alpha Hydroxyprogesterone caproate for prevention of recurrent preterm birth is recommended for use in the United States. OBJECTIVE We sought to assess the clinical effectiveness of 17-alpha hydroxyprogesterone caproate to prevent recurrent preterm birth ≤35 weeks compared to similar births in our obstetric population prior to the implementation of 17-alpha hydroxyprogesterone caproate. STUDY DESIGN This was a prospective cohort study of 17-alpha hydroxyprogesterone caproate in our obstetric population. The primary outcome was the recurrence of birth ≤35 weeks for the entire study cohort compared to a historical referent rate of 16.8% of recurrent preterm birth in our population. There were 3 secondary outcomes. First, did 17-alpha hydroxyprogesterone caproate modify a woman's history of preterm birth when taking into account her prior number and sequence of preterm and term births? Second, was recurrence of preterm birth related to 17-alpha hydroxyprogesterone caproate plasma concentration? Third, was duration of pregnancy modified by 17-alpha hydroxyprogesterone caproate treatment compared to a prior preterm birth? RESULTS From January 2012 through March 2016, 430 consecutive women with prior births ≤35 weeks were treated with 17-alpha hydroxyprogesterone caproate. Nearly two thirds of the women (N = 267) began injections ≤18 weeks and 394 (92%) received a scheduled weekly injection within 10 days of reaching 35 weeks or delivery. The overall rate of recurrent preterm birth was 25% (N = 106) for the entire cohort compared to the 16.8% expected rate (P = 1.0). The 3 secondary outcomes were also negative. First, 17-alpha hydroxyprogesterone caproate did not significantly reduce the rates of recurrence regardless of prior preterm birth number or sequence. Second, plasma concentrations of 17-alpha hydroxyprogesterone caproate were not different (P = .17 at 24 weeks; P = .38 at 32 weeks) between women delivered ≤35 weeks and those delivered later in pregnancy. Third, the mean (±SD) interval in weeks of recurrent preterm birth before 17-alpha hydroxyprogesterone caproate use was 0.4 ± 5.3 weeks and the interval of recurrent preterm birth after 17-alpha hydroxyprogesterone caproate treatment was 0.1 ± 4.7 weeks (P = .63). A side effect of weekly 17-alpha hydroxyprogesterone caproate injections was an increase in gestational diabetes. Specifically, the rate of gestational diabetes was 13.4% in 17-alpha hydroxyprogesterone caproate-treated women compared to 8% in case-matched controls (P = .001). CONCLUSION 17-alpha Hydroxyprogesterone caproate was ineffective for prevention of recurrent preterm birth and was associated with an increased rate of gestational diabetes.
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Affiliation(s)
- David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jeffrey McDonald
- Department of Molecular Genetics, University of Texas Southwestern Medical Center, Dallas, TX
| | - John Gard
- Women and Infant Services, Parkland Health and Hospital System, Dallas, TX
| | - Paula Turrichi
- Women and Infant Services, Parkland Health and Hospital System, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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Affiliation(s)
- Steven L Bloom
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
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Morgan JL, Nelson DB, Casey BM, Bloom SL, McIntire DD, Leveno KJ. Impact of metabolic acidemia at birth on neonatal outcomes in infants born before 34 weeks’ gestation. J Matern Fetal Neonatal Med 2016; 30:1902-1905. [DOI: 10.1080/14767058.2016.1229767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Jamie L. Morgan
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David B. Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brian M. Casey
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven L. Bloom
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donald D. McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kenneth J. Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Affiliation(s)
- Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX.
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
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Hughes BL, Clifton RG, Hauth JC, Leveno KJ, Myatt L, Reddy UM, Varner MW, Wapner RJ, Mercer BM, Peaceman AM, Ramin SM, Tolosa JE, Saade G, Sorokin Y. Is Mid-trimester Insulin Resistance Predictive of Subsequent Puerperal Infection? A Secondary Analysis of Randomized Trial Data. Am J Perinatol 2016; 33:983-90. [PMID: 27120478 PMCID: PMC5240039 DOI: 10.1055/s-0036-1583188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective The objective of this study was to examine whether there is an association between insulin resistance and subsequent development of puerperal infection by measuring insulin resistance in the mid-trimester using the homeostasis model assessment (HOMA:IR). Methods Secondary analysis of low-risk nulliparas enrolled in a multicenter preeclampsia prevention trial. HOMA:IR was measured on fasting plasma glucose and insulin concentrations among low-risk nulliparas between 22 and 26 weeks' gestation. Median HOMA:IR was compared between women who did and did not develop puerperal infection using Wilcoxon rank sum test. Logistic regression was used to control for potential confounders. Results Of 1,180 women with fasting glucose and insulin available, 121 (10.3%) had a puerperal infection. Median HOMA:IR was higher among those with subsequent puerperal infection (4.3 [interquartile, IQR: 2.2-20.5] vs. 2.6 [IQR: 1.5-6.7], p < 0.0001). After controlling for potentially confounding variables HOMA:IR was only marginally associated with an increased risk of development of puerperal infection, adjusted odds ratio: 1.01 (95% confidence interval: 1.00-1.02; p = 0.04) per unit increase. Elevated HOMA:IR performed poorly as a predictor of puerperal infection, with a positive predictive value of 15% and a negative predictive value of 92%. Conclusion Though associated with an increased risk of puerperal infection, insulin resistance, measured by HOMA:IR, is not a clinically useful predictor of puerperal infection.
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Affiliation(s)
- Brenna L. Hughes
- Department of Obstetrics and Gynecology, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Rebecca G. Clifton
- The George Washington University Biostatistics Center, Washington, District of Columbia
| | - John C. Hauth
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kenneth J. Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Leslie Myatt
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio
| | - Uma M. Reddy
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Michael W. Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Ronald J. Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Brian M. Mercer
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Alan M. Peaceman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Susan M. Ramin
- Department of Obstetrics and Gynecology, Children’s Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jorge E. Tolosa
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - George Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
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Grobman WA, Lai Y, Iams JD, Reddy UM, Mercer BM, Saade G, Tita AT, Rouse DJ, Sorokin Y, Wapner RJ, Leveno KJ, Blackwell SC, Esplin MS, Tolosa JE, Thorp JM, Caritis SN. Prediction of Spontaneous Preterm Birth Among Nulliparous Women With a Short Cervix. J Ultrasound Med 2016; 35:1293-1297. [PMID: 27151903 PMCID: PMC5086428 DOI: 10.7863/ultra.15.08035] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/30/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate whether demographic and sonographic factors associated with spontaneous preterm birth among nulliparous women with a cervical length of less than 30 mm could be combined into an accurate prediction model for spontaneous preterm birth. METHODS We conducted a secondary analysis of a trial of nulliparous women with a singleton gestation and a cervical length of less than 30 mm on transvaginal sonography between 16 and 22 weeks who lacked other risk factors for spontaneous (eg, prior cervical excisional procedure) or medically indicated (eg, chronic hypertension) preterm birth, who were randomized to either 17α-hydroxyprogesterone caproate treatment or a placebo. Risk factors associated with spontaneous preterm birth within the entire cohort were identified by univariable analysis. Factors significantly associated (P < .05) with spontaneous preterm birth were included in a multivariable logistic regression analysis to determine whether an accurate prediction model could be developed. RESULTS Of the 657 randomized patients, 109 (16.6%) had spontaneous preterm birth before 37 weeks' gestation. Logistic regression analysis revealed only cervical length (odds ratio, 1.06 per 1-mm decrease; 95% confidence interval, 1.02-1.10) to be associated with spontaneous preterm birth. The area under the receiver operating characteristic curve based on this regression was low (0.63; 95% confidence interval, 0.58-0.69). Results were similar for the outcome of spontaneous preterm birth before 34 weeks. CONCLUSIONS An accurate prediction model for spontaneous preterm birth among nulliparous women with a short cervix could not be developed.
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Affiliation(s)
- William A Grobman
- Departments of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois USA
| | - Yinglei Lai
- George Washington University Biostatistics Center, Washington, DC USA
| | - Jay D Iams
- Ohio State University, Columbus, Ohio USA
| | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland USA
| | - Brian M Mercer
- Case Western Reserve University-MetroHealth Medical Center, Cleveland, Ohio USA
| | - George Saade
- University of Texas Medical Branch, Galveston, Texas USA
| | - Alan T Tita
- University of Alabama at Birmingham, Birmingham, Alabama USA
| | | | | | | | - Kenneth J Leveno
- University of Texas Southwestern Medical Center, Dallas, Texas USA
| | - Sean C Blackwell
- University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas USA
| | - M Sean Esplin
- University of Utah Health Sciences Center, Salt Lake City, Utah USA
| | - Jorge E Tolosa
- Oregon Health and Science University, Portland, Oregon USA
| | - John M Thorp
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina USA
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Duryea EL, Nelson DB, Wyckoff MH, Grant EN, Tao W, Sadana N, Chalak LF, McIntire DD, Leveno KJ. The impact of ambient operating room temperature on neonatal and maternal hypothermia and associated morbidities: a randomized controlled trial. Am J Obstet Gynecol 2016; 214:505.e1-505.e7. [PMID: 26874298 DOI: 10.1016/j.ajog.2016.01.190] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 01/11/2016] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Neonatal hypothermia is common at the time of cesarean delivery and has been associated with a constellation of morbidities in addition to increased neonatal mortality. Additionally, maternal hypothermia is often uncomfortable for the surgical patient and has been associated with intraoperative and postoperative complications. Various methods to decrease the rates of neonatal and maternal hypothermia have been examined and found to have varying levels of success. OBJECTIVE We sought to determine whether an increase in operating room temperature at cesarean delivery results in a decrease in the rate of neonatal hypothermia and associated morbidities. STUDY DESIGN In this single-center randomized trial, operating room temperatures were adjusted weekly according to a cluster randomization schedule to either 20°C (67°F), which was the standard at our institution, or 23°C (73°F), which was the maximum temperature allowable per hospital policy. Neonatal hypothermia was defined as core body temperature <36.5°C (97.7°F) per World Health Organization criteria. The primary study outcome was neonatal hypothermia on arrival to the admitting nursery. Measures of neonatal morbidity potentially associated with hypothermia were examined. RESULTS From February through July 2015, 791 women who underwent cesarean deliveries were enrolled, resulting in 410 infants in the 20°C standard management group and 399 in the 23°C study group. The rate of neonatal hypothermia on arrival to the admitting nursery was lower in the study group as compared to the standard management group: 35% vs 50%, P < .001. Moderate to severe hypothermia was infrequent when the operating room temperature was 23°C (5%); in contrast such hypothermia occurred in 19% of the standard management group, P < .001. Additionally, neonatal temperature in the operating room immediately following delivery and stabilization was also higher in the study group, 37.1 ± 0.6°C vs 36.9 ± 0.6°C, P < .001. We found no difference in rates of intubation, ventilator use, hypoglycemia, metabolic acidemia, or intraventricular hemorrhage. Fever (temperature >38.0°C or 100.4°F) on arrival to the admitting unit was uncommon and did not differ between the study groups. Maternal temperature on arrival to the operating room was not different between the 2 groups, however by delivery it was significantly lower in the standard management group, 36.2 ± 0.6°C vs 36.4 ± 0.6°C, P < .001. This effect persisted, as maternal temperature on arrival to the postoperative care area was lower in the standard management group, 36.1 ± 0.6°C vs 36.2 ± 0.6°C, P < .001, and the rate of hypothermia was higher, 77% vs 69%, P = .008. CONCLUSION A modest increase in operating room temperature at the time of cesarean reduces the rate of neonatal and maternal hypothermia. We did not detect a decrease in neonatal morbidity, but the power to detect a small change in these outcomes was limited.
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Affiliation(s)
- Elaine L Duryea
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
| | - David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Myra H Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Erica N Grant
- Department of Anesthesia, University of Texas Southwestern Medical Center, Dallas, TX
| | - Weike Tao
- Department of Anesthesia, University of Texas Southwestern Medical Center, Dallas, TX
| | - Neeti Sadana
- Department of Anesthesia, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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Leveno KJ, Nelson DB, McIntire DD. Second-stage labor: how long is too long? Am J Obstet Gynecol 2016; 214:484-489. [PMID: 26546847 DOI: 10.1016/j.ajog.2015.10.926] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 10/07/2015] [Accepted: 10/28/2015] [Indexed: 10/22/2022]
Abstract
The management of labor has come under increased scrutiny due to the rapid escalation of cesarean delivery in the United States. A workshop of the Society for Maternal-Fetal Medicine, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the American Congress of Obstetricians and Gynecologists was convened to address the rising cesarean delivery rates and one of their recommendations was that the accepted upper limit of the second stage of labor should be increased to ≥4 hours in nulliparous women with epidural analgesia and to ≥3 hours in parous women with epidural. This led to the inaugural Obstetric Care Consensus series document, "Safe Prevention of the Primary Cesarean Delivery," wherein the workshop recommendations on second-stage labor were promulgated nationally. The result is that the now acceptable maximum length of the second stage of labor exceeds the obstetric precepts that have been in use for >50 years. In this Clinical Opinion, we review the evidence on infant safety, vis-à-vis length of the second stage of labor. Our examination of the evidence begins at the outset of the 20th century and culminates in the very recent (2014) recommendation to abandon the long accepted obstetric paradigm that second-stage labor >3 hours in nulliparous women with labor epidural is unsafe for the unborn infant. We conclude that the currently available evidence fails to support the Obstetric Care Consensus position that longer second-stage labor is safe for the unborn infant. Indeed, the evidence suggests quite the opposite. We suggest that when infant safety is at stake the evidence should be robust before a new clinical road is taken. The evidence is not robust.
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Morgan JL, Nelson DB, Casey BM, Bloom SL, McIntire DD, Leveno KJ. 393: Does metabolic acidemia increase the risks of prematurity-related morbidity and mortality in early preterm births? Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Duryea EL, Nelson DB, Wyckoff MH, Grant EN, Tao W, Sadana N, Chalak LF, McIntire DD, Leveno KJ. 44: The impact of operating room temperature on neonatal hypothermia and morbidity: results from a randomized trial. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Duryea EL, Nelson DB, Wyckoff MH, Grant EN, Tao W, Sadana N, Chalak LF, McIntire DD, Leveno KJ. 365: The impact of operating room temperature on hypothermia and morbidity in preterm infants. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Reddy UM, Rice MM, Grobman WA, Bailit JL, Wapner RJ, Varner MW, Thorp JM, Leveno KJ, Caritis SN, Prasad M, Tita ATN, Saade GR, Sorokin Y, Rouse DJ, Blackwell SC, Tolosa JE. Serious maternal complications after early preterm delivery (24-33 weeks' gestation). Am J Obstet Gynecol 2015; 213:538.e1-9. [PMID: 26164696 DOI: 10.1016/j.ajog.2015.06.064] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/29/2015] [Accepted: 06/30/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We sought to describe the prevalence of serious maternal complications following early preterm birth by gestational age (GA), delivery route, and type of cesarean incision. STUDY DESIGN Trained personnel abstracted data from maternal and neonatal charts for all deliveries on randomly selected days representing one third of deliveries across 25 US hospitals over 3 years (n = 115,502). All women delivering nonanomalous singletons between 23-33 weeks' gestation were included. Women were excluded for antepartum stillbirth and highly morbid conditions for which route of delivery would not likely impact morbidity including nonreassuring fetal status, cord prolapse, placenta previa, placenta accreta, placental abruption, and severe and unstable maternal conditions (cardiopulmonary collapse, acute respiratory distress syndrome, seizures). Serious maternal complications were defined as: hemorrhage (blood loss ≥1500 mL, blood transfusion, or hysterectomy for hemorrhage), infection (endometritis, wound dehiscence, or wound infection requiring antibiotics, reopening, or unexpected procedure), intensive care unit admission, or death. Delivery route was categorized as classic cesarean delivery (CCD), low transverse cesarean delivery (LTCD), low vertical cesarean delivery (LVCD), and vaginal delivery. Association of delivery route with complications was estimated using multivariable regression models yielding adjusted relative risks (aRR) controlling for maternal age, race, body mass index, hypertension, diabetes, preterm premature rupture of membranes, preterm labor, GA, and hospital of delivery. RESULTS Of 2659 women who met criteria for inclusion in this analysis, 8.6% of women experienced serious maternal complications. Complications were associated with GA and were highest between 23-27 weeks of gestation. The frequency of complications was associated with delivery route; compared with 3.5% of vaginal delivery, 23.0% of CCD (aRR, 3.54; 95% confidence interval (CI), 2.29-5.48), 12.1% of LTCD (aRR, 2.59; 95% CI, 1.77-3.77), and 10.3% of LVCD (aRR, 2.27; 95% CI, 0.68-7.55) experienced complications. There was no significant difference in complication rates between CCD and LTCD (aRR, 1.37; 95% CI, 0.95-1.97) or between CCD and LVCD (aRR, 1.56; 95% CI, 0.48-5.07). CONCLUSION The risk of maternal complications after early preterm delivery is substantial, particularly in women who undergo cesarean delivery. Obstetricians need to be prepared to manage potential hemorrhage, infection, and intensive care unit admission for early preterm births requiring cesarean delivery.
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Affiliation(s)
- Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD.
| | | | - William A Grobman
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jennifer L Bailit
- Department of Obstetrics and Gynecology, MetroHealth Medical Center-Case Western Reserve University, Cleveland, OH
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Steve N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mona Prasad
- Department of Obstetrics and Gynecology, Ohio State University College of Medicine, Columbus, OH
| | - Alan T N Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI
| | - Sean C Blackwell
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX
| | - Jorge E Tolosa
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
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Nelson DB, Doty M, Mcintire DD, Leveno KJ. Rates and precipitating factors for postpartum depression following screening in consecutive births. J Matern Fetal Neonatal Med 2015; 29:2275-9. [DOI: 10.3109/14767058.2015.1083004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Tao W, Grant EN, Craig MG, McIntire DD, Leveno KJ. Continuous Spinal Analgesia for Labor and Delivery: An Observational Study with a 23-Gauge Spinal Catheter. Anesth Analg 2015; 121:1290-4. [PMID: 26273746 DOI: 10.1213/ane.0000000000000903] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The aim of the study was to assess postdural puncture headache, pain relief, motor blockade, and success rate of conversion to cesarean delivery anesthesia of a 23-gauge spinal catheter (Wiley Spinal®) for labor analgesia. METHODS After insertion of the spinal catheter, intrathecal bupivacaine 2.5 mg was administered, followed by patient-controlled intrathecal analgesia (basal infusion of 0.0625% bupivacaine with fentanyl 2 μg/mL at a rate of 2 mL/h, demand bolus 1 mL, lockout interval 20 minutes). Bupivacaine 0.5%, up to 25 mg, was administered via the catheter along with fentanyl 20 μg for cesarean delivery anesthesia, if necessary. The catheter was removed after delivery or after 12 hours, whichever was longer. RESULTS One hundred thirteen women were enrolled. In 12 women (11%), the catheter was not successfully inserted or maintained in position. Continuous spinal analgesia was used in 101 women. Three women (2.6%, 95% confidence interval, 0.7%-8.1%) developed postdural puncture headache. There were 83 spontaneous, 12 operative vaginal, and 18 cesarean deliveries. Of the 18 cesarean deliveries, 16 had continuous spinal analgesia when the decision was made to perform a cesarean delivery; conversion from labor analgesia to cesarean anesthesia was successful in 15 women (94%, 95% confidence interval, 67.7%-99.7%). CONCLUSIONS The 23-gauge spinal catheter can be used for analgesia for labor. It can also be converted to surgical anesthesia for cesarean deliveries. Further studies are warranted to determine whether the spinal catheter will be a useful addition to the neuraxial techniques available for obstetric anesthesia care.
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Affiliation(s)
- Weike Tao
- From the *Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas; and †Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
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Duryea EL, McIntire DD, Leveno KJ. The rate of preterm birth in the United States is affected by the method of gestational age assignment. Am J Obstet Gynecol 2015; 213:231.e1-5. [PMID: 25935778 DOI: 10.1016/j.ajog.2015.04.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/06/2015] [Accepted: 04/27/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The objective of the study was to examine the rate of preterm birth in the United States using 2 different methods of gestational age assignment and determine which method more closely correlates with the known morbidities associated with preterm birth. STUDY DESIGN Using National Center for Health Statistics data from 2012 United States birth certificates, we computed the rate of preterm birth defined as a birth at 36 or fewer completed weeks with gestational age assigned using the obstetric estimate as specified in the revised birth certificate. This rate was then compared with the rate when gestational age is calculated using the last menstrual period alone. The rates of neonatal morbidities associated with preterm birth were examined for each method of assigning gestational age. RESULTS The rate of preterm birth was 9.7% when the obstetric estimate is used to calculate gestational age, which is significantly different from the rate of 11.5% when gestational age is calculated using the last menstrual period alone. In addition, the neonates identified as preterm by obstetric estimate were more likely to qualify as low birthweight (54% vs 42%; P < .001) and suffer morbidities such as need for assisted ventilation and surfactant use than those identified with the last menstrual period alone. That is to say obstetric estimate is more sensitive and specific for preterm birth by all available markers of prematurity. CONCLUSION The preterm birth rate is 9.7% vs 11.5% and more closely correlates with adverse neonatal outcomes associated with preterm birth when gestational age is assigned using the obstetric estimate. This method of gestational age assignment is currently used by most industrialized nations and should be considered for future reporting of US outcomes.
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Affiliation(s)
- Elaine L Duryea
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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Abstract
BACKGROUND The purpose of this open, cluster randomized controlled trial was to evaluate whether use of a fiber optic-regulated warming mattress would decrease the incidence of hypothermia in women undergoing cesarean delivery. PATIENTS AND METHODS A total of 484 women were randomized via the cluster method on a rotating weekly basis allocating participants to either use of the warming mattress or the standard method of warming at Parkland Hospital (heat-retaining caps, warmed intravenous and irrigation fluids, and warmed blankets). The primary outcome of interest was maternal hypothermia. Surgical site infections and neonatal outcomes were also assessed. RESULTS The incidence of maternal hypothermia at the conclusion of the surgery was decreased in the warming mattress group, 67 versus 80% in the standard method group (p = 0.013). There were no significant differences in maternal hypothermia at delivery or on arrival to the postanesthesia care unit. The difference in surgical site infections and neonatal outcomes were nonsignificant. CONCLUSION Use of a warming mattress reduced the incidence of maternal hypothermia at the conclusion of surgery; however, on admission to the postanesthesia care unit, these effects had dissipated.
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Affiliation(s)
- Erica N Grant
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Margaret G Craig
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Weike Tao
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, Texas
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Bailit JL, Grobman WA, McGee P, Reddy UM, Wapner RJ, Varner MW, Thorp JM, Leveno KJ, Iams JD, Tita ATN, Saade G, Sorokin Y, Rouse DJ, Blackwell SC. Does the presence of a condition-specific obstetric protocol lead to detectable improvements in pregnancy outcomes? Am J Obstet Gynecol 2015; 213:86.e1-86.e6. [PMID: 25659468 DOI: 10.1016/j.ajog.2015.01.055] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/16/2014] [Accepted: 01/29/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We sought to evaluate whether the presence of condition-specific obstetric protocols within a hospital was associated with better maternal and neonatal outcomes. STUDY DESIGN This was a cohort study of a random sample of deliveries performed at 25 hospitals over 3 years. Condition-specific protocols were collected from all hospitals and categorized independently by 2 authors. Data on maternal and neonatal outcomes, as well as data necessary for risk adjustment were collected. Risk-adjusted outcomes were compared according to whether the patient delivered in a hospital with condition-specific obstetric protocols at the time of delivery. RESULTS Hemorrhage-specific protocols were not associated with a lower rate of postpartum hemorrhage or with fewer cases of estimated blood loss >1000 mL. Similarly, in the presence of a shoulder dystocia protocol, there were no differences in the frequency of shoulder dystocia or number of shoulder dystocia maneuvers used. Conversely, preeclampsia-specific protocols were associated with fewer intensive care unit admissions (odds ratio, 0.28; 95% confidence interval, 0.18-0.44) and fewer cases of severe maternal hypertension (odds ratio, 0.86; 95% confidence interval, 0.77-0.96). CONCLUSION The presence of condition-specific obstetric protocols was not consistently shown to be associated with improved risk-adjusted outcomes. Our study would suggest that the presence or absence of a protocol does not matter and regulations to require protocols are not fruitful.
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Affiliation(s)
- Jennifer L Bailit
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH.
| | - William A Grobman
- Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern University, Chicago, IL
| | - Paula McGee
- Department of Obstetrics and Gynecology, George Washington University Biostatistics Center, Washington, DC
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jay D Iams
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH
| | - Alan T N Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - George Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, Alpert Medical School, Brown University, Providence, RI
| | - Sean C Blackwell
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX
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Grobman WA, Bailit JL, Rice MM, Wapner RJ, Reddy UM, Varner MW, Thorp JM, Leveno KJ, Caritis SN, Iams JD, Tita ATN, Saade G, Rouse DJ, Blackwell SC, Tolosa JE, VanDorsten JP. Racial and ethnic disparities in maternal morbidity and obstetric care. Obstet Gynecol 2015; 125:1460-1467. [PMID: 26000518 PMCID: PMC4443856 DOI: 10.1097/aog.0000000000000735] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate whether racial and ethnic disparities exist in obstetric care and adverse outcomes. METHODS We analyzed data from a cohort of women who delivered at 25 hospitals across the United States over a 3-year period. Race and ethnicity was categorized as non-Hispanic white, non-Hispanic black, Hispanic, or Asian. Associations between race and ethnicity and severe postpartum hemorrhage, peripartum infection, and severe perineal laceration at spontaneous vaginal delivery as well as between race and ethnicity and obstetric care (eg, episiotomy) relevant to the adverse outcomes were estimated by univariable analysis and multivariable logistic regression. RESULTS Of 115,502 studied women, 95% were classified by one of the race and ethnicity categories. Non-Hispanic white women were significantly less likely to experience severe postpartum hemorrhage (1.6% non-Hispanic white compared with 3.0% non-Hispanic black compared with 3.1% Hispanic compared with 2.2% Asian) and peripartum infection (4.1% non-Hispanic white compared with 4.9% non-Hispanic black compared with 6.4% Hispanic compared with 6.2% Asian) than others (P<.001 for both). Severe perineal laceration at spontaneous vaginal delivery was significantly more likely in Asian women (2.5% non-Hispanic white compared with 1.2% non-Hispanic black compared with 1.5% Hispanic compared with 5.5% Asian; P<.001). These disparities persisted in multivariable analysis. Many types of obstetric care examined also were significantly different according to race and ethnicity in both univariable and multivariable analysis. There were no significant interactions between race and ethnicity and hospital of delivery. CONCLUSION Racial and ethnic disparities exist for multiple adverse obstetric outcomes and types of obstetric care and do not appear to be explained by differences in patient characteristics or by delivery hospital. LEVEL OF EVIDENCE II.
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Affiliation(s)
- William A Grobman
- Departments of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Case Western Reserve University-MetroHealth Medical Center, Cleveland, Ohio; Columbia University, New York, New York; University of Utah Health Sciences Center, Salt Lake City, Utah; the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the University of Texas Southwestern Medical Center, Dallas, Texas; the University of Pittsburgh, Pittsburgh, Pennsylvania; The Ohio State University, Columbus, Ohio; the University of Alabama at Birmingham, Birmingham, Alabama; the University of Texas Medical Branch, Galveston, Texas; Brown University, Providence, Rhode Island; the University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas; Oregon Health & Science University, Portland, Oregon; the Medical University of South Carolina, Charleston, South Carolina; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Olson G, Weiner SJ, Rouse DJ, Reddy UM, Mercer BM, Varner MW, Leveno KJ, Iams JD, Wapner RJ, Ramin SM, Malone FD, Carpenter MW, O’Sullivan MJ, Dinsmoor MJ, Hankins GDV, Caritis SN. Relation between birth weight and weight and height at the age of 2 in children born preterm. Am J Perinatol 2015; 32:591-8. [PMID: 25730133 PMCID: PMC4485423 DOI: 10.1055/s-0035-1544947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate associations between fetal growth and weight at 2 years in infants born preterm using a customized approach for birth weight. STUDY DESIGN This is a secondary analysis of a multicenter trial that included a 2-year follow-up of children born prematurely. Customized birth weight percentiles were calculated using the Gardosi model for a U.S. population, and the relation between customized percentile and weight and height at 2 years (adjusted for gender using z-score) was determined using regression analysis and by comparing z-scores for children with birth weight <10th versus ≥10th percentile. RESULTS Weight z-score at 2 years was significantly lower in the <10th than in the ≥10th percentile group (median [interquartile range, IQR]: -0.66 [-1.58, -0.01] vs. -0.23 [-1.05, 0.55]; p < 0.001), and remained after adjusting for maternal education (p < 0.001). A similar relationship was noted for height z-score between groups (median [IQR]: -0.56 [-1.29, 0.19] vs. -0.24 [-0.99, 0.37]; p < 0.001). Positive relationships between customized birth weight percentile and weight and height at 2 years were noted (p < 0.001 for both), but were not strong (R (2) = 0.04 and 0.02, respectively). CONCLUSION Customized birth weight percentile is a minor determinant of weight at 2 years among children born preterm.
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Affiliation(s)
- Gayle Olson
- Departments of Obstetrics and Gynecology of the University of Texas Medical Branch Galveston, Galveston, TX
| | - Steven J. Weiner
- George Washington University Biostatistics Center, Washington, DC
| | | | - Uma M. Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, M.D
| | - Brian M. Mercer
- Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH and University of Tennessee, Memphis, TN
| | | | | | | | - Ronald J. Wapner
- Thomas Jefferson University and Drexel University, Philadelphia, PA
| | - Susan M. Ramin
- University of Texas Health Science Center at Houston, Houston, TX
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Horton AL, Lai Y, Rouse DJ, Spong CY, Leveno KJ, Varner MW, Mercer BM, Iams JD, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, O'Sullivan MJ, Hankins GDV, Caritis SN. Effect of magnesium sulfate administration for neuroprotection on latency in women with preterm premature rupture of membranes. Am J Perinatol 2015; 32:387-92. [PMID: 25241107 PMCID: PMC4369158 DOI: 10.1055/s-0034-1387930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study aims to evaluate whether magnesium sulfate administration for neuroprotection prolongs latency in women with preterm premature rupture of membranes (PPROM) between 24 and 31(6/7) weeks' gestation. STUDY DESIGN This is a secondary analysis of a randomized controlled trial of magnesium sulfate for prevention of cerebral palsy. Gravid women with a singleton pregnancy between 24 and 31(6/7) weeks' gestation with PPROM without evidence of labor were randomized to receive magnesium sulfate, administered intravenously as a 6-g bolus followed by a constant infusion of 2 g per hour up to 12 hours, or placebo. Maternal outcomes for this analysis were delivery in less than 48 hours and in less than 7 days from randomization. Neonatal outcomes included a composite of respiratory distress syndrome, interventricular hemorrhage grades 3 or 4, periventricular leukomalacia, sepsis, necrotizing enterocolitis, retinopathy of prematurity, or death. RESULTS A total of 1,259 women were included. The rate of delivery < 48 hours was not different in the magnesium sulfate and the placebo groups (22.2 and 20.7%, p = 0.51). Delivery < 7 days was similar between groups (55.4 and 51.4%, p = 0.16). Median latency was also similar between groups (median [interquartile range], 6.0 days [range, 2.4-13.8 days] and 6.6 days [range, 2.4-15.1 days], p = 0.29). Composite neonatal outcomes did not differ between groups. CONCLUSION Magnesium sulfate administration given for neuroprotection in women with a singleton gestation with PPROM and without labor before 32 weeks does not impact latency.
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Affiliation(s)
- Amanda L Horton
- Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, Illinois
| | - Yinglei Lai
- Department of Obstetrics and Gynecology, George Washington University Biostatistics Center, Washington, District of Columbia
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Catherine Y Spong
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, Ohio
| | - Jay D Iams
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Thomas Jefferson University and Drexel University, Philadelphia, Pennsylvania
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Susan M Ramin
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas
| | - Fergal D Malone
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Mary J O'Sullivan
- Department of Obstetrics and Gynecology, University of Miami, Miami, Florida
| | - Gary D V Hankins
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Steve N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Bailit JL, Grobman W, Zhao Y, Wapner RJ, Reddy UM, Varner MW, Leveno KJ, Caritis SN, Iams JD, Tita AT, Saade G, Sorokin Y, Rouse DJ, Blackwell SC, Tolosa JE, VanDorsten JP, Mercer B, Milluzzi C, Dalton W, Dotson T, McDonald P, Brezine C, McGrail A, Mallett G, Ramos-Brinson M, Roy A, Stein L, Campbell P, Collins C, Jackson N, Dinsmoor M, Senka J, Paychek K, Peaceman A, Talucci M, Zylfijaj M, Reid Z, Leed R, Benson J, Forester S, Kitto C, Davis S, Falk M, Perez C, Hill K, Sowles A, Postma J, Alexander S, Andersen G, Scott V, Morby V, Jolley K, Miller J, Berg B, Thorp J, Dorman K, Mitchell J, Kaluta E, Clark K, Spicer K, Timlin S, Wilson K, Moseley L, Santillan M, Price J, Buentipo K, Bludau V, Thomas T, Fay L, Melton C, Kingsbery J, Benezue R, Simhan H, Bickus M, Fischer D, Kamon T, DeAngelis D, Shubert P, Latimer C, Guzzo L, Johnson F, Gerwig L, Fyffe S, Loux D, Frantz S, Cline D, Wylie S, Iams J, Wallace M, Northen A, Grant J, Colquitt C, Moss J, Salazar A, Acosta A, Hankins G, Hauff N, Palmer L, Lockhart P, Driscoll D, Wynn L, Sudz C, Dengate D, Girard C, Field S, Breault P, Smith F, Annunziata N, Allard D, Silva J, Gamage M, Hunt J, Tillinghast J, Corcoran N, Jimenez M, Ortiz F, Givens P, Rech B, Moran C, Hutchinson M, Spears Z, Carreno C, Heaps B, Zamora G, Seguin J, Rincon M, Snyder J, Farrar C, Lairson E, Bonino C, Smith W, Beach K, Van Dyke S, Butcher S, Thom E, Rice M, McGee P, Momirova V, Palugod R, Reamer B, Larsen M, Williams T, Spong C, Tolivaisa S. Nonmedically indicated induction vs expectant treatment in term nulliparous women. Am J Obstet Gynecol 2015; 212:103.e1-7. [PMID: 24983681 DOI: 10.1016/j.ajog.2014.06.054] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 05/27/2014] [Accepted: 06/23/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study was to compare maternal and neonatal outcomes in nulliparous women with nonmedically indicated inductions at term vs those expectantly treated. STUDY DESIGN Data were obtained from maternal and neonatal charts for all deliveries on randomly selected days across 25 US hospitals over a 3-year period. A low-risk subset of nulliparous women with vertex nonanomalous singleton gestations who delivered 38 0/7 to 41 6/7 weeks were selected. Maternal and neonatal outcomes for nonmedically indicated induction within each week were compared with women who did not undergo nonmedically indicated induction during that week. Multivariable analysis was used to adjust for hospital, maternal age, race/ethnicity, body mass index, cigarette use, and insurance status. RESULTS We found 31,169 women who met our criteria. Neonatal complications were either less frequent with nonmedically indicated induction or no different between groups. Nonmedically indicated induction was associated with less frequent peripartum infections (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.16-0.98) at 38 weeks of gestation and less frequent third- and fourth-degree lacerations (OR, 0.60; 95% CI, 0.42-0.86) and less frequent peripartum infections (OR, 0.66; 95% CI, 0.49-0.90) at 39 weeks of gestation. Nonmedically indicated induction was associated with a longer admission-to-delivery time by approximately 3-4 hours and increased odds of cesarean delivery at 38 (OR, 1.50; 95% CI, 1.08-2.08) and 40 weeks (OR, 1.30; 95% CI, 1.15-1.46) of gestation. CONCLUSION At 39 weeks of gestation, nonmedically indicated induction is associated with lower maternal and neonatal morbidity than women who are expectantly treated.
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Abramovici A, Gandley RE, Clifton RG, Leveno KJ, Myatt L, Wapner RJ, Thorp JM, Mercer BM, Peaceman AM, Samuels P, Sciscione A, Harper M, Saade G, Sorokin Y. Prenatal vitamin C and E supplementation in smokers is associated with reduced placental abruption and preterm birth: a secondary analysis. BJOG 2014. [PMID: 25516497 DOI: 10.1111/1471‐0528.13201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Smoking and pre-eclampsia (PE) are associated with increases in preterm birth, placental abruption and low birthweight. We evaluated the relationship between prenatal vitamin C and E (C/E) supplementation and perinatal outcomes by maternal self-reported smoking status focusing on outcomes known to be impacted by maternal smoking. DESIGN/SETTING/POPULATION A secondary analysis of a multi-centre trial of vitamin C/E supplementation starting at 9-16 weeks in low-risk nulliparous women with singleton gestations. METHODS We examined the effect of vitamin C/E by smoking status at randomisation using the Breslow-Day test for interaction. MAIN OUTCOME MEASURES The trial's primary outcomes were PE and a composite outcome of pregnancy-associated hypertension (PAH) with serious adverse outcomes. Perinatal outcomes included preterm birth and abruption. RESULTS There were no differences in baseline characteristics within subgroups (smokers versus nonsmokers) by vitamin supplementation status. The effect of prenatal vitamin C/E on the risk of PE (P = 0.66) or PAH composite outcome (P = 0.86) did not differ by smoking status. Vitamin C/E was protective for placental abruption in smokers (relative risk [RR] 0.09; 95% CI 0.00-0.87], but not in nonsmokers (RR 0.92; 95% CI 0.52-1.62) (P = 0.01), and for preterm birth in smokers (RR 0.76; 95% CI 0.58-0.99) but not in nonsmokers (RR 1.03; 95% CI 0.90-1.17) (P = 0.046). CONCLUSION In this cohort of women, smoking was not associated with a reduction in PE or the composite outcome of PAH. Vitamin C/E supplementation appears to be associated with a reduction in placental abruption and preterm birth among smokers.
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Affiliation(s)
- A Abramovici
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - R E Gandley
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA, USA
| | - R G Clifton
- Department of Obstetrics and Gynecology, The George Washington University Biostatistics Center, Washington, DC, USA
| | - K J Leveno
- Department of Obstetrics and Gynecology, Southwestern Medical Center, University of Texas, Dallas, TX, USA
| | - L Myatt
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, OH, USA
| | - R J Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - J M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - B M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, USA
| | - A M Peaceman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, USA
| | - P Samuels
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, USA
| | - A Sciscione
- Department of Obstetrics and Gynecology, Drexel University, Philadelphia, PA, USA
| | - M Harper
- Department of Obstetrics and Gynecology, Wake Forest University Health Sciences, Winston-Salem, NC, USA
| | - G Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Y Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
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