Background Placental abruption traditionally is defined as the premature separation of the implanted placenta before the delivery of the fetus. The existing clinical criteria of severity rely ...exclusively on fetal (fetal distress or fetal death) and maternal complications without consideration of neonatal or preterm delivery-related complications. However, two-thirds of abruption cases are accompanied by fetal or neonatal complications, including preterm delivery. A clinically meaningful classification for abruption therefore should include not only maternal complications but also adverse fetal and neonatal outcomes that include intrauterine growth restriction and preterm delivery. Objectives The purpose of this study was to define severe placental abruption and to compare serious maternal morbidity profiles of such cases with all other cases of abruption (ie, mild abruption) and nonabruption cases. Study Design We performed a retrospective cohort analysis using the Premier database of hospitalizations that resulted in singleton births in the United States between 2006 and 2012 (n = 27,796,465). Severe abruption was defined as abruption accompanied by at least 1 of the following events: maternal (disseminated intravascular coagulation, hypovolemic shock, blood transfusion, hysterectomy, renal failure, or in-hospital death), fetal (nonreassuring fetal status, intrauterine growth restriction, or fetal death), or neonatal (neonatal death, preterm delivery or small for gestational age) complications. Abruption cases that did not qualify as being severe were classified as mild abruption cases. The morbidity profile included amniotic fluid embolism, pulmonary edema, acute respiratory or heart failure, acute myocardial infarction, cardiomyopathy, puerperal cerebrovascular disorders, or coma. Associations were expressed as rate ratios with 95% confidence intervals that were derived from fitting log-linear Poisson regression models. Results The overall prevalence rate of abruption was 9.6 per 1000, of which two-thirds of cases were classified as being severe (6.5 per 1000). Serious maternal complications occurred in 15.4, 33.3, and 141.7 per 10,000 among nonabruption cases and mild and severe abruption cases, respectively. In comparison with no abruption, the rate ratio for serious maternal complications were 1.52 (95% confidence interval, 1.35–1.72) and 4.29 (95% confidence interval, 4.11–4.47) in women with mild and severe placental abruption, respectively. Rate ratios for the individual complications were 2- to 7-fold higher among severe abruption cases. Furthermore, the rate ratios for serious maternal complications among severe abruption cases compared with mild abruption cases was 3.47 (95% confidence interval, 3.05–3.95). This association was considerably stronger for virtually all maternal complications among cases with severe abruption compared with mild abruption. Annual rates of mild and severe abruption were fairly constant during the study period. Although the maternal complication rate among non-abruption births was stable from 2006-2012, the rate of complications among mild abruption cases dropped from 2006-2008 and then leveled off thereafter. In contrast, the rate of serious complications among severe abruption cases remained fairly stable from 2006-2010 and increased sharply thereafter. Conclusions Severe abruption was associated with a distinctively higher morbidity risk profile compared with the other 2 groups. The clinical characteristics and morbidity profile of mild abruption were more similar to those of women without an abruption. These findings suggest that the definition of severe placental abruption based on the proposed specific criteria is clinically relevant and may facilitate epidemiologic and genetic research.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Placental implantation abnormalities, including placenta previa, placenta accreta, vasa previa, and velamentous cord insertion, can have catastrophic consequences for both mother and fetus, ...especially as pregnancy progresses to term. In these situations, current recommendations for management usually call for an indicated preterm delivery even in asymptomatic patients. However, the recommended gestational age(s) for delivery in asymptomatic patients are empirically determined without consideration of the recent literature regarding the usefulness of specific ultrasound findings to help individualize management. The purpose of this article is to propose literature-supported guidelines to the current opinion-based management of asymptomatic patients with placental implantation abnormalities based on relevant and specific ultrasound findings such as cervical length, distance between the internal cervical os and placenta, and placental edge thickness.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
There is currently no standard national approach to the management of category II fetal heart rate (FHR) patterns, yet such patterns occur in the majority of fetuses in labor. Under such ...circumstances, it would be difficult to demonstrate the clinical efficacy of FHR monitoring even if this technique had immense intrinsic value, since there has never been a standard hypothesis to test dealing with interpretation and management of these abnormal patterns. We present an algorithm for the management of category II FHR patterns that reflects a synthesis of available evidence and current scientific thought. Use of this algorithm represents one way for the clinician to comply with the standard of care, and may enhance our overall ability to define the benefits of intrapartum FHR monitoring.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
We sought to evaluate the extent of the association between placental implantation abnormalities (PIA) and preterm delivery in singleton gestations. We conducted a systematic review of ...English-language articles published from 1980 onward using PubMed, MEDLINE, EMBASE, CINAHL, LILACS, and Google Scholar, and by identifying studies cited in the references of published articles. Search terms were PIA defined as ≥1 of the following: placenta previa, placenta accreta, vasa previa, and velamentous cord insertion. Observational and experimental studies were included for review if data were available regarding any of the aforementioned PIA and regarding gestational age at delivery or preterm delivery. Case reports and case series were excluded. Studies were reviewed and data extracted. The primary outcome was gestational age at delivery or preterm delivery <37 weeks’ gestation. Secondary outcomes included birthweight, 1- and 5-minute Apgar scores, neonatal intensive care unit (NICU) admission, neonatal and perinatal death, and small for gestational age. Of the 1421 studies identified, 79 met the defined criteria; 56 studies were descriptive and 23 were comparative. Based on the descriptive studies, the preterm delivery rates for low-lying/marginal placenta, placenta previa, placenta accreta, vasa previa, and velamentous cord insertion were 26.9%, 43.5%, 57.7%, 81.9%, and 37.5%, respectively. Based on the comparative studies using controls, there was decreased pregnancy duration for every PIA; more specifically, there was an increased risk for preterm delivery in patients with placenta previa (risk ratio RR, 5.32; 95% confidence interval CI, 4.39–6.45), vasa previa (RR, 3.36; 95% CI, 2.76–4.09), and velamentous cord insertion (RR, 1.95; 95% CI, 1.67–2.28). Risks of NICU admissions (RR, 4.09; 95% CI, 2.80–5.97), neonatal death (RR, 5.44; 95% CI, 3.03–9.78), and perinatal death (RR, 3.01; 95% CI, 1.41–6.43) were higher with placenta previa. Perinatal risks were also higher in patients with vasa previa (perinatal death rate RR, 4.52; 95% CI, 2.77–7.39) and velamentous cord insertion (NICU admissions RR, 1.76; 95% CI, 1.68–1.84, small for gestational age RR, 1.69; 95% CI, 1.56–1.82, and perinatal death RR, 2.15; 95% CI, 1.84–2.52). In singleton gestations, there is a strong association between PIA and preterm delivery resulting in significant perinatal morbidity and mortality.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Midtrimester ultrasound is a valuable method for identifying asymptomatic women at risk for spontaneous preterm delivery (PTD). However, response to various treatments (cerclage, ...progestogen) has been variable in the clinical setting. It remains unclear how other biomarkers may be used to guide intervention strategies. Objective We applied an amniotic fluid inflammatory scoring system to determine if the degree of inflammation is associated with intervention efficacy in patients with midtrimester short cervix. Study Design Women carrying a singleton fetus between 16-24 weeks’ gestation with a short cervix (≤25 mm) on transvaginal ultrasound underwent amniocentesis and were assigned to McDonald cerclage, no cerclage, or weekly 17-alpha hydroxyprogesterone caproate (17OHP-C). Our previously described inflammatory risk score (comprised of 14 inflammatory markers) was used to classify patients as high (score ≥8) or low (score <8) risk for inflammation. Gestational age at delivery was compared for each intervention and risk score status. Risk of delivering as a function of the remaining gestation was evaluated using modified Cox proportional hazards models with incorporation of methods to account for both left and right truncation bias. Results Ninety patients were included: 24 were in the nonintervention control group, 51 received cerclage, and 15 received 17OHP-C. Inflammation status at time of sampling influenced the efficacy of the treatment ( P < .001). Compared to the nonintervention control group, in patients with low inflammation (score < 8), both cerclage (adjusted hazard ratio HR, 2.86; 95% confidence interval CI, 1.28–6.37) and 17OHP-C (HR, 3.11; 95% CI, 1.04–9.30) were associated with increased hazard of PTD. In contrast, in patients with high inflammation (score ≥8) both cerclage (HR, 0.22; 95% CI, 0.08–0.65) and 17OHP-C (HR, 0.20; 95% CI, 0.05–0.81) were associated with lower hazard of delivering preterm. Conclusion Cerclage placement or administration of 17OHP-C therapy for midtrimester short cervix for PTD prevention appears beneficial only in the subset of patients with high inflammation. Knowledge of the amniotic fluid inflammatory status may aid in guiding the appropriate therapy for women presenting with midtrimester short cervix who are at increased risk of PTD.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Objective We sought to determine the timing of administration of antenatal corticosteroids (AS) for indicated preterm births and to identify which indications are associated with the most optimal ...timing of administration. Study Design This was a retrospective cohort of patients who received AS in anticipation of indicated preterm birth from 2009 through 2012 at Winthrop University Hospital, Mineola, NY. Medical records of patients who received AS, as identified through the hospital pharmacy database, were reviewed. Patients were included if they had a singleton or twin gestation and they received AS for maternal or fetal indications. Women were excluded if they received AS for spontaneous preterm labor or preterm rupture of membranes. Maternal demographic and obstetrical characteristics were compared between those who received AS ≤7 days vs >7 days from delivery using parametric and nonparametric tests with relative risks and 95% confidence intervals. P <.05 was considered significant. Results In all, 193 patients were included in this study. Median latency from AS administration to delivery was 9 days (range, 0–83); 93 patients (48%) received AS within 7 days of delivery. There were no significant differences between the 2 groups with regards to baseline maternal characteristics. Those delivering within 7 days of AS administration were more likely to have maternal vs fetal indications (84% vs 16%). Conclusion Only 48% of patients with an indication for preterm birth received AS within 7 days of its administration. AS appear to be more optimally timed in the presence of maternal rather than fetal indications.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background The rising cesarean birth rate has drawn attention to risks associated with repeat cesarean birth. Prevention of adhesions with adhesion barriers has been promoted as a way to decrease ...operative difficulty. However, robust data demonstrating effectiveness of such interventions are lacking. Objective We report data from a multicenter trial designed to evaluate the short-term safety and effectiveness of a modified sodium hyaluronic acid (HA)-carboxymethylcellulose (CMC) absorbable for reduction of adhesions following cesarean delivery. Study Design Patients who underwent primary or repeat cesarean delivery were included in this multicenter, single-blinded (patient), randomized controlled trial. Patients were randomized into either HA-CMC (N = 380) or no treatment (N = 373). No other modifications to their treatment were part of the protocol. Short-term safety data were collected following randomization. The location and density of adhesions (primary outcome) were assessed at their subsequent delivery using a validated tool, which can also be used to derive an adhesion score that ranges from 0-12. Results No differences in baseline characteristics, postoperative course, or incidence of complications between the groups following randomization were noted. Eighty patients from the HA-CMC group and 92 controls returned for subsequent deliveries. Adhesions in any location were reported in 75.6% of the HA-CMC group and 75.9% of the controls ( P = .99). There was no significant difference in the median adhesion score; 2 (range 0-10) for the HA-CMC group vs 2 (range 0-8) for the control group ( P = .65). One third of the HA-CMC patients met the definition for severe adhesions (adhesion score >4) compared to 15.5% in the control group ( P = .052). There were no significant differences in the time from incision to delivery ( P = .56). Uterine dehiscence in the next pregnancy was reported in 2 patients in HA-CMC group vs 1 in the control group ( P = .60). Conclusion Although we did not identify any short-term safety concerns, HA-CMC adhesion barrier applied at cesarean delivery did not reduce adhesion formation at the subsequent cesarean delivery.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Objective To examine the association between electronic fetal heart rate monitoring and neonatal and infant mortality, as well as neonatal morbidity. Study Design We used the United States 2004 ...linked birth and infant death data. Multivariable log-binomial regression models were fitted to estimate risk ratio for association between electronic fetal heart rate monitoring and mortality, while adjusting for potential confounders. Results In 2004, 89% of singleton pregnancies had electronic fetal heart rate monitoring. Electronic fetal heart rate monitoring was associated with significantly lower infant mortality (adjusted relative risk, 0.75); this was mainly driven by the lower risk of early neonatal mortality (adjusted relative risk, 0.50). In low-risk pregnancies, electronic fetal heart rate monitoring was associated with decreased risk for Apgar scores <4 at 5 minutes (relative risk, 0.54); in high-risk pregnancies, with decreased risk of neonatal seizures (relative risk, 0.65). Conclusion In the United States, the use of electronic fetal heart rate monitoring was associated with a substantial decrease in early neonatal mortality and morbidity that lowered infant mortality.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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