The patient with obesity represents unique challenges to the medical community and, in the setting of pregnancy, additional risks to both mother and fetus. This document will focus on the risks and ...considerations needed to care for the women with obesity and her fetus during the antepartum, intrapartum, and immediate postpartum stages of pregnancy. Specific attention will be given to pregnancy in the setting of class III and super morbid obesity.
Objective To estimate the association between the lengths of the first stage of labor, mode of delivery, and perinatal outcomes in women undergoing labor induction. Study Design Retrospective cohort ...study of singleton, term pregnancies with labor induction and delivered during the second stage. The length of the first stage was examined by 6-hour intervals as predictors of mode of delivery and perinatal morbidity using χ2 test and multivariable logistic regression analysis. Results There were 3620 women who met study criteria. Compared with women with a first stage between 0-12 hours, women with longer first stages had a higher risk of cesarean delivery during the second stage, up to an adjusted odds ratio of 7.44 in those with a first stage ≥24 hours (95% confidence interval CI, 3.43–16.1). Women with a first stage ≥24 hours also had higher odds of postpartum hemorrhage (adjusted odds ratio aOR, 3.16; 95% CI, 1.73–5.79), chorioamnionitis (aOR, 2.83; 95% CI, 1.19–6.69), and neonatal admission to the intensive care nursery (aOR, 2.03; 95% CI, 1.10–3.74). Conclusion In women who underwent induction of labor, even when a second stage of labor was reached, the risk for cesarean delivery and maternal morbidity remained increased when the length of the first stage was longer than 24 hours. However, in this clinical scenario, the frequency of cesarean delivery remains less than 50%. The decision for surgical intervention thus should not be based on the elapse of time alone.
OBJECTIVE:To compare the risk of gestational hypertension and preeclampsia in pregnancies conceived through standard in vitro fertilization (IVF) using autologous oocytes with pregnancies conceived ...using donated oocytes.
METHODS:We conducted a retrospective, matched cohort study of women undergoing IVF using autologous compared with donor oocytes between 1998 and 2005. Women with live births resulting from oocyte donor pregnancies were matched for age and plurality (singleton or twin) with women undergoing autologous IVF. Primary outcomes were the incidence of preeclampsia or gestational hypertension (with and without proteinuria) in the third trimester. Data on preterm delivery, low birth weight, and embryo cryopreservation were also recorded.
RESULTS:Outcome data were available for 158 pregnancies, including 77 ovum-donor recipient pregnancies and 81 pregnancies using autologous oocytes. There were no differences in age, parity, and gestational type between the two cohorts. The incidence of gestational hypertension and preeclampsia was significantly higher in ovum-donor recipients compared with women undergoing autologous IVF (24.7% compared with 7.4%, P<.01, and 16.9% compared with 4.9%, P=.02, respectively). Ovum-donor recipients were more likely than women undergoing autologous IVF to deliver prematurely (34% compared with 19%). This association remained after controlling for multiple gestation (odds ratio 2.6, 95% confidence interval 1.04–6.3). Sixteen pregnancies from cryopreserved embryos were more likely to have hypertensive disorders of pregnancy (odds ratio 5.0, 95% confidence interval 1.2–20.5).
CONCLUSION:Pregnancies derived from donor oocytes and cryopreserved–thawed embryos may be at a higher risk for hypertensive disorders of pregnancy. These findings inform future research and help counsel women using assisted reproductive technology.
LEVEL OF EVIDENCE:II
Abstract Objective To determine whether 1,5-anhydroglucitol is predictive of neonatal birth weight. Study design A retrospective cohort study including 85 pregnancies complicated by diabetes (Type 1 ...= 37, Type 2 = 24, gestational = 24). Women had simultaneous hemoglobin A1c and 1,5-anhydroglucitol measurements every 4–8 weeks throughout pregnancy until delivery. Neonatal birth weight was evaluated by standardized z-scores. Linear regression analysis was performed to determine an association of 1,5-anhydroglucitol with neonatal birth weight z -score. Results Type 1 diabetic patients had the lowest mean 1,5-anhydroglucitol of 3.5 mcg/mL (SD = 1.6 mcg/mL) and highest mean hemoglobin A1c of 6.5% (SD = 0.74%) compared to gestational diabetic patients who had the highest mean 1,5-anhydroglucitol of 6.7 mcg/mL (SD = 3.8 mcg/mL) and lowest mean hemoglobin A1c of 6.0% (SD = 0.94%). Mean 1,5-anhydroglucitol values were significantly different between diabetes types ( p < 0.01). Mean neonatal birth weight was above population averages for all diabetes classifications, although mean birth weight z -scores did not differ significantly between diabetic types ( p = 0.38). Multivariate linear regression showed a negative association between log-transformed 1,5-anhydroglucitol and birth weight (coefficient −0.82, 95% CI −1.19, −0.46). Conclusion In pregnancies complicated by diabetes, low 1,5-anhydroglucitol was associated with increased neonatal birth weight. 1,5-Anhydroglucitol may be useful in the assessment of glycemic control in pregnancy in addition to A1c.
Maternal serum alpha-fetoprotein is a valuable laboratory test used in pregnant women as an indicator to detect certain clinical abnormalities. These can be grouped into four main categories: fetal ...factors, pregnancy complications, placental abnormalities, and maternal factors. Imaging is an invaluable tool to investigate the various etiologies leading to altered maternal serum alpha-fetoprotein. By reading this article, the radiologist, sonologist, or other health care practitioner should be able to define the probable pathology leading to the laboratory detected abnormal maternal serum levels, thus helping the clinician to appropriately manage the pregnancy and counsel the patient.
Summary Introduction With advances in genitourinary reconstructive surgery, women with exstrophy–epispadias complex (EEC) have improved health and quality of life, and may reach reproductive age and ...consider pregnancy. Despite literature suggesting impaired fertility and higher risk with pregnancy, childbirth is possible. Medical comorbidities, including müllerian anomalies, contribute to increased risk of obstetric and urologic complications during pregnancy. Objectives We reviewed our experience with EEC patients who achieved pregnancy to investigate (1) urological characteristics of women who achieved pregnancy; (2) pregnancy management, complications, and delivery; and (3) neonatal outcomes. We developed recommendations for managing pregnancy in women with EEC. Study design/Results This was a retrospective chart review of 36 female patients with EEC seen at our institution between 1996 and 2013. Female patients less than 18 years, and patients who did not have documented pregnancy were excluded. This resulted in a total of 12 patients with 22 pregnancies. All women with successful pregnancy had bladder exstrophy. The majority had undergone prior bladder augmentation (75%) and were on self-catheterization programs (92%). Thirty-six percent had symptomatic urinary tract infections (UTIs) during pregnancy. Five women had more than one pregnancy. There were four terminations of pregnancy. Of 18 desired pregnancies, there were four spontaneous abortions (SABs) (22%) and 16 live births (78%). The cesarean delivery (CD) rate was 100% (14/14), of which the majority were vertical (classical) uterine incisions with a paramedian skin incision. With the exception of one patient, there were no CD surgical complications. The mean gestational age at delivery was 36 weeks (Range 25 4/7 to 39 4/7 weeks) among eight pregnancies with known gestational age. There were no stillbirths, one neonatal death and no birth defects. Discussion Women with EEC can have successful pregnancies, though at increased risk for preterm delivery and SABs. In our cohort, the rate of SAB is similar to that described in prior studies. Symptomatic UTIs likely due to self-catheterization were common. Cesarean delivery using a paramedian skin incision and classical uterine incision were not associated with major complications in this cohort. Limitations include reliance on retrospective data and small sample size. The strength of this study is the longitudinal detailed management of pregnancies in EEC women by a single team over time. A multidisciplinary approach to providing a continuum of care from pediatrics through adolescence to adulthood optimizes successful transitions, reproductive health, and successful pregnancies. Based on our experience, an algorithm providing guidance for pregnancy management was developed. Table Pregnancy resulting in live birth versus spontaneous abortion or termination. Outcomes of 22 pregnancies in 12 EEC patients Outcome Total pregnancies ( n = 22) Bladder exstrophy pregnancies ( n = 20) Cloacal exstrophy pregnancies ( n = 2) Total pregnancies 22 (100%) 20 2 Spontaneous abortion <24 weeks 4 (18%) 3 (15%) 1 (50%) Terminations 4 (18%) 3 (15%) 1 (50%) Live births 14 (64%) 14 (70%) 0
Black racial designation is the only race for which adjustment is recommended for maternal prenatal serum alpha-fetoprotein (AFP) screening. The objective of this study is to reevaluate the ...relationship between maternal race and maternal serum AFP values in prenatal analyte screening.
This was a single-center retrospective analysis of patients who underwent prenatal analyte screening between January 2007 and December 2020. Nomograms for raw maternal serum AFP values by gestational age were created and compared between patients identified as "Black" and "non-Black" on the laboratory requisition. Multivariable linear regression models were created to evaluate the relationship among gestational age, maternal weight, and maternal race on maternal serum AFP levels. The new models were compared with the laboratory-derived calculations, which used historically determined race adjustments.
A total of 43,997 patients underwent analyte screening, and 27,710 patients had complete data for analysis. Of these, 6% were identified as Black. Black patients had laboratory blood draws at a mean gestational age of 123 days, compared with 120 days in non-Black patients ( P <.001), and had higher maternal weight (mean 170 vs 161 lbs, P <.001). Nomograms for raw maternal serum AFP values did not differ between Black and non-Black patients ( P =.065). When adjusted for gestational age and maternal weight, no difference in maternal serum AFP values was identified between Black and non-Black individuals ( P =.81).
No difference in maternal serum AFP values was identified between Black and non-Black pregnant individuals when adjusted by maternal weight and gestational age at blood draw. These findings suggest that routine race-based adjustment of maternal serum AFP screening should be discontinued.
The objective of this study is to determine placental transfusion blood volumes with intact and cut umbilical cord milking in term newborns.
Sixty women at ≥37 weeks' gestation were enrolled. ...Following delivery, the umbilical cord was immediately clamped and cut to separate the newborn. Either intact umbilical cord milking (I-UCM) of the placental-umbilical cord unit or cut umbilical cord milking (C-UCM) of the cut umbilical cord segment was performed. For I-UCM, the cord underwent milking three or four times while being attached to placental circulation. For C-UCM, a 10, 20, or 30 cm cord segment was cut separately and milked four times. Blood volumes were compared between I-UCM and C-UCM methods.
Mean blood volume with I-UCM (×4) was increased compared to the 30 cm C-UCM technique (48.5 ± 19.0 vs. 24.8 ± 4.0 mL, P < 0.001). For C-UCM, blood volume increased proportionally to cord length and, by the second milking, 98.1 ± 4.5% of blood volume was delivered.
I-UCM provides a greater blood volume than C-UCM. With C-UCM, milking the cord more than twice offers no additional advantage.
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