Placenta previa-accreta: Risk factors and complications Usta, Ihab M.; Hobeika, Elie M.; Abu Musa, Antoine A. ...
American journal of obstetrics and gynecology,
09/2005, Letnik:
193, Številka:
3
Journal Article, Conference Proceeding
Recenzirano
The purpose of this study was to identify risk factors and complications of placenta previa-accreta (PA).
Patients with placenta previa (n
=
347) delivered over 20 years were reviewed, divided into ...PA (cases, n
=
22) and no accreta (controls, n
=
325), and compared.
Cases were older with a higher incidence of smoking and previous cesarean delivery (CS). Grandmultiparity, recurrent abortions, anterior/central placentae, and low socioeconomic status were similar. PA incidence increased with the number of previous CS: 1.9%, 15.6%, 23.5%, 29.4%, 33.3%, and 50.0% after 0, 1, 2, 3, 4, and 5 previous CS, respectively. Hypertensive disorders (odds ratio OR 13.9, 95%CI 2.1-91.2,
P
=
.006), smoking (OR 3.4, 95%CI 1.1-10.2,
P
=
.031) and previous CS (OR 7.9, 95%CI 1.7-37.4,
P
=
.009) were selected by the stepwise logistic regression analysis as predictors of PA. Cases had a longer hospital stay, a higher estimated blood loss, and need for transfusion. Cesarean hysterectomy and hypogastric artery ligation were only performed in PA cases. The 2 groups had a similar delivery gestational age and neonatal outcome.
Hypertensive disorders, smoking, and previous cesarean are risk factors for accreta in placenta previa patients. Placenta previa-accreta is associated with higher maternal morbidity, but similar neonatal outcome compared with patients with an isolated placenta previa.
Background
In twin pregnancies, the rates of adverse perinatal outcome and subsequent long‐term morbidity are substantial, and mainly result from preterm birth (PTB).
Objectives
To assess the ...effectiveness of progestogen treatment in the prevention of neonatal morbidity or PTB in twin pregnancies using individual participant data meta‐analysis (IPDMA).
Search strategy
We searched international scientific databases, trial registration websites, and references of identified articles.
Selection criteria
Randomised clinical trials (RCTs) of 17–hydroxyprogesterone caproate (17Pc) or vaginally administered natural progesterone, compared with placebo or no treatment.
Data collection and analysis
Investigators of identified RCTs were asked to share their IPD. The primary outcome was a composite of perinatal mortality and severe neonatal morbidity. Prespecified subgroup analyses were performed for chorionicity, cervical length, and prior spontaneous PTB.
Main results
Thirteen trials included 3768 women and their 7536 babies. Neither 17Pc nor vaginal progesterone reduced the incidence of adverse perinatal outcome (17Pc relative risk, RR 1.1; 95% confidence interval, 95% CI 0.97–1.4, vaginal progesterone RR 0.97; 95% CI 0.77–1.2). In a subgroup of women with a cervical length of ≤25 mm, vaginal progesterone reduced adverse perinatal outcome when cervical length was measured at randomisation (15/56 versus 22/60; RR 0.57; 95% CI 0.47–0.70) or before 24 weeks of gestation (14/52 versus 21/56; RR 0.56; 95% CI 0.42–0.75).
Author's conclusions
In unselected women with an uncomplicated twin gestation, treatment with progestogens (intramuscular 17Pc or vaginal natural progesterone) does not improve perinatal outcome. Vaginal progesterone may be effective in the reduction of adverse perinatal outcome in women with a cervical length of ≤25 mm; however, further research is warranted to confirm this finding.
Please cite this paper as: Awwad J, Usta I, Succar J, Musallam K, Ghazeeri G, Nassar A. The effect of maternal fasting during Ramadan on preterm delivery: a prospective cohort study. BJOG ...2012;119:1379–1386.
Objective To determine the effect of fasting during the month of Ramadan on the rate of preterm delivery (PTD).
Design A prospective cohort study of women with singleton pregnancies who elected to fast and matched controls.
Setting Four medical centres in Beirut, Lebanon.
Population Women presenting for prenatal care (20–34 weeks of gestation) during the month of Ramadan, September 2008.
Methods Data were collected prospectively. The frequency of PTD was evaluated in relation to the duration of fasting and the stage of gestation at the time of fasting.
Main outcome measures The primary endpoint was the percentage of pregnant women who had PTD, defined as delivery before 37 completed weeks of gestation.
Results A total of 468 women were approached, of whom 402 were included in the study. There were no differences in smoking history and employment. There was no difference in the proportion of women who had PTD at <37 weeks (10.4% versus 10.4%) or PTD at <32 weeks (1.5% versus 0.5%) in the Ramadan‐fasted group and the controls, respectively. The PTD rate was also similar in those who fasted before or during the third trimester. The mean birthweight was lower (3094 ± 467 g versus 3202 ± 473 g, P = 0.024) and the rate of ketosis and ketonuria was higher in the Ramadan‐fasted women. On multivariate stepwise logistic regression analysis, fasting was not associated with an increased risk of PTD (odds ratio 0.72; 95% confidence interval 0.34–1.54; P = 0.397). The only factor that had a significant effect on the PTD rate was body mass index (odds ratio 0.43; 95% confidence interval 0.20–0.93; P = 0.033).
Conclusions Fasting during the month of Ramadan does not seem to increase the baseline risk of preterm delivery in pregnant women regardless of the gestational age during which this practice is observed.
Objective
To determine whether 17 alpha‐hydroxyprogesterone caproate (17OHPC) prolongs gestation beyond 37 weeks of gestation (primary outcome) and reduces neonatal morbidity (secondary outcome) in ...twin pregnancy.
Design
Randomised controlled double‐blind clinical trial.
Setting
Tertiary‐care university medical centre.
Population
Unselected women with twin pregnancies.
Methods
Participants received weekly injections of 250 mg 17OHPC (n = 194) or placebo (n = 94), from 16–20 to 36 weeks of gestation. Randomisation was performed using the permuted‐block randomisation method. Data were analysed on an intention‐to‐treat basis.
Main outcome measure
Preterm birth (PTB) rate before 37 weeks of gestation.
Results
There were no significant differences in the average gestational age at delivery, or in the rates of PTB before 37, 32, and 28 weeks of gestation, between the two groups. The proportion of very‐low‐birthweight neonates (<1500 g) was significantly lower in the 17OHPC group (7.6%) compared with placebo (14.3%) (relative risk, RR 0.5; 95% confidence interval, 95% CI 0.3–0.9; P = 0.01). Progestogen‐treated neonates had a significantly lower composite neonatal morbidity (19.1%) compared with placebo (30.9%) (odds ratio, OR 0.53; 95% CI 0.31–0.90; P = 0.02), with significantly lower odds for respiratory distress syndrome (14.4 versus 23.4%; OR 0.55; 95% CI 0.31–0.98; P = 0.04), retinopathy of prematurity (1.1 versus 4.6%; OR 0.21; 95% CI 0.05–0.96; P = 0.04), and culture‐confirmed sepsis (3.4 versus 12.8%; OR 0.24; 95% CI 0.10–0.57; P = 0.00).
Conclusions
Intramuscular 17OHPC therapy did not reduce PTB before 37 weeks of gestation in unselected twin pregnancies. Nonetheless, 17OHPC significantly reduced neonatal morbidity parameters and increased birthweight.
Objective To assess whether application of cocoa butter lotion reduces the development of striae gravidarum (SG).
Design Multicentre, double‐blind, randomised and placebo‐controlled trial.
Setting ...Beirut and Tripoli, Lebanon.
Population Nulliparous women presenting for prenatal care.
Methods Nulliparous women presenting in the first trimester were randomly assigned to receive a lotion containing cocoa butter or a placebo lotion. Women were instructed to apply the assigned lotion daily until delivery.
Main outcome measure The development of striae over the abdomen, breasts and thighs postpartum.
Results Of 210 women enrolled, 175 (83%) completed the study. Ninety‐one women received the study lotion and 84 received the placebo. There was no difference in the development of SG (45.1% versus 48.8%; P = 0.730) or the severity of SG between cases and controls. The results did not change when presence of stretch marks at enrolment or compliance with the regimen were taken into account.
Conclusion Topical application of a lotion containing cocoa butter does not appear to reduce the likelihood of developing striae gravidarum.
Design and statistical analysis of observational studies Usta, IM; Awwad, J; Nassar, AH
BJOG : an international journal of obstetrics and gynaecology,
June 2013, 2013-Jun, 2013-06-00, 20130601, Letnik:
120, Številka:
7
Journal Article
OBJECTIVE: The purpose of this study was to compare maternal and neonatal complications in spontaneous versus in vitro fertilization twins.
STUDY DESIGN: Twin gestations that were delivered from 1995 ...to 2000 were reviewed. Cases consisted of 56 in vitro fertilization twins, each of which was matched to two control mothers by age and parity. They were compared regarding various maternal and neonatal complications.
RESULTS: In vitro fertilization twins were more likely to have preterm labor compared with control twins, with no difference in the incidences of pregnancy-induced hypertension, gestational diabetes mellitus, placenta previa, or preterm premature rupture of membranes between the two groups. The cesarean delivery rate was significantly higher in cases of twins who were conceived by in vitro fertilization (76.8% vs 58.0%,
P
=
.026), despite a similar rate of elective cesarean delivery and the incidence of nonvertex twin A in both groups. The preterm delivery rate was significantly higher (67.9% vs 41.1%,
P
=
.002) and the gestational age was significantly lower (35±3 weeks vs 36±3 weeks,
P
=
.043) in cases compared with control subjects. Both twins were, on the average, 230 g lighter in the in vitro fertilization group compared with the control group. However, intrauterine growth restriction was more frequent in the control group (36.6% vs 25%,
P
=
.044). There was a significantly higher incidence of admission to the neonatal intensive care unit, respiratory distress syndrome, a need for mechanical ventilation, and pneumothorax in cases compared with control subjects.
CONCLUSION: When compared with spontaneous twins, in vitro fertilization twins are more likely to be delivered by cesarean delivery and to have a higher incidence of preterm birth and prematurity-related respiratory complications with a longer nursery stay.
This study was undertaken to evaluate the risks and pregnancy outcome in women with prosthetic heart valves on different anticoagulent regimens.
A retrospective chart review of 82 pregnancies in 33 ...women with mechanical valve prostheses at a tertiary referral center from 1987 to 2002. The main outcome measures were major maternal complications and perinatal outcome.
The valve replaced was mitral (60.6%), aortic (18.2%), and both (21.2%). Fifty-four pregnancies (65.9%) resulted in live births, 9 (11.0%) had stillbirths (all on warfarin), and 12 (14.6%) had spontaneous and 7 (8.5%) therapeutic abortions (all on warfarin). The rate of spontaneous abortion was highest in women on warfarin throughout pregnancy
(P < .01). The live birth rate was higher in women on heparin compared with those on warfarin (
P < .01), and in those on heparin/warfarin compared with warfarin alone
(P < .01). There were no maternal deaths; however, 3 patients had mitral valve thrombosis (2 on heparin and 1 on warfarin) necessitating surgery in 1 patient and medical thrombolysis in 2 patients. Hemorrhagic complications occurred in 5 patients, 4 of whom required transfusion.
No single anticoagulant regimen confers complete protection from thromboembolic phenomena in pregnancy. Despite a high maternal morbidity rate, the perinatal outcome is acceptable when pregnancy progresses beyond the first trimester.
Objective To compare patient satisfaction with two routes of misoprostol for term labour induction.
Design Prospective randomised trial.
Setting Tertiary care hospital.
Population A total of 170 ...women admitted at ≥37 weeks of gestation for induction of labour.
Methods Women were randomised to receive 50 micrograms of either sublingual or vaginal misoprostol.
Main outcome measures Patient satisfaction with the route of administration.
Results Despite a similar proportion reporting the labour induction as more painful than expected in both groups, a significantly lower proportion mentioned that the pelvic examinations were very painful in the sublingual group (19.7 versus 36.1%, relative risk RR 0.5, 95% CI 0.3–0.9). Request for analgesia was similar in both groups. More women in the sublingual group thought that the labour experience was better than expected (RR 2.0, 95% CI 1.2–3.3), had a positive attitude towards induction in subsequent pregnancies (RR 1.6, 95% CI 1.1–2.3) and preferred the same route in subsequent pregnancies (RR 3.1, 95% CI 2.2–4.5). Mean number of misoprostol doses, oxytocin augmentation, tachysystole and hyperstimulation, induction to vaginal delivery interval, vaginal delivery after a single dose, vaginal birth within 12 and 24 hours, and caesarean delivery rates were similar in both groups.
Conclusion Sublingual misoprostol (50 micrograms) is associated with a significantly higher patient satisfaction rate compared with a similar dose of vaginal misoprostol. Sublingual administration offers additional choice to women, in particular those wishing to avoid vaginal administration.
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