The rise in maternal morbidity and mortality has resulted in national and international attention at optimally organizing systems and teams for pregnancy care. Given that maternal morbidity and ...mortality can occur unpredictably in any obstetric setting, specialists in general obstetrics and gynecology along with other primary maternal care providers should be integrally involved in efforts to improve the safety of obstetric care delivery. Quality improvement initiatives remain vital to meeting this goal. The evidence-based utilization of triggers, bundles, protocols, and checklists can aid in timely diagnosis and treatment to prevent or limit the severity of morbidity as well as facilitate interdisciplinary, patient-centered care. The purpose of this document is to summarize the pertinent elements from this forum to assist primary maternal care providers in their utilization and implementation of these safety tools.
Objective The purpose of this study was to calculate first and second trimester reference ranges and within-woman correlations for TSH, free T4, and thyroid antibodies. Study Design TSH, free T4, and ...thyroid antibodies were measured in paired sera from 9562 women in the FaSTER trial of Down syndrome screening. Results The median first trimester TSH (1.05 mIU/L) is lower than the second (1.23 mIU/L); and 98th centile is higher (4.15 vs 3.77 mIU/L). Within-woman paired TSH correlations are moderately strong ( r2 = 0.64). Among women with first trimester TSH values above the 98th centile, second trimester values are over the 95th centile in 68%. Median first trimester free T4 values (1.10 ng/dL) are higher than second (1.01 ng/dL). Paired free T4 measurements correlate weakly ( r2 = 0.23). Among women with first trimester free T4 values below the 2nd centile, second trimester values are below the 5th centile in 32%. Antibody measurements correlate strongly between trimesters (thyroperoxidase r2 = 0.79, thyroglobulin r2 = 0.83). Conclusion TSH and free T4 measurements require gestation-specific reference ranges.
Objective Fetal growth is associated with long-term health yet no appropriate standards exist for the early identification of undergrown or overgrown fetuses. We sought to develop contemporary fetal ...growth standards for 4 self-identified US racial/ethnic groups. Study Design We recruited for prospective follow-up 2334 healthy women with low-risk, singleton pregnancies from 12 community and perinatal centers from July 2009 through January 2013. The cohort comprised: 614 (26%) non-Hispanic whites, 611 (26%) non-Hispanic blacks, 649 (28%) Hispanics, and 460 (20%) Asians. Women were screened at 8w0d to 13w6d for maternal health status associated with presumably normal fetal growth (aged 18-40 years; body mass index 19.0-29.9 kg/m2 ; healthy lifestyles and living conditions; low-risk medical and obstetrical history); 92% of recruited women completed the protocol. Women were randomized among 4 ultrasonography schedules for longitudinal fetal measurement using the Voluson E8 (GE Healthcare, Milwaukee, WI). In-person interviews and anthropometric assessments were conducted at each visit; medical records were abstracted. The fetuses of 1737 (74%) women continued to be low risk (uncomplicated pregnancy, absent anomalies) at birth, and their measurements were included in the standards. Racial/ethnic-specific fetal growth curves were estimated using linear mixed models with cubic splines. Estimated fetal weight (EFW) and biometric parameter percentiles (5th, 50th, 95th) were determined for each gestational week and comparisons made by race/ethnicity, with and without adjustment for maternal and sociodemographic factors. Results EFW differed significantly by race/ethnicity >20 weeks. Specifically at 39 weeks, the 5th, 50th, and 95th percentiles were 2790, 3505, and 4402 g for white; 2633, 3336, and 4226 g for Hispanic; 2621, 3270, and 4078 g for Asian; and 2622, 3260, and 4053 g for black women (adjusted global P < .001). For individual parameters, racial/ethnic differences by order of detection were: humerus and femur lengths (10 weeks), abdominal circumference (16 weeks), head circumference (21 weeks), and biparietal diameter (27 weeks). The study-derived standard based solely on the white group erroneously classifies as much as 15% of non-white fetuses as growth restricted (EFW <5th percentile). Conclusion Significant differences in fetal growth were found among the 4 groups. Racial/ethnic-specific standards improve the precision in evaluating fetal growth.
Background Systematic evaluation and estimation of growth trajectories in twins require ultrasound measurements across gestation that are performed in controlled clinical settings. Currently, there ...are few such data for contemporary populations. There is also controversy about whether twin fetal growth should be evaluated with the use of the same benchmarks as singleton growth. Objectives Our objective was to define the trajectory of fetal growth in dichorionic twins empirically using longitudinal 2-dimensional ultrasonography and to compare the fetal growth trajectories for dichorionic twins with those based on a growth standard that was developed by our group for singletons. Study Design A prospective cohort of 171 women with twin gestations was recruited from 8 US sites from 2012–2013. After an initial sonogram at 11 weeks 0 days–13 weeks 6 days of gestation during which dichorionicity was confirmed, women were assigned randomly to 1 of 2 serial ultrasonography schedules. Growth curves and percentiles were estimated with the use of linear mixed models with cubic splines. Percentiles were compared statistically at each gestational week between the twins and 1731 singletons, after adjustment for maternal age, race/ethnicity, height, weight, parity, employment, marital status, insurance, income, education, and infant sex. Linear mixed models were used to test for overall differences between the twin and singleton trajectories with the use of likelihood ratio tests of interaction terms between spline mean structure terms and twin-singleton indicator variables. Singleton standards were weighted to correspond to the distribution of maternal race in twins. For those ultrasound measurements in which there were significant global tests for differences between twins and singletons, we tested for week-specific differences using Wald tests that were computed at each gestational age. In a separate analysis, we evaluated the degree of reclassification in small for gestational age, which was defined as <10th percentile that would be introduced if fetal growth estimation for twins was based on an unweighted singleton standard. Results Women underwent a median of 5 ultrasound scans. The 50th percentile abdominal circumference and estimated fetal weight trajectories of twin fetuses diverged significantly beginning at 32 weeks of gestation; biparietal diameter in twins was smaller from 34–36 weeks of gestation. There were no differences in head circumference or femur length. The mean head circumference/abdominal circumference ratio was progressively larger for twins compared with singletons beginning at 33 weeks of gestation, which indicated a comparatively asymmetric growth pattern. At 35 weeks of gestation, the average gestational age at delivery for twins, the estimated fetal weights for the 10th, 50th, and 90th percentiles were 1960, 2376, and 2879 g for dichorionic twins, respectively, and 2180, 2567, and 3022 g for the singletons, respectively. At 32 weeks of gestation, the initial week when the mean estimated fetal weight for twins was smaller than that of singletons, 34% of twins would be classified as small for gestational age with the use of a singleton, non-Hispanic white standard. By 35 weeks of gestation, 38% of twins would be classified as small for gestational age. Conclusion The comparatively asymmetric growth pattern in twin gestations, initially evident at 32 weeks of gestation, is consistent with the concept that the intrauterine environment becomes constrained in its ability to sustain growth in twin fetuses. Near term, nearly 40% of twins would be classified as small for gestational age based on a singleton growth standard.
The role of maternal age in twin pregnancy outcomes McLennan, Amelia S., MD; Gyamfi-Bannerman, Cynthia, MD, MSc; Ananth, Cande V., PhD, MPH ...
American journal of obstetrics and gynecology,
07/2017, Letnik:
217, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Background There are limited data on how maternal age is related to twin pregnancy outcomes. Objective The purpose of this study was to assess the relationship between maternal age and risk for ...preterm birth, fetal death, and neonatal death in the setting of twin pregnancy. Study Design This population-based study of US birth, fetal death, and period-linked birth-infant death files from 2007–2013 evaluated neonatal outcomes for twin pregnancies. Maternal age was categorized as 15–17, 18–24, 25–29, 30–34, 35–39, and ≥40 years of age. Twin live births and fetal death delivered at 20–42 weeks were included. Primary outcomes included preterm birth (<34 weeks and <37 weeks), fetal death, and neonatal death at <28 days of life. Analyses of preterm birth at <34 and <37 weeks were adjusted for demographic and medical factors, with maternal age modeled with the use of restricted spline transformations. Results A total of 955,882 twin live births from 2007–2013 were included in the analysis. Preterm birth rates at <34 and <37 weeks gestation were highest for women 15–17 years of age, decreased across subsequent maternal age categories, nadired for women 35–39 years old, and then increased slightly for women ≥40 years old. Risk for fetal death generally decreased across maternal age categories. Risk for fetal death was 39.9 per 1000 live births for women 15–17 years old, 24.2 for women 18–24 years old, 17.8 for women 25–29 years old, 16.4 for women 30–34 years old, 17.2 for women 35–39 years old, and 15.8 for women ≥40 years old. Risk for neonatal death at <28 days was highest for neonates born to women 15–17 years old (10.0 per 1,000 live births), decreased to 7.3 for women 18–24 years old and 5.5 for women 25–29 years old and ranged from 4.3–4.6 for all subsequent maternal age categories. In adjusted models, risk for preterm birth at <34–<37 weeks gestation was not elevated for women in their mid-to-late 30s; however, risk was elevated for women <20 years old and increased progressively with age for women in their 40s. Conclusion Although twin pregnancy is associated with increased risk for most adverse perinatal outcomes, this analysis did not find advanced maternal age to be an additional risk factor for fetal death and infant death. Preterm birth risk was relatively low for women in their late 30s. Risks for adverse outcomes were higher among younger women; further research is indicated to improve outcomes for this demographic group. It may be reasonable to counsel women in their 30s that their age is not a major additional risk factor for adverse obstetric outcomes in the setting of twin pregnancy.
Background In the setting of persistently high risk for maternal death and severe obstetric morbidity, little is known about the relationship between hospital delivery volume and maternal outcomes. ...Objective The objectives of this analysis were (1) to determine maternal risk for severe morbidity during delivery hospitalizations by hospital delivery volume in the United States and (2) to characterize, by hospital volume, the risk for death in the setting of severe obstetric morbidity, a concept known as failure to rescue. Study Design This cohort study evaluated 50,433,539 delivery hospitalizations across the United States from 1998–2010. The main outcome measures were (1) severe morbidity that was defined as a composite of any 1 of 15 diagnoses that are representative of acute organ injury and critical illness and (2) failure to rescue that was defined as death in the setting of severe morbidity. Results The prevalence of severe morbidity rose from 471.2–751.5 cases per 100,000 deliveries from 1998–2010, which was an increase of 59.5%. Failure to rescue was highest in 1998 (1.5%), decreased to 0.6% in 2007, and rose to 0.9% in 2010. In models that were adjusted for comorbid risk and hospital factors, both low and high annualized delivery volume were associated with increased risk for failure to rescue and severe morbidity. However, the relative importance of hospital volume for both outcomes compared with other factors was relatively small. Conclusion Although low-and high-delivery volume are associated with increased risk for both failure to rescue and severe maternal morbidity, other factors, in particular characteristics of individual centers, may be more important in the determination of outcomes.
Objective The objective of the study was to examine the effect of selective fetoscopic laser photocoagulation (SFLP) vs serial amnioreduction (AR) on perinatal mortality in severe twin-twin ...transfusion syndrome (TTTS). Study Design This was a 5 year multicenter, prospective, randomized controlled trial. The primary outcome variable was 30 day postnatal survival of donors and recipients. Results There was no statistically significant difference in 30-day postnatal survival between SFLP or AR treatment for donors at 55% (11 of 20) vs 55% (11 of 20) ( P = 1.0, odds ratio OR 1, 95% confidence interval CI 0.242 to 4.14) or recipients at 30% (6 of 20) vs 45% (9 of 20) ( P = .51, OR 1.88, 95% CI 0.44 to 8.64). There was no difference in 30 day survival of 1 or both twins on a per-pregnancy basis between AR at 75% (15 of 20) and SFLP at 65% (13 of 20) ( P = .73, OR 1.62, 95% CI 0.34 to 8.09). Overall survival (newborns divided by the number of fetuses treated) was not statistically significant for AR at 60% (24 of 40) vs SFLP 45% (18 of 40) ( P = .18, OR 2.01, 95% CI 0.76 to 5.44). There was a statistically significant increase in fetal recipient mortality in the SFLP arm at 70% (14 of 20) vs the AR arm at 35% (7 of 20) ( P = .25, OR 5.31, 95% CI 1.19 to 27.6). This was offset by increased recipient neonatal mortality of 30% (6 of 20) in the AR arm. Echocardiographic abnormality in recipient twin Cardiovascular Profile Score is the most significant predictor of recipient mortality ( P = .055, OR 3.025/point) by logistic regression analysis. Conclusion The outcome of the trial did not conclusively determine whether AR or SFLP is a superior treatment modality. TTTS cardiomyopathy appears to be an important factor in recipient survival in TTTS.
Background Gastroschisis is a severe congenital anomaly the etiology of which is unknown. Research evidence supports attempted vaginal delivery for pregnancies complicated by gastroschisis in the ...absence of obstetric indications for cesarean delivery. Objective The objectives of the study evaluating pregnancies complicated by gastroschisis were to determine the proportion of women undergoing planned cesarean vs attempted vaginal delivery and to provide up-to-date epidemiology on the risk factors associated with this anomaly. Study Design This population-based study of US natality records from 2005 through 2013 evaluated pregnancies complicated by gastroschisis. Women were classified based on whether they attempted vaginal delivery or underwent a planned cesarean (n = 24,836,777). Obstetrical, medical, and demographic characteristics were evaluated. Multivariable log-linear regression models were developed to determine the factors associated with the mode of delivery. Factors associated with the occurrence of the anomaly were also evaluated in log-linear models. Results Of 5985 pregnancies with gastroschisis, 63.5% (n = 3800) attempted vaginal delivery and 36.5% (n = 2185) underwent a planned cesarean delivery. The rate of attempted vaginal delivery increased from 59.7% in 2005 to 68.8% in 2013. Earlier gestational age and Hispanic ethnicity were associated with lower rates of attempted vaginal delivery. Factors associated with the occurrence of gastroschisis included young age, smoking, high educational attainment, and being married. Protective factors included chronic hypertension, black race, and obesity. The incidence of gastroschisis was 3.1 per 10,000 pregnancies and did not increase during the study period. Conclusion Attempted vaginal delivery is becoming increasingly prevalent for women with a pregnancy complicated by gastroschisis. Recommendations from the research literature findings may be diffusing into clinical practice. A significant proportion of women with this anomaly still deliver by planned cesarean, suggesting further reduction of surgical delivery for this anomaly is possible.
Objective To develop and evaluate a method of estimating patient-specific risk for fetal loss by combining maternal characteristics with serum markers. Study Design Data were obtained on 36,014 women ...from the FaSTER trial. Separate likelihood ratios were estimated for significant maternal characteristics and serum markers. Patient-specific risk was calculated by multiplying the incidence of fetal loss by the likelihood ratios for each maternal characteristic and for different serum marker combinations. Results Three hundred eighteen women had fetal loss < 24 weeks (early) and 103 > 24 weeks (late). Clinical characteristics evaluated included maternal age, body mass index, race, parity, threatened abortion, previous preterm delivery, and previous early loss. Serum markers studied as possible predictors of early loss included first-trimester pregnancy-associated plasma protein A and second-trimester alpha-fetoprotein, and unconjugated estriol. A risk assessment for early loss based on all of these factors yielded a 46% detection rate, for a fixed 10% false-positive rate, 39% for 5% and 28% for 1%. The only significant marker for late loss was inhibin A. The detection rate was 27% for a fixed 10% false-positive rate and only increased slightly when clinical characteristics were added to the model. Conclusion Patient-specific risk assessment for early fetal loss using serum markers, with or without maternal characteristics, has a moderately high detection. Patient-specific risk assessment for late fetal loss has low detection rates.
Background The effect of maternal mood disorders on neonatal measurements is not well-defined. The Fetal Growth Studies–Singletons provide a unique opportunity to evaluate the relationship between ...perceived maternal stress and neonatal growth measurements. Objective The purpose of this study was to determine whether perceived maternal stress during pregnancy is associated with anthropometric measurements in the neonate. Study Design This analysis was based on a prospective, multicenter longitudinal study of fetal growth. Women 18-40 years old with a body mass index of 19.0–29.9 kg/m2 were screened at 8+0 to 13+6 weeks gestation for low-risk status associated with optimal fetal growth (eg, healthy, nonsmoking) and underwent serial sonographic examination at 6 study visits throughout gestation. At each study visit, women completed the Cohen’s Perceived Stress Survey, which could have a score that ranges from 0–40. We used a latent class trajectory model to identify distinct groupings (ie, classes) of the Perceived Stress Survey trajectories over pregnancy. Trend analysis was used to determine whether neonatal measurements including birthweight, length, head circumference, and abdominal circumference differed by Perceived Stress Survey class and whether this relationship was modified by maternal race/ethnicity, after adjustment for gestational age at delivery, maternal height, age, and parity. Results Of the 2334 women enrolled in the study, 1948 women had complete neonatal anthropometry and were included in the analysis. Latent class analysis identified 3 Perceived Stress Survey trajectory classes, with mean Perceived Stress Survey scores of 2.82 (low), 7.95 (medium), and 14.80 (high). Neonatal anthropometric measures of birthweight, length, head circumference and abdominal circumference were similar ( P =.78, =.10, =.18, and =.40 respectively), regardless of the participants’ Perceived Stress Survey class. There was no effect modification by maternal race/ethnicity. Conclusion Neonatal measurements did not differ by levels of perceived stress among low-risk pregnant women.
PDF