Oxytocin is a peptide hormone that plays a key role in regulating the female reproductive system, including during labor and lactation. It is produced primarily in the hypothalamus and secreted by ...the posterior pituitary gland. Oxytocin can also be administered as a medication to initiate or augment uterine contractions. To study the effectiveness and safety of oxytocin, previous studies have randomized patients to low- and high-dose oxytocin infusion protocols either alone or as part of an active management of labor strategy along with other interventions. These randomized trials demonstrated that active management of labor and high-dose oxytocin regimens can shorten the length of labor and reduce the incidence of clinical chorioamnionitis. The safety of high-dose oxytocin regimens is also supported by no associated differences in fetal heart rate abnormalities, postpartum hemorrhage, low Apgar scores, neonatal intensive care unit admissions, and umbilical artery acidemia. Most studies reported no differences in the cesarean delivery rates with active management of labor or high-dose oxytocin regimens, thereby further validating its safety. Oxytocin does not have a predictable dose response, thus the pharmacologic effects and the amplitude and frequency of uterine contractions are used as physiological parameters for oxytocin infusion titration to achieve adequate contractions at appropriate intervals. Used in error, oxytocin can cause patient harm, highlighting the importance of precise administration using infusion pumps, institutional safety checklists, and trained nursing staff to closely monitor uterine activity and fetal heart rate changes. In this review, we summarize the physiology, pharmacology, infusion regimens, and associated risks of oxytocin.
To assess the comparative effectiveness and potential harms of cervical ripening in the outpatient compared with the inpatient setting, or different methods of ripening in the outpatient setting ...alone.
Searches for articles in English included MEDLINE, EMBASE, CINAHL, Cochrane Library, ClinicalTrials.gov, and reference lists (up to August 2020).
Using predefined criteria and DistillerSR software, 10,853 citations were dual-reviewed for randomized controlled trials (RCTs) and cohort studies of outpatient cervical ripening using prostaglandins and mechanical methods in pregnant women at or beyond 37 weeks of gestation.
Using prespecified criteria, study data abstraction and risk of bias assessment were conducted by two reviewers, random-effects meta-analyses were conducted and strength of evidence was assessed. We included 30 RCTs and 10 cohort studies (N=9,618) most generalizable to women aged 25-30 years with low-risk pregnancies. All findings were low or insufficient strength of evidence and not statistically significant. Incidence of cesarean delivery was not different for any comparison of inpatient and outpatient settings, or comparisons of different methods in the outpatient setting (most evidence available for single-balloon catheters and dinoprostone). Harms were inconsistently reported or inadequately defined. Differences were not found for neonatal infection (eg, sepsis) with outpatient compared with inpatient dinoprostone, birth trauma (eg, cephalohematoma) with outpatient compared with inpatient single-balloon catheter, shoulder dystocia with outpatient dinoprostone compared with placebo, maternal infection (eg, chorioamnionitis) with outpatient compared with inpatient single-balloon catheters or outpatient prostaglandins compared with placebo, and postpartum hemorrhage with outpatient catheter compared with inpatient dinoprostone. Evidence on misoprostol, hygroscopic dilators, and other outcomes (eg, perinatal mortality and time to vaginal birth) was insufficient.
In women with low-risk pregnancies, outpatient cervical ripening with dinoprostone or single-balloon catheters did not increase cesarean deliveries. Although there were no clear differences in harms when comparing outpatient with inpatient cervical ripening, the certainty of evidence is low or insufficient to draw definitive conclusions.
PROSPERO, CRD42020167406.
To investigate the relationship between body mass index (BMI) and the onset of parturition throughout gestation.
This was a secondary analysis of the Maternal-Fetal Medicine Units Network Preterm ...Prediction Study. Time-to-spontaneous-birth-event (ie, "survival") methods were used to study the association of BMI with the timing of spontaneous onset of labor throughout gestation with indicated births censored at delivery. A Kaplan-Meier estimate of the probability of spontaneous labor was compared with a log rank test across five categories of BMI (kg/m): underweight (less than 18.5), normal weight (18.5-24.99), preobese (25-29.99), obese I (30-34.99), and obese II+ (35 or greater). A proportional hazards model was estimated to compare time to spontaneous onset of labor adjusted for multiple variables known to be associated with the onset of labor.
Normal-weight women (n=1,054) had a median delivery gestational age of 39 3/7 weeks. Obese II+ women (n=178) had a median delivery gestational age 5 days later than normal-weight women (P<.001). Delivery gestational age of preobese (n=866) and obese I (n=548) women was not significantly different from normal-weight women. Underweight women (n=41) had a median delivery gestational age 5 days earlier than normal-weight women (P<.001). Compared with women with normal BMIs, obese II+ women were significantly less likely and underweight women significantly more likely to enter spontaneous labor at all gestational ages. In the multivariable model, BMI was significantly associated with spontaneous onset of labor throughout pregnancy (BMI five-unit adjusted hazard ratio 0.874, 0.829-0.921).
Body mass index is significantly associated with the likelihood of the spontaneous onset of labor at all gestational ages with gestational age at the time of delivery and BMI being inversely related. This novel observation unifies previous reports focusing on the association of overweight and underweight BMIs and preterm and postterm birth and may inform discussions surrounding elective induction of labor at term.
The role of extracellular vesicles (EVs), specifically exosomes, in intercellular communication likely plays a key role in placental orchestration of pregnancy and maternal immune sensing of the ...fetus. While murine models are powerful tools to study pregnancy and maternal-fetal immune interactions, in contrast to human placental exosomes, the content of murine placental and pregnancy exosomes remains largely understudied. Using a recently developed in vitro culture technique, murine trophoblast stem cells derived from B6 mice were differentiated into syncytial-like cells. EVs from the conditioned media, as well as from pregnant and non-pregnant sera, were enriched for exosomes. The RNA composition of these murine trophoblast-derived and pregnancy-associated exosome-enriched-EVs (ExoE-EVs) was determined using RNA-sequencing analysis and expression levels confirmed by qRT-PCR. Differentially abundant miRNAs were detected in syncytial differentiated ExoE-EVs, particularly from the X chromosome cluster (mmu-miR-322-3p, mmu-miR-322-5p, mmu-miR-503-5p, mmu-miR-542-3p, and mmu-miR-450a-5p). These were confirmed to be increased in pregnant mouse sera ExoE-EVs by qRT-PCR analysis. Interestingly, fifteen miRNAs were only present within the pregnancy-derived ExoE-EVs compared to non-pregnant controls. Mmu-miR-292-3p and mmu-miR-183-5p were noted to be some of the most abundant miRNAs in syncytial ExoE-EVs and were also present at higher levels in pregnant versus non-pregnant sera ExoE-EVs. The bioinformatics tool, MultiMir, was employed to query publicly available databases of predicted miRNA-target interactions. This analysis reveals that the X-chromosome miRNAs are predicted to target ubiquitin-mediated proteolysis and intracellular signaling pathways. Knowing the cargo of placental and pregnancy-specific ExoE-EVs as well as the predicted biological targets informs studies using murine models to examine not only maternal-fetal immune interactions but also the physiologic consequences of placental-maternal communication.
Antenatal corticosteroids given prior to preterm deliveries reduce the risk of adverse neonatal outcomes. However, steroid administration in the setting of a viral respiratory infection can worsen ...maternal outcomes. Therefore, the decision to administer corticosteroids must balance the neonatal benefits with the potential harm to the mother if she is infected with the novel coronavirus disease 2019 (COVID-19). This study aimed to determine the gestational ages for which administering antenatal corticosteroids to women at high risk of preterm labor with concurrent COVID-19 infection results in improved combined maternal and infant outcomes.
A decision-analytic model using TreeAge (2020) software was constructed for a theoretical cohort of hospitalized women with COVID-19 in the United States. All model inputs were derived from the literature. Outcomes included maternal intensive care unit (ICU) admission and death, along with infant outcomes of death, respiratory distress syndrome, intraventricular hemorrhage, and neurodevelopmental delay. Quality-adjusted life years (QALYs) were assessed from the maternal and infant perspectives. Sensitivity analyses were performed to determine if the results were robust over a range of assumptions.
In our theoretical cohort of 10,000 women delivering between 24 and 33 weeks of gestation with COVID-19, corticosteroid administration resulted in 2,200 women admitted to the ICU and 110 maternal deaths. No antenatal corticosteroid use resulted in 1,500 ICU admissions and 75 maternal deaths. Overall, we found that corticosteroid administration resulted in higher combined QALYs up to 31 weeks of gestation in all hospitalized patients, and up to 29 weeks of gestation in ICU patients.
Administration of antenatal corticosteroids at less than 32 weeks of gestation for hospitalized patients and less than 30 weeks of gestation for patients admitted to the ICU resulted in higher combined maternal and infant outcomes compared with expectant management for women at high risk of preterm birth with COVID-19 infection. These results can guide clinicians in their counseling and management of these pregnant women.
· Antenatal steroids reduce adverse neonatal outcomes.. · Steroids worsen maternal outcomes in COVID-19.. · Steroids given < 32 weeks result in improved outcomes..
Aplastic anemia is a hematologic condition occasionally presenting during pregnancy. This pathological process is associated with significant maternal and neonatal morbidity and mortality. Obstetric ...and anesthetic management is challenging, and treatment requires a coordinated effort by an interdisciplinary team, in order to provide safe care to these patients. In this review, we describe the current state of the literature as it applies to the complexity of aplastic anemia in pregnancy, focusing on pathophysiologic aspects of the disease in pregnancy, as well as relevant obstetric and anesthetic considerations necessary to treat this challenging problem. A multidisciplinary-team approach to the management of aplastic anemia in pregnancy is necessary to coordinate prenatal care, optimize maternofetal outcomes, and plan peripartum interventions. Conservative transfusion management is critical to prevent alloimmunization. Although a safe threshold-platelet count for neuraxial anesthesia has not been established, selection of anesthetic technique must be evaluated on a case-to-case basis.
Objective
To evaluate the association between marijuana use and a composite adverse pregnancy outcome using biological sampling.
Design
Retrospective cohort study.
Setting
Single tertiary center.
...Population
Young women (13–22 years old) with singleton, non‐anomalous pregnancies delivered from September 2011 to May 2017.
Methods
Exposure was defined as marijuana detected on universal urine toxicology testing or by self‐report. Multivariable logistic regression modelling was used to estimate the effect of any marijuana use on the primary composite outcome. The effect of marijuana exposure was also estimated for self‐reported use, toxicology‐detected use, and multiple use detected by toxicology.
Main outcome measure
The primary composite outcome included spontaneous preterm birth, hypertensive disorders of pregnancy, stillbirth, or small for gestational age.
Results
Of 1206 pregnant young women, 17.5% (n = 211) used marijuana. Among the women who used marijuana, 8.5% (n = 18) were identified by self‐report alone, 63% (n = 133) by urine toxicology alone, and 28.4% (n = 60) by both. Urine toxicology testing results were available for 1092 (90.5%) births. The composite outcome occurred more frequently in pregnancies exposed to marijuana (46 versus 34%, P < 0.001). This remained significant after adjusting for race/ethnicity and tobacco in the multivariable model (adjusted OR 1.50, 95% CI 1.09–2.05). When marijuana exposure was defined by self‐report only, the association with adverse pregnancy outcome became non‐significant (adjusted OR 1.01, 95% CI 0.62–1.64).
Conclusion
In a population of young women with nearly universal biological sampling, marijuana exposure was associated with adverse pregnancy outcomes. The heterogeneity of findings in existing studies evaluating the impact of marijuana on mothers and neonates may result from the incomplete ascertainment of exposure.
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Marijuana use, as detected by universal urine testing, was associated with a composite adverse pregnancy outcome among young mothers.
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Marijuana use, as detected by universal urine testing, was associated with a composite adverse pregnancy outcome among young mothers.
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