Evidence-based Cesarean Delivery: Preoperative Management (Part 7)

The preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery (CD). The preoperative time period starts prior to the patient's arrival to the hospital and ends immediately prior to skin incision. Skin cleansing in addition to CDC recommendations of showering with either soap or an antiseptic solution at least the night prior to a procedure has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision is not necessary, however if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours prior and a light meal up to 6 hours prior to CD. Consider giving a preoperative carbohydrate drink to non-diabetic patients up to 2 hours prior to planned CD. Weight-based intravenous (IV) cefazolin is recommended 60 minutes prior to skin incision: 1-2g IV for patients without obesity and 2g for patients with obesity or weight ≥ 80kg. Adjunctive azithromycin 500mg IV is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as may decrease pain scores with movement in the postoperative period. Tranexamic acid (1g in 10-20mL of saline or 10mg/kg IV) is recommended prophylactically for patients at high-risk of postpartum hemorrhage, and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music, active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams, however a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared to right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone-iodine. Placement of an indwelling urinary catheter is not necessary. Non-adhesive drapes are recommended. Cell salvage, while effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all CDs.

Patient Perception of Telemedicine in Maternal-Fetal Medicine

Background: Maternal-fetal medicine (MFM) is a medical subspecialty that cares for patients with high-risk pregnancies. Methods: An IRB-approved survey was offered to patients in MFM offices of a tertiary health care system from March 2022 to May 2022. Demographics and responses to 15 statements about telemedicine were collected via a 5-point Likert scale. Exploratory factor analysis was performed to identify factors affecting patient perception of the telemedicine experience. We sought to examine perception of telemedicine in MFM, identify factors affecting perception, and identify whether specific demographics were associated with patients who view telemedicine appointments favorably. Results: Surveys were completed by 327 of 347 (94%) patients. A total of 233 (71%) patients felt that the telemedicine experience was equal in quality to in-person appointments, and 257 (79%) were open to telemedicine appointments in the future. Exploratory factor analysis yielded two factors: "physician attentiveness" and "technology comfort." Telemedicine was viewed favorably or neutrally for both factors. Education (lower) and marital status (single) were associated with a favorable perception of physician attentiveness. Ethnicity (Hispanic), employment status (employed), and prior telemedicine experience were associated with a favorable perception of technology comfort. Conclusion: Most patients felt the quality of telemedicine appointments was equal to those completed in person. Physician attentiveness and technology comfort affect telemedicine perception. Specific patient demographic characteristics were associated with differing perceptions of telemedicine in MFM. Our findings suggest that telemedicine is positively viewed for MFM and can be used for improving health care delivery efficiency in MFM.

Preeclampsia and Long-term Kidney Outcomes: An Observational Cohort Study

RATIONALE & OBJECTIVE

Preeclampsia is a pregnancy-related complication characterized by acute hypertension and end-organ dysfunction. We evaluated the long-term association between preeclampsia and the risk of developing chronic hypertension and kidney disease.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

27,800 adults with deliveries in the Geisinger Health System between 1996 and 2019.

EXPOSURE

Preeclampsia.

OUTCOME

Hypertension, reduced estimated glomerular filtration rate (eGFR)<60mL/min/1.73m2), and albuminuria>300mg/g.

ANALYTICAL APPROACH

Propensity-score matching and Cox proportional hazards models to evaluate the association between preeclampsia and incident hypertension, reduced eGFR, and albuminuria.

RESULTS

Of 27,800 adults with pregnancies during the study period (mean age, 28 years; 3% Black race), 2,977 (10.7%) had at least 1 pregnancy complicated by preeclampsia. After matching for multiple characteristics, individuals with preeclampsia had a higher risk of developing chronic hypertension (HR, 1.77 [95% CI, 1.45-2.16]), eGFR<60mL/min/1.73m2 (HR, 3.23 [95% CI, 1.64-6.36]), albuminuria (HR, 3.60 [95% CI, 2.38-5.44]), and a subsequent episode of preeclampsia (HR, 24.76 [95% CI, 12.47-48.36]), compared with matched controls without preeclampsia. Overall, postpartum follow-up testing was low. In the first 6 months after delivery, 31% versus 14% of individuals with and without preeclampsia had serum creatinine tests, respectively, and testing for urine protein was the same in both groups, with only 26% having follow-up testing.

LIMITATIONS

Primarily White study population, observational study, reliance on ICD codes for medical diagnosis.

CONCLUSIONS

Individuals with a pregnancy complicated by preeclampsia had a higher risk of hypertension, reduced eGFR, and albuminuria compared with individuals without preeclampsia.

PLAIN-LANGUAGE SUMMARY

Preeclampsia is a significant contributor to perinatal and maternal morbidity and is marked by new-onset hypertension and end-organ damage, including acute kidney injury or proteinuria. To gain insight into the long-term kidney effects of the disease, we compared adults with deliveries complicated by preeclampsia with those without preeclampsia in the Geisinger Health System, while also assessing postpartum testing rates. Our results demonstrate that pregnant individuals with preeclampsia are at a heightened risk for future hypertension, reduced eGFR, and albuminuria, with overall low rates of postpartum testing among both individuals with and without preeclampsia. These findings underscore the need to consider preeclampsia as an important risk factor for the development of chronic kidney disease. Further studies are required to determine optimal postpreeclampsia monitoring strategies.

Comparison of three antepartum risk assessment tools to predict significant postpartum hemorrhage in livebirths

BACKGROUND

To adequately predict significant postpartum hemorrhage (PPH) at hospital admission, we evaluated and compared the accuracy of three risk assessment tools: 1. California Maternal Quality Care Collaborative (CMQCC), 2. American College of Obstetrics and Gynecology Safe Motherhood Initiative (ACOG SMI) and 3. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN).

STUDY DESIGN AND METHODS

This is a retrospective cohort study of people who delivered liveborn infants from January 2018 to June 2021 at our center. Patients with comorbidities necessitating higher hemoglobin values, those who refused blood transfusions, and missing pertinent data were excluded. Significant PPH was defined as a blood transfusion within 48 hours following delivery. Diagnostic statistics were calculated for each tool.

RESULTS

Of the 11,679 included pregnancies, 232 (1.9%) people had significant PPH. Amongst those diagnosed as high-risk by the CMQCC tool, 67/1485 (4.5%) had significant PPH; 62/1672 (3.7%) by the ACOG SMI tool, and 85/1864 (4.6%) by the AWHONN tool had significant PPH. All tools have low sensitivity and high negative predictive values. The area under the receiver operating characteristics curve of the three tools is moderately poor (CMQCC: 0.58, ACOG SMI: 0.55, AWHONN:0.61).

DISCUSSION

Upon admission to labor and delivery, all three studied tools are poor predictors of significant PPH. The development and validation of better PPH risk stratification tools are required with the inclusion of additional important variables.

Pregnancy Outcomes in Patients Enrolled in the Healthy Beginnings Plus Program

OBJECTIVE

To evaluate the effectiveness of enrollment in the Healthy Beginnings Plus Program (HB) on pregnancy outcomes.

DESIGN

Retrospective cohort study of 12,299 singleton pregnancies birthed between January 2007 and December 2018.

SETTING/LOCAL PROBLEM

Individuals of low socioeconomic status are at increased risk for adverse pregnancy outcomes, such as preterm birth (PTB) and low-birth-weight (LBW) neonates. Pennsylvania offers HB to pregnant individuals with Medical Assistance insurance to provide additional psychosocial and obstetric resources to routine prenatal care to minimize risk.

PARTICIPANTS

Individuals with Medical Assistance insurance enrolled in HB (n = 4,645), individuals with Medical Assistance insurance not enrolled in HB (n = 2,874), and individuals with private insurance (n = 4,780).

MEASUREMENTS

Primary outcomes were rates of PTB and LBW neonates. Secondary outcomes included rates of gestational diabetes, gestational hypertension, small-for-gestational-age neonates, and admission to the NICU.

RESULTS

There were no differences in PTB (adjusted OR [aOR] = 0.93, 95% confidence interval [CI] [0.76, 1.13]) or LBW neonates (aOR = 1.06, 95% CI [0.86, 1.31]) between individuals with Medical Assistance enrolled in HB versus those with Medical Assistance insurance not enrolled in HB. Individuals with Medical Assistance enrolled in HB were less likely to develop gestational hypertension compared to individuals with Medical Assistance insurance not enrolled in HB (aOR = 1.41, 95% CI [1.25, 1.59]) and individuals with private insurance (aOR = 0.85, 95% CI [0.76, 0.96]). They also attended more prenatal visits than individuals with Medical Assistance insurance not enrolled in HB (12.0 vs. 14.0, p < .01).

CONCLUSION

Although there was no significant difference between groups for the primary outcomes studied, individuals with Medical Assistance insurance enrolled in HB attended more prenatal visits than those who did not enroll in HB. Similar programs should evaluate outcomes and consider whether changes are needed.

Women's beliefs of pain after childbirth: Critical insight for promoting behavioral strategies to regulate pain and reduce risks for maternal mortality

OBJECTIVE

Promoting behavioral strategies to better regulate pain and decrease the use of prescription pain medications immediately after childbirth is an attractive approach to reduce risks for adverse outcomes associated with the maternal mortality crisis. This study aimed to understand women's beliefs and experiences about pain management to identify important insights for promoting behavioral strategies to control postpartum pain.

METHODS

N = 32 postpartum women participated in a semi-structured interview about beliefs/experiences with managing postpartum pain. Higher- and lower-order themes were coded; descriptive statistics were used to summarize results.

RESULTS

Major trends emerging from the data were: (1) most women used a combination of medications (e.g., oxycodone and acetaminophen) and behavioral strategies (e.g., physical activity) in the hospital (94 %) and at discharge (83 %); (2) some women reported disadvantages like negative side effects of medications and fatigue from physical activity; and (3) some women reported they would have preferred to receive more evidence-based education on behavioral strategies during prenatal visits.

CONCLUSION

Our findings showed that most women were prescribed medications while in the hospital and at discharge, and used non-prescription, behavioral strategies.

PRACTICAL IMPLICATIONS

Future research is needed to test behavioral strategies in randomized clinical trials and clinical care settings to identify impact on reducing adverse maternal health outcomes.

Retrospective application of algorithms to improve identification of pregnancy outcomes from the electronic health record

OBJECTIVE

To improve upon the accuracy of ICD codes for identifying maternal and neonatal outcomes by developing algorithms that incorporate readily available EHR data.

STUDY DESIGN

Algorithms were developed for gestational hypertension (GHTN), pre-eclampsia (PreE), gestational diabetes mellitus (GDM) and were compared to ICD codes and chart review. Accuracy and sensitivity analyses were calculated with their respective 95% confidence limits for each of the comparisons between algorithms, ICD codes alone, and chart review.

RESULTS

Sensitivity of GHTN ICD codes was 8.1% vs. 83.8% for the algorithm when compared to chart review. In comparison to chart review, sensitivity of ICD codes for PreE was 7.5% vs. 71.4% for the algorithm. GDM had similar sensitivity rates for both ICD codes and the algorithm.

CONCLUSION

Application of algorithms, validated by chart review, enhanced capture of several outcomes. Algorithms should be obligatory adjunct tools to the ICD codes for identification of outcomes of interest.

Obstetricians' prescribing practices for pain management after delivery

Aim: To examine postpartum opioid prescribing practices. Materials & methods: Obstetricians were interviewed about opioids: choice of opioid, clinical factors considered when prescribing, thoughts/beliefs about prescribing, and typical counseling provided. Inductive thematic analyses were used to identify themes. Results: A total of 38 interviews were analyzed. Several key points emerged. The choice of opioid, dosing and number of pills prescribed varied widely. The mode of delivery is the primary consideration for prescribing opioids. All providers would prescribe opioids to breastfeeding women. Some providers offered counseling on nonopioid treatment of pain. Discussion: At two large tertiary centers in Pennsylvania, the 38 physicians interviewed wrote 38 unique opioid prescriptions. Patient counseling addressed short-term pain management, but not the chronic overuse of opioids.

Factors that shape pregnant women's perceptions regarding the safety of cannabis use during pregnancy

Background

Cannabis use among pregnant women has increased. We surveyed pregnant women in rural Pennsylvania to examine cannabis use and opinions regarding its safety during pregnancy. We examined associations between challenges of pregnancy (e.g., exhaustion, pain, nausea) and cannabis use.

Methods

A cross-sectional survey was administered to a convenience sample of English-speaking pregnant women receiving prenatal care at Geisinger, May–June 2019. Principal component analysis (PCA) was used to construct three scores (overwhelmed/exhausted, happy/optimistic, and health worries) based on 10 questions regarding common experiences during pregnancy (e.g., nausea/vomiting, pain, exhaustion, mood). A score based on four questions regarding cannabis safety during pregnancy was also constructed.

Results

From a maximum of 300 surveys distributed, 284 were completed (95%). Most participants were white (87%), married (49%) or living with a partner (38%), and had private health insurance (62%). Most women indicated it was unsafe to use alcohol and tobacco products during pregnancy (> 90%), but that proportion dropped to 82% and 63% regarding recreational cannabis and medical cannabis, respectively. Only women with prior cannabis use (23% of sample) continued to do so during pregnancy: 57% of women reporting daily cannabis use prior to pregnancy continued to use cannabis during pregnancy with 33% reporting daily use. Two thirds of users during pregnancy indicated they were self-medicating for: nausea (90%), anxiety (70%), insomnia (30%), and pain management (30%). Many (56%) of the women who used cannabis during pregnancy believed it is safe. Younger women and women who were overwhelmed/exhausted or less happy/optimistic were more likely to believe cannabis use is safe. Women valued healthcare provider advice more than advice from family and friends. Study strengths include a high response rate. Weaknesses include self-report and that is was a convenience sample; however, the demographics of the sample were similar to past studies.

Conclusion

Women with a history of cannabis use, especially daily use, are at risk of continuing during pregnancy and should receive counseling. Younger women and women with greater stressors during pregnancy also are at greater risk. Screening for prior use and for stressors may identify patients that would benefit from enhanced counseling.

A retrospective review of pregnancy outcomes in women with uncomplicated mild to moderate chronic hypertension

OBJECTIVE

To examine pregnancy complications in women with uncomplicated mild-moderate chronic hypertension (CHTN) treated with antihypertensives prior to 20 weeks compared to those not on antihypertensives.

STUDY DESIGN

This retrospective cohort study examined singleton pregnancies of women with mild-moderate CHTN who delivered from 01/2014-3/2019. Pregnancies complicated by hypertension at ≥ 20 weeks, end organ damage, preexisting diabetes mellitus, early-onset gestational diabetes, multifetal gestation, and fetal anomalies were excluded. Adjusted logistic regression analyses were performed for each of the outcomes. Adjusted odds ratios (aOR) were reported along with associated 95% confidence intervals (CI) and p-values.

MAIN OUTCOME MEASURES

Primary outcome was superimposed preeclampsia with severe features. Additional maternal outcomes were superimposed preeclampsia without severe features, severe hypertension, indicated preterm delivery, placental abruption, and mode of delivery. Neonatal outcomes included composite perinatal outcomes (fetal growth restriction, intrauterine fetal demise, and small for gestational age neonate), low birth weight, very low birth weight, admission to the neonatal intensive care unit, and Apgar score <7 at 5-minutes.

RESULTS

345 women were identified: 232 (67.2%) were not taking antihypertensives and 113 (32.8%) were taking ≥1 antihypertensive. There was no significant difference in the primary outcome (p = 0.65; aOR = 0.88; 95% CI 0.51-1.52) among the group taking antihypertensive therapy as compared to those not taking antihypertensives. No statistically significant differences were seen for any of the other secondary maternal or neonatal outcomes.

CONCLUSIONS

Our data supports that the use of antihypertensive therapy in women with mild-moderate CHTN does not reduce the risk of developing superimposed preeclampsia.

Duration of postpartum magnesium sulfate for seizure prophylaxis in women with preeclampsia: a systematic review and meta-analysis

OBJECTIVE

Pregnant women diagnosed with preeclampsia are at increased risk of eclampsia. Magnesium sulfate is the standard of care for maternal seizure prophylaxis. Traditional regimens of magnesium sulfate have continued infusions for 24 h postpartum. More recent evidence suggests shortened courses of postpartum magnesium sulfate. The purpose of this systematic review is to evaluate whether the duration of postpartum magnesium sulfate for seizure prophylaxis in women with preeclampsia affects the incidence of seizures postpartum.

DATA SOURCE

MEDLINE, Cochrane Library, and clinicaltrials.gov were reviewed from inception until 1 May 2020.

METHODS OF STUDY SELECTION

Two hundred and fifty-three studies were reviewed by three individual authors. Inclusion criteria were as follows: published, randomized controlled trials (RCTs) that included pregnant women diagnosed with preeclampsia who received a maintenance infusion of magnesium sulfate in the postpartum period. Studies were excluded if either arm did not provide maintenance dosing of magnesium sulfate in the postpartum period. We also excluded ongoing, unpublished, and non-randomized trials.

RESULTS

Nine RCTs (n = 1369) were included in the systematic review. Data were abstracted and reviewed by three authors, then entered into Review Manager data software. The primary outcome of eclampsia was reported in all nine studies. An eclamptic event occurred in 2/696 women who received <24 h of postpartum magnesium compared to 0/673 events in women who received ≥24 h of postpartum magnesium (RD 0.00, 95% CI -0.01, 0.01; p=.71). Women who received <24 h of postpartum magnesium sulfate had a significantly faster time to ambulation postpartum (MD -10.57, 95% CI -17.43, -3.71; p=.003) and shorter durations of indwelling urinary catheter placement (MD -18.97, 95% CI -34.64, -3.29; p=.02).

CONCLUSIONS

As eclampsia is a rare occurrence, this review was not powered to show a difference in the rate of eclampsia. However, the two cases of eclampsia that were reported occurred in the group of women who received <24 h of postpartum magnesium sulfate. Therefore, the results of this systematic review support continued use of 24 h of postpartum magnesium sulfate for seizure prophylaxis.

Obstetric Physicians' Beliefs and Knowledge on Guidelines and Screening Tools to Reduce Opioid Use After Childbirth

OBJECTIVE

To examine obstetric physicians' beliefs about using professional or regulatory guidelines, opioid risk-screening tools, and preferences for recommending nonanalgesic therapies for postpartum pain management.

METHODS

A qualitative study design was used to conduct semi-structured interviews with obstetric and maternal-fetal medicine physicians (N=38) from two large academic health care institutions in central Pennsylvania. An interview guide was used to direct the discussion about each physicians' beliefs in response to questions about pain management after childbirth.

RESULTS

Three trends in the data emerged from physicians' responses: 1) 71% of physicians relied on their clinical insight rather than professional or regulatory guidelines to inform decisions about pain management after childbirth; 2) although many reported that a standard opioid patient screening tool would be useful to inform clinical decisions about pain management, nearly all (92%) physician respondents reported not currently using one; and 3) 63% thought that nonpharmacologic pain management therapies should be used whenever possible to manage pain after childbirth. Key physician barriers (eg, lack time and evidence, being unaware of how to implement) and patient barriers (eg, take away from other responsibilities, no time or patience) to implementation were also identified.

CONCLUSION

These findings suggest that obstetric physicians' individual beliefs and clinical insight play a key role in pain management decisions for women after childbirth. Practical and scalable strategies are needed to: 1) encourage obstetric physicians to use professional or regulatory guidelines and standard opioid risk-screening tools to inform clinical decisions about pain management after childbirth, and 2) educate physicians and patients about nonopioid and nonpharmacologic pain management options to reduce exposure to prescription opioids after childbirth.

Maternal risk factors associated with persistent placenta previa

INTRODUCTION

Maternal risk factors associated with placenta previa are well documented in the literature. However, there are limited studies identifying maternal characteristics associated with the persistence of placenta previa. The objective of the study was to determine maternal characteristics associated with the persistent placenta previa.

METHODS

A retrospective cohort study was conducted in which 705 pregnant women diagnosed with low-lying placenta or placenta previa between 17 and 24 weeks gestation were identified from a single institution between 2003 and 2017. The primary outcome included persistent placenta previa (i.e., persistent placental tissue within 2 cm of the internal os) at or after 36 weeks 0 days. Those with abnormal placentation (e.g., vasa previa, placenta accreta) or delivery prior to 36 weeks 0 days were excluded. Multivariable logistic regression modeling was utilized to determine significant maternal characteristics associated with persistent placenta previa among women diagnosed with either placenta previa or low-lying placenta.

RESULTS

Women with a prior cesarean delivery were seven times more likely to have persistent placenta previa (odds ratio, 7.0, 95% confidence interval, 3.7-13.1). A history of intrauterine curettage or evacuation in the setting of placenta previa increases the likelihood of persistent placenta previa almost 3-fold (odds ratio, 2.5, 95% confidence interval, 1.3-5.0).

DISCUSSION

To date, our study is the largest, retrospective cohort study assessing maternal risk factors associated with persistent placenta previa; and is the first to detect a statistically significant correlation between a history of intrauterine surgeries and persistent placenta previa.

Comparison of different methods of patient education on preeclampsia: a randomized controlled trial

BACKGROUND

Preeclampsia is a life-threatening condition unique to pregnancy that contributes to maternal mortality worldwide. Delays in diagnosis and treatment are contributing factors for most maternal deaths from preeclampsia. Patients who are educated and knowledgeable regarding this disease process may present earlier for care.

OBJECTIVE

To assess whether two different visual aids are effective methods to educate patients about preeclampsia, and to evaluate the potential impact of these visual aids on patient anxiety.

STUDY DESIGN

Primigravid participants at a tertiary care center were given a survey regarding preeclampsia knowledge 18-25 weeks gestation. Participants were then randomized to preeclampsia education with a graphic card, an educational video, or through routine prenatal care. Participants completed the survey again at 32-37 weeks gestation. We compared the follow-up preeclampsia knowledge score for each type of education as well as the level of anxiety after viewing the video or graphic card.

RESULTS

Recruitment began 9 May 2016 and ceased 18 January 2017. A total of 179 patients were randomized and 150 participants completed the study, with 56 shown the graphic card, 45 shown the educational video, and 49 who had only routine prenatal counseling. The remaining 28 patients were lost to follow up and 1 was withdrawn. There was no significant difference in preeclampsia knowledge score at follow-up. There was no significant difference in anxiety score before and after viewing either educational tool for those randomized to either the graphic card (p = .64) or the video (p = .63).

CONCLUSIONS

There is no additional improvement of patient knowledge retention when patients receive education with a graphic card versus an educational video over routine prenatal counseling. Patient anxiety does not appear to be impacted by preeclampsia education with a graphic card or an educational video.

Comparing Diagnosis of Fetal Growth Restriction and the Potential Impact on Management and Outcomes Using Different Growth Curves

OBJECTIVES

The diagnosis of fetal growth restriction (FGR) is managed with close fetal surveillance and often requires iatrogenic delivery, as there is an associated increased risk of fetal demise. However, there is no standard reference for fetal growth. We sought to compare the intrauterine growth curve of Hadlock et al (Radiology 1991; 181:129-133) to other known growth curves to determine which one best identifies fetuses at risk without overburdening the patient and health care system with unnecessary intervention.

METHODS

We retrospectively reviewed charts of singleton euploid pregnancies with a diagnosis of FGR (per Hadlock) at a tertiary care center from June 2014 to May 2015. We applied the estimated fetal weights from ultrasound at diagnosis of FGR to 4 population-based growth curves by Brenner et al (Am J Obstet Gynecol 1976; 126:555-564), Williams et al (Obstet Gynecol 1982; 59:624-632), Alexander et al (Obstet Gynecol 1996; 87:163-168), and Duryea et al (Obstet Gynecol 2014; 124:16-22) and reassessed the incidence of FGR using each curve. We reviewed pregnancy demographics, risk factors, pregnancy management, and outcomes of FGR cohorts on each curve to evaluate whether poor outcomes may be missed or interventions may be avoided using the population-based curves. A sensitivity analysis was also done to see how well each curve predicted small-for-gestational-age birth weights.

RESULTS

Applying any of the population-based growth curves decreased the number of FGR diagnoses, iatrogenic deliveries, and primary cesarean deliveries. Brenner's growth curve identified the least number of FGR diagnoses at 22 of the 107 identified by Hadlock. Williams' growth curve performed best in the sensitivity analysis with sensitivity of 99% and specificity of 97%. A small number of patients with absent/reversed end-diastolic flow would have been missed by applying the population curves.

CONCLUSIONS

Applying the population-based growth curves instead of Hadlock's for diagnosis of FGR decreases its incidence, therefore decreasing the number of visits for ultrasound and fetal surveillance and the number of iatrogenic deliveries. However, using these curves could miss a few fetuses with increased risk of fetal demise.

Associations Between Maternal Body Mass Index, Gestational Weight Gain, Maternal Complications, and Birth Outcome in Singleton, Term Births in a Largely Non-Hispanic White, Rural Population

Background: In 2009, the Institute of Medicine (IOM) published guidance on gestational weight gain (GWG) modified by body mass index (BMI). GWG outside of IOM recommendations negatively affects birth outcomes and child health. This study examined the relationship between BMI, GWG, birth complications, and birth outcomes in a rural, non-Hispanic white population over 10 years. Materials and Methods: We examined maternal BMI, GWG, birth weight, birth complications, and Apgar score in 18,217 term singleton births from medical records at Geisinger, PA from 2006 to 2015. Primary outcomes were GWG, delivery mode, Apgar score, and infant birth weight. Results: A majority of women (74.2%) had GWG outside of recommendations. Prevalence of cesarean delivery was highest for women with GWG above recommendations regardless of BMI. One in five neonates of obese women with GWG above recommendations had Apgar scores below eight. Although most births were normal for gestational age (88%), underweight women who gained below recommendations had the highest percentage of small for gestational age (SGA) births (10.4%) and obese women who gained above recommendations had the highest percentage of large for gestational age (LGA) births (22.2%). Among women with BMIs above 35 kg/m² and GWG within recommendations, 18.9% of births were LGA. Conclusions: Most pregnant women are not gaining weight within recommendations. GWG outside of IOM recommendations resulted in poorer birth outcomes, particularly in underweight and obese women. Underweight women with GWG below recommendations are at increased risk for SGA neonates. We suggest reducing GWG recommendations for women above 35 kg/m² to decrease LGA births and pregnancy complications.

Short- and Long-Term Growth as a Function of Abnormal Doppler Flow in Growth-Restricted Fetuses

OBJECTIVES: To evaluate short- and long-term growth in fetuses with growth restriction (FGR) and elevated umbilical artery Doppler (UAD) systolic/diastolic (S/D) ratios.

METHODS: In this prospective observational study, two UAD waveforms were obtained from each umbilical artery weekly and were classified as normal or abnormal. Fetal growth was assessed every 3 weeks. Short-term growth was calculated from the first visit with elevated ratios until next growth assessment. Results were grouped by number of initial elevated S/D ratios (maximum, 4). Long-term growth was evaluated by change in estimated fetal weight from diagnosis of FGR to birth weight. Fetuses were grouped by average number of elevated S/D ratios and compared to a reference population of growth restricted fetuses with normal testing.

RESULTS: Of 241 fetuses evaluated, 105 demonstrated elevated S/D ratios. Short-term growth was impaired when fetuses had elevated S/D ratios. Long-term growth was affected when the average number of elevated S/D ratios was ≥1 per visit. Progressive 3 or 4 growth delay was noted as the average number of abnormal S/D ratios increased.

CONCLUSIONS: Short- and long-term fetal growth are affected by elevated UAD S/D ratios. Fetuses with more abnormal values initially and those with a higher average of elevated values over pregnancy demonstrate decreased growth.

Patient preferences for method of cesarean skin closure: secondary outcomes from a randomized trial

Objective: To assess patient preference for sutures or staples for cesarean wound closure.Methods: This is a planned secondary analysis of a randomized controlled trial of 746 women in which suture and staples were compared for cesarean skin closure. Enrolled patients were asked to complete preoperative and postoperative surveys to assess preferred closure. Reasons for expressed preferences were elicited for each patient. Preferences were stratified by a number of cesarean deliveries (CD). We sought to determine if patients had a specific preference for wound closure due to personal experience or a personal belief that one method may be more beneficial with respect to pain and appearance.Results: We surveyed 550 patients preoperatively and 627 postoperatively. Women with a prior CD were more likely to have a skin closure preference compared with women having a primary CD (p < .05). Women who had a prior closure with suture rather than staples were significantly more likely to have a preference for the same wound closure method (p < .01). Avoiding the need for staple removal was the main reason women preferred suture closure, both preoperatively and postoperatively. The higher the number of the previous CD, the greater the preference for future closure with suture over staples (p < .05).Conclusions: Women undergoing cesarean delivery prefer suture as the method for skin closure compared with staples.

A retrospective study of gestational weight gain in relation to the Institute of Medicine's recommendations by maternal body mass index in rural Pennsylvania from 2006 to 2015

Background

In 2009, the Institute of Medicine (IOM) published guidance on gestational weight gain (GWG) modified by maternal pre-pregnancy body mass index (BMI). Estimates indicate that less than half of US pregnant women have GWG within recommendations. This study examined GWG from before (2006–2009) and after (2010–2015) the release of the IOM guidance in a rural, non-Hispanic white population to assess the proportion of women with GWG outside of IOM guidance, whether GWG became more likely to be within IOM guidance after 2010, and identify potential maternal factors associated with GWG outside of recommendations.

Methods

We examined GWG in 18,217 term singleton births between 2006 and 2015 in which maternal pre-pregnancy BMI could be calculated from electronic medical records at Geisinger, PA, and a subset of 12,912 births in which weekly GWG in the third trimester could be calculated. The primary outcome was whether GWG was below, within, or above recommendations based on maternal BMI. The relationships between GWG, maternal BMI, parity, age at conception, gestation length, and maternal blood pressure were examined.

Results

GWG declined with increasing maternal BMI, however, more than 50% of overweight and obese women gained above IOM recommendations. About one of five women gained below recommendations (21.3%) with underweight women the most likely to gain below recommendations (33.0%). The proportion of births with usable data increased after 2010, driven by a higher probability of recording maternal weight. However, the proportion of women who gained below, within or above recommendations did not change over the ten years. GWG above recommendations was associated with higher maternal BMI, lower parity, and longer gestation. GWG below recommendations was associated with lower maternal BMI, higher parity, shorter gestation, and younger age at conception. Maternal blood pressure was higher for GWG outside recommendations.

Conclusions

Despite the publication of IOM recommendations in 2009 and an apparent increase in tracking maternal weight after 2010, GWG in this population did not change between 2006 and 2015. A majority of overweight and obese women gained above recommendations. GWG below recommendations continues to occur, and is prevalent among underweight women.

Patient satisfaction and cosmetic outcome in a randomized study of cesarean skin closure

Objective: To evaluate patient satisfaction and patient and physician assessment of scar appearance after cesarean skin closure with suture versus staples. Methods: Women undergoing cesarean delivery (CD) at ≥23 weeks' gestation via low-transverse skin incisions at three hospitals in the CROSS Consortium were randomized to receive skin closure using subcuticular absorbable suture or nonabsorbable metal staples. The primary outcome of this substudy, patient satisfaction, was assessed by surveys at the postpartum visit using a 10-point Likert scale. Scar outcomes according to patients and trained observers were assessed at the primary research site using the Patient and Observer Scar Assessment Scale (POSAS). The POSAS is comprised of a patient-completed assessment including subjective data such as pain and itchiness, and an observer-completed assessment about cosmetic criteria. Results: Between June 2010 and August 2012, 746 women were randomized; 370 received suture and 376 received staples. Satisfaction data were available for 606 (81%). Complete patient scar assessment data were available for 577 (77%) and complete observer scar assessment data were available for 275 (57% of the 480 planned for evaluation at the primary research site). Demographic data for women in the two groups were similar. Satisfaction with the closure method was higher (superior) among women who received suture closure: median 10 (interquartile range 9, 10) versus 9 (interquartile ranges (IQR) 6, 10); p < .01. The suture group also had higher satisfaction with the scar's appearance at the postpartum visit: median nine (IQR 7, 10) versus 8 (IQR 6, 10); p = .02. Receiving one's preferred closure method was associated with higher patient satisfaction, and wound complications were associated with lower satisfaction. POSAS scores were superior (lower) in the suture group. Patient Scar Assessment Scale scores were median 15 (IQR 10, 25) for sutures versus 20 (IQR 11, 28) for staples; p < .01. Observer Scar Assessment Scale scores were median 12 (IQR 9, 15) for sutures versus 13 (IQR 9, 16) for staples; p = .01. Conclusions: Satisfaction with the closure method, satisfaction with the scar's appearance, and patient and physician assessments of scar cosmesis were all superior in those closed with suture. These results further support the use of sutures for cesarean skin closure.

Prevention of preterm birth with pessary in singletons (PoPPS): randomized controlled trial

OBJECTIVE

To determine if pessary use prevents preterm birth (PTB) in women with singleton pregnancy, with short cervical length (CL) measured on transvaginal sonography (TVS) and without prior spontaneous PTB (sPTB).

METHODS

This was an open-label multicenter randomized trial of asymptomatic women presenting at 18 + 0 to 23 + 6 weeks' gestation with a singleton pregnancy, CL ≤ 25 mm on TVS and no prior sPTB. sPTB included those with spontaneous onset of labor and those with rupture of membranes prior to labor. Subjects were randomized to receive either a Bioteque cup pessary or no pessary. Pessaries were inserted by trained maternal-fetal medicine staff. Vaginal progesterone was recommended to women with CL ≤ 20 mm. The primary outcome was PTB < 37 weeks. A sample size of 121 women in each group (n = 242) was needed to detect a reduction in the primary outcome from 30% in the no-pessary group to 15% in the pessary group. The trial was stopped early before complete enrollment.

RESULTS

Between 17 March 2014 and 29 July 2016, 17 383 women underwent CL measurement on TVS. Of these, 422 (2.4%) had CL ≤ 25 mm and 391 (92.7%) met the full eligibility criteria, of which 122 (31.2%) agreed to randomization. Sixty-one (50%) women were randomized to the pessary group and 61 (50%) to the no-pessary group. Baseline characteristics were similar between the groups. There were no significant differences between the pessary and no-pessary groups in the rate of PTB < 37 weeks (43% vs 40%; relative risk 1.09; 95% CI, 0.71-1.68) or in secondary outcomes, such as rate of PTB < 34 weeks, rate of PTB < 28 weeks, gestational age at delivery, birth weight and rate of composite adverse neonatal outcome.

CONCLUSIONS

Cervical pessary use was not associated with prevention of PTB in women with a singleton pregnancy, short CL on TVS and no prior sPTB in this small, underpowered randomized controlled trial. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Trauma in pregnancy: A review of the Pennsylvania Trauma Systems Foundation database

Objective

The goal of this study is to determine if injury severity score (ISS) of ≥9 and systolic blood pressure (SBP) predict poor maternal/pregnancy outcomes in blunt and penetrating trauma, respectively.

Methods

The Pennsylvania Trauma Systems Foundation database was used to identify pregnant trauma patients. Blunt trauma patients were analyzed with regard to ISS, while penetrating trauma patients were analyzed to determine whether SBP < 90 mmHg was predictive of poor maternal outcome.

Results

Patients with severe blunt injury (ISS ≥ 9) due to motor vehicle accident were less likely to wear seatbelts (51% vs. 63%, p = 0.005), and delivery was required in 17% of these patients as compared to 6% of the less severely injured, and only 6% of those were vaginal deliveries. Severely injured patients were discharged home 68% of the time and 6% died compared to less severely injured patients of which 83% were discharged home and <1% died; all other patients required discharge to a rehabilitation facility. Patients with penetrating trauma and SBP < 90 mmHg on arrival were more likely to require delivery (35% vs. 5%, p < 0.001) and were 14 times more likely to die (58% vs. 4%, p < 0.001) when compared to the normotensive group.

Conclusion

ISS ≥ 9 and SBP < 90 mmHg are predictors for poor outcomes after trauma during pregnancy. Severely injured blunt trauma patients often require surgery and delivery. Patients who present with SBP < 90 after penetrating trauma are more likely to deliver and are 14 times more likely to die.

The impact of minor trauma on pregnancy

Purpose

To determine the impact of a single episode of minor trauma during pregnancy on maternal and fetal outcomes.

Methods

This is a retrospective cohort study of pregnant women who experienced minor trauma at ≥24 weeks gestation between 2004 and 2014. The subjects who experienced minor trauma (minor trauma group) were matched by gestational age at the time of minor trauma, body mass index, and age to a cohort of women who did not experience trauma in pregnancy (control group). The primary obstetrical outcome was preterm delivery and the primary neonatal outcomes were APGAR scores and neonatal intensive care unit admission.

Results

There were no significant differences between the two groups with respect to demographics or other risk factors for preterm delivery. Average gestational age at the time of delivery was 39 weeks regardless of whether a woman experienced minor trauma. Preterm delivery occurred more often in the control group (11.8% versus 7.9%, p = 0.0428) as did the rate of neonatal intensive care unit admissions (8.6% versus 5%, p = 0.0273). A subgroup analysis was performed excluding patients with a medically indicated delivery and there was no difference in the rate of preterm delivery (6.4% in the control group, 4% in the minor trauma group, p-value 0.9052). Among women with a spontaneous preterm delivery, the rates of preterm labor (3.0% control versus 2.0% minor trauma, p-value 0.75) and preterm premature rupture of membranes were found to be similar between the two groups (3.8% control versus 2.0% minor trauma PPROM, p-value 0.75).

Conclusions

One episode of minor trauma in pregnancy does not increase the risk for preterm delivery, premature rupture of membranes, or poor neonatal outcomes.

The effect of the MFM obesity protocol on cesarean delivery rates

BACKGROUND

Obesity in pregnancy has an impact on both the mother and the fetus. To date, no universal protocol has been established to guide the management of pregnancy in obese woman. In April 2011, the Geisinger Maternal-Fetal Medicine Department implemented an obesity protocol in which women meeting the following criteria were delivered by their estimated due dates: (1) class III obese or (2) class II obese with additional diagnoses of a large-for-gestational-age fetus or pregnancy complicated by gestational diabetes or (3) class I obese with large-for-gestational-age and gestational diabetes.

OBJECTIVE

We sought to assess the impact of this protocol on the rate of cesarean deliveries in obese women.

STUDY DESIGN

We performed a retrospective cohort study of 5000 randomly selected women who delivered at Geisinger between January 2009 and September 2013, excluding those who delivered in 2011. The data were stratified into obese and nonobese and divided into before protocol and after protocol. Comparison across all groups was accomplished using Wilcoxon rank sum and Pearson's χ(2) tests. Potential confounders were controlled for using logistic regression.

RESULTS

The cesarean delivery rate in the obese/after protocol group was 10.8% lower than in the obese/before protocol group (42.4% vs 31.6%, respectively; P < .0001). In addition, when controlling for age, race, smoking status, preeclampsia, gestational diabetes, and intrauterine growth restriction, obese women were 37% less likely to have a cesarean delivery after the protocol than they were before (odds ratio, 0.63; 95% confidence interval, 0.52, 0.76, P < .0001).

CONCLUSION

Implementation of a maternal-fetal medicine obesity protocol did not increase the rate of cesarean deliveries in obese women. On the contrary, obese women were less likely to have a cesarean delivery after implementation of the protocol.

Antenatal testing in uncomplicated pregnancies: should testing be initiated after 40 or 41 weeks?

OBJECTIVE

This study aims to compare outcomes of antenatal testing in women who received testing between 40 weeks and 40+6 weeks versus those who received testing at ≥41 weeks.

MATERIALS AND METHODS

This retrospective study included women without maternal comorbidities, who were referred for outpatient antenatal testing for gestational age ≥40 weeks. We compared women who received antenatal testing between 40 and 40+6 weeks (Group 1), to those who were only tested at ≥41 weeks (Group 2).

RESULTS

A total of 827 Group 1 and 244 Group 2 pregnancies were evaluated. One-hundred and eighty-nine (18%) were sent to labor and delivery (L&D) for further evaluation. There were no significant differences between groups in terms of being sent or admitted to labor and delivery, the reason for which women were sent, induction of labor, mode of delivery, neonatal length of stay, or admission to intensive care.

CONCLUSION

Pregnancies tested at 40 weeks were identified as abnormal and sent to L&D at the same rate as those tested at 41 weeks. Therefore, it may be reasonable to initiate fetal surveillance at the estimated date of delivery.

Antibiotic regimens for postpartum endometritis

BACKGROUND

Postpartum endometritis occurs when vaginal organisms invade the endometrial cavity during the labor process and cause infection. This is more common following cesarean birth. The condition warrants antibiotic treatment.

OBJECTIVES

Systematically, to review treatment failure and other complications of different antibiotic regimens for postpartum endometritis.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2014) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomized trials of different antibiotic regimens after cesarean birth or vaginal birth; no quasi-randomized trials were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

The review includes a total of 42 trials, and 40 of these trials contributed data on 4240 participants.Regarding the primary outcomes, seven studies compared clindamycin plus an aminoglycoside versus penicillins and showed fewer treatment failures (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.46 to 0.90). There were more treatment failures in those treated with an aminoglycoside plus penicillin when compared to those treated with gentamycin/clindamycin (RR 2.57, 95% CI 1.48 to 4.46). There were more treatment failures (RR 1.66, 95% CI 1.01 to 2.74) and wound infections (RR 1.88, 95% CI 1.08 to 3.28) in those treated with second or third generation cephalosporins (excluding cephamycins) versus those treated with clindamycin plus gentamycin. In four studies comparing once-daily with thrice-daily dosing of gentamicin, there were fewer failures with once-daily dosing. There were more treatment failures (RR 1.94, 95% CI 1.38 to 2.72) and wound infections (RR 1.88, 95% CI 1.17 to 3.02) in those treated with a regimen with poor activity against penicillin-resistant anaerobic bacteria as compared to those treated with a regimen with good activity against penicillin-resistant anaerobic bacteria. There were no differences between groups with respect to severe complications and no trials reported any maternal deaths.Regarding the secondary outcomes, three studies that compared continued oral antibiotic therapy after intravenous therapy with no oral therapy, found no differences in recurrent endometritis or other outcomes. Four trials that compared clindamycin plus aminoglycoside versus cephalosporins identified fewer wound infections in those treated with clindamycin plus an aminoglycoside (RR 0.53, 95% CI 0.30 to 0.93). There were no differences between groups for the outcomes of allergic reactions. The overall risk of bias was unclear in the most of the studies. The quality of the evidence using GRADE comparing clindamycin and an aminoglycoside with another regimen (compared with cephalosporins or penicillins) was low to very low for therapeutic failure, severe complications, wound infection and allergic reaction.

AUTHORS' CONCLUSIONS

The combination of clindamycin and gentamicin is appropriate for the treatment of endometritis. Regimens with good activity against penicillin-resistant anaerobic bacteria are better than those with poor activity against penicillin-resistant anaerobic bacteria. There is no evidence that any one regimen is associated with fewer side-effects. Following clinical improvement of uncomplicated endometritis which has been treated with intravenous therapy, the use of additional oral therapy has not been proven to be beneficial.

Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery

BACKGROUND

Given the continued rise in cesarean birth rate and the increased risk of surgical site infections after cesarean birth compared with vaginal birth, effective interventions must be established for prevention of surgical site infections. Prophylactic intravenous (IV) antibiotic administration 60 minutes prior to skin incision is recommended for abdominal gynecologic surgery; however, administration of prophylactic antibiotics has traditionally been withheld until after neonatal umbilical cord clamping during cesarean delivery due to the concern for potential transfer of antibiotics to the neonate.

OBJECTIVES

To compare the effects of cesarean antibiotic prophylaxis administered preoperatively versus after neonatal cord clamp on postoperative infectious complications for both the mother and the neonate.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2014) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing maternal and neonatal outcomes following prophylactic antibiotics administered prior to skin incision versus after neonatal cord clamping during cesarean delivery. Cluster-RCTs were eligible for inclusion but none were identified. Quasi-RCT and trials using a cross-over design were not eligible for inclusion in this review. Studies published in abstract form only were eligible for inclusion if sufficient information was available in the report.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed the studies for inclusion, assessed risk of bias, abstracted data and checked entries for accuracy. We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

We included 10 studies (12 trial reports) from which 5041 women contributed data for the primary outcome. The overall risk of bias was low.When comparing prophylactic intravenous (IV) antibiotic administration in women undergoing cesarean delivery, there was a reduction in composite maternal infectious morbidity (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.45 to 0.72, high quality evidence), which was specifically due to the reduction in endometritis (RR 0.54, 95% CI 0.36 to 0.79, high quality evidence) and wound infection (RR 0.59, 95% CI 0.44 to 0.81, high quality evidence) in those that received antibiotics preoperatively as compared to those who received antibiotics after neonatal cord clamping. There were no clear differences in neonatal sepsis (RR 0.76, 95% CI 0.51 to 1.13, moderate quality evidence).There were no clear differences for other maternal outcomes such as urinary tract infection (UTI), cystitis and pyelonephritis (moderate quality evidence), respiratory infection (low quality evidence), or any neonatal outcomes. Maternal side effects were not reported in the included studies.The quality of the evidence using GRADE was high for composite morbidity, endomyometritis, wound infection and neonatal intensive care unit admission, moderate for UTI/cystitis/pyelonephritis and neonatal sepsis, and low for maternal respiratory infection.

AUTHORS' CONCLUSIONS

Based on high quality evidence from studies whose overall risk of bias is low, intravenous prophylactic antibiotics for cesarean administered preoperatively significantly decreases the incidence of composite maternal postpartum infectious morbidity as compared with administration after cord clamp. There were no clear differences in adverse neonatal outcomes reported. Women undergoing cesarean delivery should receive antibiotic prophylaxis preoperatively to reduce maternal infectious morbidities. Further research may be needed to elucidate short- and long-term adverse effects for neonates.

Foley Catheter vs Prostaglandin as Ripening Agent in Pregnant Women With Premature Rupture of Membranes

Context: Although studies support the efficacy of the Foley catheter (FC) as a cervical ripening agent in pregnant women at term with intact membranes, its efficacy has not been well studied in women with premature rupture of membranes (PROM).

Objective: To compare the interval to delivery in women with PROM who underwent induction of labor and cervical ripening with mechanical (FC) vs nonmechanical (prostaglandin [PG]) cervical ripening agents.

Design: Retrospective medical record review at 2 hospitals of pregnant women who delivered between January 2009 and April 2011.

Setting: Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, and Christiana Care Health System in Newark, Delaware.

Patients: Pregnant women with singleton gestations 36 weeks or greater who presented with PROM.

Interventions: Cervical ripening with FC or PG.

Main Outcome Measures: The primary outcome was time from induction until delivery. Secondary outcomes included epidural use, maximum temperature during labor, number of vaginal examinations, occurrence of tachysystole, oxytocin dose, delivery mode, chorioamnionitis, and neonatal Apgar score.

Results: Of 155 medical records of patients who met the inclusion criteria, 33 women underwent cervical ripening with PG (ie, misoprostol) and 122 with FC. The interval to delivery was almost halved in women who underwent cervical ripening with FC compared with misoprostol (736 vs 1354 minutes; P<.01). Compared with the women in the misoprostol group, those in the FC group received a statistically significant higher dose of oxytocin (P<.01). There were no statistically significant differences between the groups with respect to the remaining secondary outcomes. Of note, all of the women who received FC were from Christiana Care Health System, and all women who received misoprostol were from Thomas Jefferson University Hospital.

Conclusion: Foley catheters may help shorten the interval to delivery in women who are candidates for cervical ripening after PROM at or near term. There does not appear to be an increased risk for cesarean delivery or chorioamnionitis in those treated with FC.

Tocolytics for preterm premature rupture of membranes

BACKGROUND

In women with preterm labor, tocolysis has not been shown to improve perinatal mortality; however, it is often given for 48 hours to allow for the corticosteroid effect for fetal maturation. In women with preterm premature rupture of membranes (PPROM), the use of tocolysis is still controversial. In theory, tocolysis may prolong pregnancy in women with PPROM, thereby allowing for the corticosteroid benefit and reducing the morbidity and mortality associated with prematurity.

OBJECTIVES

To assess the potential benefits and harms of tocolysis in women with preterm premature rupture of membranes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (15 January 2014).

SELECTION CRITERIA

We included pregnant women with singleton pregnancies and PPROM (23 weeks to 36 weeks and six days). We included any tocolytic therapy compared to no tocolytic, placebo, or another tocolytic.

DATA COLLECTION AND ANALYSIS

All review authors assessed the studies for inclusion. We extracted and quality assessed data.

MAIN RESULTS

We included eight studies with a total of 408 women. Seven of the studies compared tocolysis to no tocolysis. One study compared nifedipine to terbutaline. Compared to no tocolysis, tocolysis was not associated with a significant effect on perinatal mortality in women with PPROM (risk ratio (RR) 1.67; 95% confidence interval (CI) 0.85 to 3.29). Tocolysis was associated with longer latency (mean difference (MD) 73.12 hours; 95% CI 20.21 to 126.03; three trials of 198 women) and fewer births within 48 hours (average RR 0.55; 95% CI 0.32 to 0.95; six trials of 354 women; random-effects, Tau² = 0.18, I² = 43%) compared to no tocolysis. However, tocolysis was associated with increased five-minute Apgar of less than seven (RR 6.05; 95% CI 1.65 to 22.23; two trials of 160 women) and increased need for ventilation of the neonate (RR 2.46; 95% CI 1.14 to 5.34; one trial of 81 women). In the subgroup analysis comparing betamimetic to no betamimetics, tocolysis was associated with increased latency and borderline significance for chorioamnionitis. Prophylactic tocolysis with PPROM was associated with increased overall latency, without additional benefits for maternal/neonatal outcomes. For women with PPROM before 34 weeks, there was a significantly increased risk of chorioamnionitis in women who received tocolysis. However, neonatal outcomes were not significantly different. There were no significant differences in maternal/neonatal outcomes in subgroup analyses comparing cox inhibitor versus no tocolysis, calcium channel blocker versus betamimetic, antibiotic, corticosteroid or combined antibiotic/corticosteroid.

AUTHORS' CONCLUSIONS

Our review suggests there is insufficient evidence to support tocolytic therapy for women with PPROM, as there was an increase in maternal chorioamnionitis without significant benefits to the infant. However, studies did not consistently administer latency antibiotics and corticosteroids, both of which are now considered standard of care.

Morphine sleep in pregnancy

OBJECTIVES

To determine the incidence of admission in labor after morphine sleep (therapeutic rest), patient characteristics associated with labor, and adverse outcomes associated with treatment.

METHODS

We reviewed medical records of women treated with morphine sleep from December 2005 to December 2009. Variables evaluated included medications used for treatment, cervical examination, maternal demographic characteristics and obstetric history, fetal heart rate patterns, and maternal/neonatal outcomes. These characteristics were compared between those admitted in labor after morphine sleep versus those discharged.

RESULTS

Fifty-eight women received morphine sleep: 36 (62%) were admitted in labor, 17 (29%) were discharged, and 5 (9%) were admitted secondary to category II fetal heart rate tracings. All fetuses had category I fetal heart rate tracings prior to treatment. Median dose of morphine sulfate was 20 mg. Those with effacement > 50% (p < 0.01) and carrying term gestations (p < 0.01) were more likely to be admitted in labor after treatment. There were no adverse maternal outcomes. There were no significant differences in neonatal outcomes.

CONCLUSION

Sixty-two percent of women were admitted in labor after morphine sleep. Admission effacement > 50% and term gestational age were associated with admission in labor. There were no significant differences in maternal or neonatal morbidity in those admitted versus discharged home after treatment with morphine sleep.

Effectiveness of 17-α-hydroxyprogesterone caproate on preterm birth prevention in women with history-indicated cerclage

OBJECTIVE

To determine whether 17-α-hydroxyprogesterone caproate (17P) reduces the incidence of preterm birth in women with a history-indicated cerclage.

STUDY DESIGN

Retrospective cohort study of women who received a cerclage for a prior preterm birth, analyzed based on exposure to 17P. The primary outcome variable was delivery < 35 weeks. Secondary outcomes were preterm birth < 37, 32, 28, and 24 weeks; interval between cerclage placement and delivery; gestational age at delivery; and infant birth weight.

RESULTS

Fourteen women received 17P and 80 did not. Baseline characteristics did not differ between these two groups. Preterm delivery at < 35 weeks did not differ between those who received 17P and those who did not (29% versus 15%, p = 0.46). There were no significant differences between the groups for any other outcome.

CONCLUSION

17P does not appear to have an effect on preterm birth < 35 weeks in women with a history-indicated cerclage.