Trends in Attempted Vaginal Delivery among Pregnancies Complicated by Gastroschisis, 2014 to 2020

OBJECTIVE

 Gastroschisis is a full-thickness congenital defect of the abdominal wall through which intestines and other organs may herniate. In a prior analysis, attempted vaginal delivery with fetal gastroschisis appeared to increase through 2013, although cesarean delivery remained common. The objective of this analysis was to update current trends in attempted vaginal birth among pregnancies complicated by gastroschisis.

STUDY DESIGN

 We performed an updated cross-sectional analysis of live births from 2014 and 2020 using data from the U.S. National Vital Statistics System and evaluated trends in attempted vaginal deliveries among births with gastroschisis. Trends were evaluated using joinpoint regression. We constructed logistic regression models to evaluate the association between demographic and clinical variables and attempted vaginal delivery in the setting of gastroschisis.

RESULTS

 Among 5,355 deliveries with gastroschisis meeting inclusion criteria, attempted vaginal delivery increased significantly from 68.9% to 75.1%, an average annual percent change of 1.7% (95% confidence interval [CI], 0.8-2.5). Among gastroschisis-complicated pregnancies, patients 35 to 39 years old (adjusted odds ratio [aOR], 0.53; 95% CI, 0.37-0.79) and Hispanic race/ethnicity (aOR, 0.69; 95% CI, 0.58-0.62) were at lower likelihood of attempted vaginal delivery in adjusted analyses.

CONCLUSION

 These findings suggest that vaginal delivery continues to increase in the setting of gastroschisis. Further reduction of surgical delivery for this fetal defect may be possible.

KEY POINTS

· Vaginal deliveries increased among gastroschisis pregnancies.. · Hispanic patients were less likely to attempt vaginal delivery.. · Some gastroschisis pregnancies still deliver surgically..

Delivery Outcomes and Postpartum Readmissions Associated with Ehlers-Danlos Syndrome

OBJECTIVE

 Given that updated estimates of Ehlers-Danlos syndrome and risks for obstetric complications including postpartum readmission may be of public health significance, we sought to analyze associated obstetric trends and outcomes in a nationally representative population.

STUDY DESIGN

 The 2016 to 2020 Nationwide Readmissions Database was used for this retrospective cohort study. Delivery hospitalizations to women aged 15 to 54 with and without Ehlers-Danlos syndrome were identified. Temporal trends in Ehlers-Danlos syndrome diagnoses during delivery hospitalizations were analyzed using joinpoint regression to estimate the average annual percent change with 95% confidence intervals (CIs). To determine whether adverse obstetric outcomes during the delivery were associated with Ehlers-Danlos syndrome, unadjusted and adjusted logistic regression models were fit with unadjusted (odds ratio [OR]) and adjusted ORs with 95% CIs as measures of association. In addition to analyzing adverse delivery outcomes, risk for 60-day postpartum readmission was analyzed.

RESULTS

 An estimated 18,214,542 delivery hospitalizations were included of which 7,378 (4.1 per 10,000) had an associated diagnosis of Ehlers-Danlos syndrome. Ehlers-Danlos syndrome diagnosis increased from 2.7 to 5.2 per 10,000 delivery hospitalization from 2016 to 2020 (average annual percent change increase of 16.1%, 95% CI: 9.4%, 23.1%). Ehlers-Danlos syndrome was associated with increased odds of nontransfusion severe maternal morbidity (OR: 1.84, 95% CI: 1.38, 2.45), cervical insufficiency (OR: 2.14, 95% CI: 1.46, 3.13), postpartum hemorrhage (OR: 1.41, 95% CI: 1.17, 1.68), cesarean delivery (OR: 1.26, 95% CI: 1.17, 1.36), and preterm delivery (OR: 1.35, 95% CI: 1.16, 1.56). Estimates for transfusion, placental abruption, and placenta previa did not differ significantly. Risk for 60-day postpartum readmission was 3.0% among deliveries with Ehlers-Danlos (OR: 1.76, 95% CI: 1.37, 2.25).

CONCLUSION

 Ehlers-Danlos syndrome diagnoses approximately doubled over the 5-year study period and was associated with a range of adverse obstetric outcomes and complications during delivery hospitalizations as well as risk for postpartum readmission.

KEY POINTS

· Ehlers-Danlos syndrome diagnoses approximately doubled over the 5-year study period.. · Ehlers-Danlos was associated with a range of adverse obstetric outcomes.. · Ehlers-Danlos was associated with increased readmission risk..

Low-dose aspirin and racial disparities in spontaneous preterm delivery in low-risk individuals

BACKGROUND

Preterm birth is a leading cause of perinatal morbidity and mortality. There are significant racial disparities in the rates of preterm delivery in the United States, with Black individuals at disproportionately higher risk than their White counterparts. Although low-dose aspirin is currently under investigation for reducing the rates of preterm delivery, limited data are available on how the use of low-dose aspirin might affect racial and ethnic disparities in the rates of preterm delivery.

OBJECTIVE

Our group and others have shown that low-dose aspirin decreases spontaneous preterm delivery in low-risk parturients. This study aimed to examine whether the relationship between low-dose aspirin and the risk of spontaneous preterm delivery is modified by race and ethnicity.

STUDY DESIGN

This was a secondary analysis of a randomized clinical trial examining low-dose aspirin for preeclampsia prevention in low-risk nulliparous individuals. The parent trial defined low risk as the absence of preexisting hypertension or other medical comorbidities. Participants received 60-mg aspirin or placebo between 13 and 25 weeks of gestation. Here, multiple pregnancies, fetal anomalies, terminations or abortions at <20 weeks of gestation, and participants with previous miscarriages were excluded. Our exposure, race and ethnicity, was self-reported in the parent trial and categorized as non-Hispanic White, Hispanic, non-Hispanic Black, and other. The primary outcome was spontaneous preterm delivery at <34 weeks of gestation; the secondary outcomes included spontaneous preterm delivery at <37 weeks of gestation and all preterm deliveries at <34 and <37 weeks of gestation. Fit logistic regression models were used to examine how the use of low-dose aspirin modified the relationship between race and ethnicity and preterm delivery, adjusting for confounders. Furthermore, sensitivity analyses were performed to compare the rates of preterm delivery by race and ethnicity.

RESULTS

Of note, 2528 of 3171 parent study participants were included in this analysis. Of the participants, 425 (16.8%) were White, 819 (32.4%) were Hispanic, 1265 (50%) were Black, and 19 (0.8%) were other. The baseline characteristics differed among racial and ethnic groups, including maternal age, body mass index, education level, marital status, tobacco and alcohol use, and pregnancy loss. The rate of spontaneous preterm delivery at <34 weeks of gestation was significantly higher in Black participants (2.8%) than in White (1.2%) and Hispanic (1.2%) participants (P=.04). Logistical regression analysis showed that Black race was no longer an independent risk factor for spontaneous preterm delivery at <34 weeks of gestation when controlling for low-dose aspirin (adjusted odds ratio, 1.71; 95% confidence interval, 0.67-4.40). A similar pattern was found for spontaneous preterm delivery at <37 weeks of gestation and preterm delivery at <34 and <37 weeks of gestation. In our sensitivity analyses, spontaneous preterm delivery at <34 weeks of gestation differed by race and ethnicity in the placebo group (P=.01) but did not differ in the low-dose aspirin group (P=.90).

CONCLUSION

The use of low-dose aspirin mitigated racial disparities in spontaneous preterm delivery at <34 weeks of gestation. Additional investigation is warranted to assess the reproducibility of our findings.

Cesarean Delivery Trends Among Patients at Low Risk for Cesarean Delivery in the US, 2000-2019

Importance

Reducing rates of unnecessary cesarean deliveries is both a national and a global health objective. However, there are limited national US data on trends in indications for low-risk cesarean delivery.

Objective

To determine temporal trends in and indications for cesarean delivery among patients at low risk for the procedure over a 20-year period.

Design, Setting, and Participants

This cross-sectional study analyzed 2000 to 2019 delivery hospitalizations using the National Inpatient Sample. Births at low risk for cesarean delivery were identified using a definition from the Society for Maternal-Fetal Medicine and additional criteria. Temporal trends in cesarean birth were analyzed using joinpoint regression to estimate the average annual percentage change (AAPC) with 95% CIs. Data analysis was performed from August 2022 to January 2023.

Exposure

This analysis evaluated cesarean birth trends in a population at low risk for this procedure over a 20-year period.

Main Outcomes and Measures

In addition to overall cesarean birth risk, cesarean deliveries for nonreassuring fetal status and labor arrest were individually analyzed.

Results

Of an estimated 76.7 million delivery hospitalizations, 21.5 million were excluded according to the Society for Maternal-Fetal Medicine definition, and 14.7 million were excluded according to additional criteria. Of the estimated 40 517 867 deliveries included, 12.1% (4 885 716 deliveries) were by cesarean delivery. Cesarean deliveries among patients at low risk for the procedure increased from 9.7% to 13.9% between 2000 and 2009, plateaued, and then decreased from 13.0% to 11.1% between 2012 and 2019. The AAPC for cesarean delivery was 6.4% (95% CI, 5.2% to 7.6%) from 2000 to 2005, 1.2% from 2005 to 2009 (95% CI, -1.2% to 3.7%), and -2.2% from 2009 to 2019 (95% CI, -2.7% to -1.8%). Cesarean delivery for nonreassuring fetal status increased from 3.4% of all deliveries in 2000 to 5.1% in 2019 (AAPC, 2.1%; 95% CI, 1.7% to 2.5%). Cesarean delivery for labor arrest increased from 3.6% in 2000 to a peak of 4.8% in 2009 before decreasing to 2.7% in 2019. Cesarean deliveries for labor arrest increased during the first half of the study (2000-2009) for the active phase (from 1.5% to 2.1%), latent phase (from 1.1% to 1.5%), and second stage (from 0.9% to 1.3%) and then decreased from 2010 to 2019, from 2.1% to 1.7% for the active phase, from 1.5% to 1.2% for the latent phase, and from 1.2% to 0.9% for the second stage.

Conclusions and Relevance

Cesarean deliveries among patients at low risk for cesarean birth appeared to decrease over the latter years of the study period, with cesarean deliveries for labor arrest becoming less common.

Latency Period after Preterm Premature Rupture of Membranes: Singletons versus Twins

OBJECTIVE

Several studies have evaluated the differences in duration of latency and clinical outcomes between singleton and twin pregnancies after preterm premature rupture of membranes (PPROM); however, these data are limited to single-institution analyses and based on small sample sizes. The aim of this study was to assess differences in latency and clinical outcomes in singletons versus twin gestations affected by PPROM in a large, diverse cohort of women.

STUDY DESIGN

This is a secondary analysis of a multicenter trial of magnesium for neuroprotection in women at high risk of preterm birth. Our study included women with PPROM ≥ 24 weeks with singleton and twin gestations. We compared singleton versus twin gestation and our primary outcome was duration of latency after PPROM. Secondary outcomes included selected perinatal and neonatal outcomes including long-term neurodevelopmental outcomes. We fit a linear regression model to assess independent risk factors for latency duration.

RESULTS

Our study included 1,753 women, 1,602 singleton gestations (91%) and 151 twin gestations (9%). The median latency period was significantly shorter in twins (4 [interquartile range, IQR: 1-10] vs. 7 [IQR: 3-16] days, p < 0.001) and gestational age at delivery was significantly earlier (29.3 vs. 30.1 weeks, p = 0.001). Twins were more likely to develop neonatal sepsis (20.1 vs. 13.4%, p = 0.004), but rates of chorioamnionitis and abruption did not differ. Twins were more likely to suffer from adverse short-term neonatal outcomes, had higher rates of neonatal demise (7.9 vs. 3.8%, p = 0.002), and had higher rates of cerebral palsy (7.3 vs. 3.7, p = 0.005). When adjusting for confounders, twin gestation remained an independent risk factor for shorter latency (p < 0.001).

CONCLUSION

Twin gestations affected by PPROM had shorter latency, earlier delivery, and higher rates of short- and long-term morbidity. Despite having longer latency, singleton gestations did not have higher rates of complications associated with expectant management.

KEY POINTS

· Twins affected by PPROM had shorter latency duration and earlier gestational at delivery.. · Twins with PPROM had higher rates of both short- and long-term perinatal morbidity.. · Rates of chorioamnionitis and abruption did not differ between twins and singletons with PPROM..

Trends in and outcomes associated with obstructive sleep apnea during deliveries in the United States, 2000-2019

BACKGROUND

Population-level data on obstructive sleep apnea among pregnant women in the United States and associated risk for adverse outcomes during delivery may be of clinical importance and public health significance.

OBJECTIVE

This study aimed to assess trends in and outcomes associated with obstructive sleep apnea during delivery hospitalizations.

STUDY DESIGN

This repeated cross-sectional study analyzed delivery hospitalizations using the National Inpatient Sample. Temporal trends in obstructive sleep apnea were analyzed using joinpoint regression to estimate the average annual percentage change with 95% confidence intervals. Survey-adjusted logistic regression models were fit to assess the association between obstructive sleep apnea and mechanical ventilation or tracheostomy, acute respiratory distress syndrome, hypertensive disorders of pregnancy, peripartum hysterectomy, pulmonary edema/heart failure, stillbirth, and preterm birth.

RESULTS

From 2000 to 2019, an estimated 76,753,013 delivery hospitalizations were identified, of which 54,238 (0.07%) had a diagnosis of obstructive sleep apnea. During the study period, the presence of obstructive sleep apnea during delivery hospitalizations increased from 0.4 to 20.5 cases per 10,000 delivery hospitalizations (average annual percentage change, 20.6%; 95% confidence interval, 19.1-22.2). Clinical factors associated with obstructive sleep apnea included obesity (4.3% of women without and 57.7% with obstructive sleep apnea), asthma (3.2% of women without and 25.3% with obstructive sleep apnea), chronic hypertension (2.0% of women without and 24.5% with obstructive sleep apnea), and pregestational diabetes mellitus (0.9% of women without and 10.9% with obstructive sleep apnea). In adjusted analyses accounting for obesity, other clinical factors, demographics, and hospital characteristics, obstructive sleep apnea was associated with increased odds of mechanical ventilation or tracheostomy (adjusted odds ratio, 21.9; 95% confidence interval, 18.0-26.7), acute respiratory distress syndrome (adjusted odds ratio, 5.9; 95% confidence interval, 5.4-6.5), hypertensive disorders of pregnancy (adjusted odds ratio, 1.6; 95% confidence interval, 1.6-1.7), stillbirth (adjusted odds ratio, 1.2; 95% confidence interval, 1.0-1.4), pulmonary edema/heart failure (adjusted odds ratio, 3.7; 95% confidence interval, 2.9-4.7), peripartum hysterectomy (adjusted odds ratio, 1.66; 95% confidence interval, 1.23-2.23), and preterm birth (adjusted odds ratio, 1.2; 95% confidence interval, 1.1-1.2).

CONCLUSION

Obstructive sleep apnea diagnoses are increasingly common in the obstetrical population and are associated with a range of adverse obstetrical outcomes during delivery hospitalizations.

Vancomycin during delivery hospitalizations for women with group B streptococcus

OBJECTIVE

Vancomycin use for intrapartum GBS prophylaxis is not well characterized. The objective of this study was to describe trends in the use of vancomycin among women undergoing vaginal delivery with group B Streptococcus (GBS) colonization.

METHODS

An administrative inpatient database that includes medications was analyzed to evaluate antibiotic use in women undergoing vaginal delivery hospitalizations complicated by GBS colonization from January 2006 to March 2015. Patients with other obstetric or infectious indications for antibiotics were excluded. Frequency of use of individual antibiotic agents was determined. The Cochran-Armitage test was used to assess temporal trends. An adjusted log-linear regression model accounting for demographic and hospital factors with vancomycin receipt as the outcome was performed with adjusted risk ratios (aRR) and 95% confidence intervals (CI) as the measure of effect. Hospital level variation in administration of vancomycin was also evaluated.

RESULTS

469,717 deliveries met inclusion criteria and were included in this analysis. Use of vancomycin increased from 0.8% of patients in 2006 to 3.8% of patients in the first quarter of 2015. Comparing 2015 to 2006 both the unadjusted (relative risk 4.89 95% CI 4.26-5.60) and adjusted (aRR 4.52 95% 3.94-5.19) models demonstrated significantly increased likelihood of vancomycin administration. In evaluating hospital level vancomycin use, variation was noted with 8.0% of centers administering vancomycin to ≥6.0% of patients.

CONCLUSIONS

Vancomycin is becoming increasingly commonly used for intrapartum GBS prophylaxis. Further research and quality improvements initiatives are indicated to optimize intrapartum GBS antibiotic prophylaxis.

Pregnancy-specific Adaptations in Leptin and Melanocortin Neuropeptides in Early Human Gestation

INTRODUCTION

Pregnancy is characterized by increased appetitive drive beginning early in gestation, yet the central mechanisms underlying this adaptation are poorly understood in humans. To elucidate central mechanisms underlying appetite regulation in early pregnancy, we examine plasma and cerebrospinal fluid (CSF) leptin and Agouti-related peptide (AgRP) as well as CSF proopiomelanocortin (POMC) as surrogates for brain melanocortin activity.

METHODS

Plasma leptin, soluble leptin receptor, AgRP, and CSF leptin, POMC, and AgRP were collected from pregnant women before cerclage placement (16.6 ± 1.1 weeks; N = 24), scheduled cesarean section (39.2 ± 0.2 weeks; N = 24), and from nonpregnant controls (N = 24), matched for age and body mass index.

RESULTS

Plasma leptin was 1.5 times higher in pregnancy vs controls (P = 0.01), but CSF leptin did not differ. CSF/plasma leptin percentage was lower in early pregnancy vs controls (0.8 ± 0.1 vs 1.7 ± 0.2; P < 0.0001) and remained unchanged at term (0.9 ± 0.1), supporting a decrease in leptin transport into CSF in pregnancy. Plasma AgRP, a peripheral biomarker of the orexigenic hypothalamic neuropeptide, was higher in early pregnancy vs controls (95.0 ± 7.8 vs 67.5 ± 5.3; P = 0.005). In early gestation, CSF AgRP did not differ from controls, but CSF POMC was 25% lower (P = 0.006). In contrast, at term, CSF AgRP was 42% higher vs controls (P = 0.0001), but CSF POMC no longer differed. Overall, the CSF AgRP/POMC ratio was 1.5-fold higher in early pregnancy vs controls, reflecting a decrease in melanocortin tone favoring appetitive drive.

CONCLUSIONS

Pregnancy-specific adaptions in the central regulation of energy balance occur early in human gestation and are consistent with decreased leptin transport into brain and resistance to the effects of leptin on target melanocortin neuropeptides.

Maternal and Neonatal Outcomes in Nulliparous Participants Undergoing Labor Induction by Cervical Ripening Method

OBJECTIVE

 This study aimed to evaluate maternal and neonatal outcomes by method of cervical ripening for labor induction among low-risk nulliparous individuals.

STUDY DESIGN

 This is a secondary analysis of a multicenter randomized trial of labor induction at 39 weeks versus expectant management in low-risk nulliparous participants. Participants undergoing cervical ripening for labor induction in either group were included. Participants were excluded for preripening membrane rupture, abruption, chorioamnionitis, fetal demise, or cervical dilation ≥3.5 cm. Cervical ripening was defined by the initial method used: prostaglandin only (PGE; referent), Foley with concurrent prostaglandin (Foley-PGE), Foley only (Foley), and Foley with concurrent oxytocin (Foley-oxytocin). Coprimary outcomes were adverse maternal and neonatal composites. Secondary outcomes included cesarean delivery and length of labor and delivery (L&D) stay. Multivariable analysis was used to adjust for patient characteristics.

RESULTS

 Of 6,106 participants included in the trial, 2,376 (38.9%) met criteria for this analysis. Of these, 1,247 (52.4%) had cervical ripening with PGE, 290 (12.2%) had Foley-PGE, 385 (16.2%) had Foley, and 454 (19.1%) had Foley-oxytocin. The maternal composite outcome was similar among participants who received Foley-PGE (24.1%, adjusted relative risk [aRR] = 1.21, 95% confidence interval [CI]: 0.96-1.52), Foley (21.3%, aRR = 1.16, 95% CI: 0.92-1.45), or Foley-oxytocin (19.4%, aRR = 1.04, 95% CI: 0.83-1.29), compared with PGE (19.7%). The neonatal composite outcome was less frequent in participants who received the Foley-PGE (2.4%, aRR = 0.35, 95% CI: 0.16-0.75) or Foley (3.6%, aRR = 0.51, 95% CI: 0.29-0.89) but did not reach statistical significance for participants who received Foley-oxytocin (4.6%, aRR = 0.63, 95% CI: 0.40-1.01) compared with PGE only (6.8%). Participants who received Foley-PGE or Foley-oxytocin had a shorter L&D stay (adjusted mean difference = -1.97 hours, 95% CI: -3.45 to -0.49 and -5.92 hours, 95% CI: -7.07 to -4.77, respectively), compared with PGE.

CONCLUSION

 In term low-risk nulliparous participants, Foley alone or concurrent with PGE is associated with a lower risk of adverse neonatal outcomes than with PGE alone. Length of L&D stay was the shortest with concurrent Foley-oxytocin.

KEY POINTS

· Adverse maternal outcomes are similar among different methods of cervical ripening in low-risk women.. · Adverse neonatal outcomes are less frequent with use of Foley alone or in combination with PGE.. · The use of Foley alone, or in combination with other agents, appears to be beneficial..

Clinical and Demographic Risk Factors for COVID-19 during Delivery Hospitalizations in New York City

OBJECTIVE

This study was aimed to review 4 weeks of universal novel coronavirus disease 2019 (COVID-19) screening among delivery hospitalizations, at two hospitals in March and April 2020 in New York City, to compare outcomes between patients based on COVID-19 status and to determine whether demographic risk factors and symptoms predicted screening positive for COVID-19.

STUDY DESIGN

This retrospective cohort study evaluated all patients admitted for delivery from March 22 to April 18, 2020, at two New York City hospitals. Obstetrical and neonatal outcomes were collected. The relationship between COVID-19 and demographic, clinical, and maternal and neonatal outcome data was evaluated. Demographic data included the number of COVID-19 cases ascertained by ZIP code of residence. Adjusted logistic regression models were performed to determine predictability of demographic risk factors for COVID-19.

RESULTS

Of 454 women delivered, 79 (17%) had COVID-19. Of those, 27.9% (n = 22) had symptoms such as cough (13.9%), fever (10.1%), chest pain (5.1%), and myalgia (5.1%). While women with COVID-19 were more likely to live in the ZIP codes quartile with the most cases (47 vs. 41%) and less likely to live in the ZIP code quartile with the fewest cases (6 vs. 14%), these comparisons were not statistically significant (p = 0.18). Women with COVID-19 were less likely to have a vaginal delivery (55.2 vs. 51.9%, p = 0.04) and had a significantly longer postpartum length of stay with cesarean (2.00 vs. 2.67days, p < 0.01). COVID-19 was associated with higher risk for diagnoses of chorioamnionitis and pneumonia and fevers without a focal diagnosis. In adjusted analyses, including demographic factors, logistic regression demonstrated a c-statistic of 0.71 (95% confidence interval [CI]: 0.69, 0.80).

CONCLUSION

COVID-19 symptoms were present in a minority of COVID-19-positive women admitted for delivery. Significant differences in obstetrical outcomes were found. While demographic risk factors demonstrated acceptable discrimination, risk prediction does not capture a significant portion of COVID-19-positive patients.

KEY POINTS

· COVID-19 symptoms were present in a minority of COVID-19-positive women admitted.. · COVID-19 symptomatology did not appear to differ before or after the apex of infection in New York.. · Demographic risk factors are unlikely to capture a significant portion of COVID-19-positive patients..

Population risk factors for nulliparous, term, singleton, vertex caesarean birth: a national cross-sectional study

OBJECTIVE

To characterise medical, obstetric and demographic risk factors associated with nulliparous, term, singleton, vertex (NTSV) caesarean birth.

STUDY DESIGN

Cross-sectional study.

SETTING

United States delivery hospitalisations.

POPULATION

NTSV births in 2016-18 US natality data.

METHODS

This study analysed a national sample of natality data generated by the United States National Vital Statistics System. NTSV deliveries were identified. The primary outcome was caesarean birth. Risk factors including maternal age, body mass index (BMI) and pregestational diabetes were analysed. Multivariable log-linear regression models analysed factors associated with NTSV caesarean with adjusted risk ratios (aRR) as measures of effect.

RESULTS

Of 11 622 400 deliveries, 3 764 707 met NTSV criteria, and their caesarean section rate was 25.9%. Maternal age 35-39 years (aRR 1.51, 95% CI 1.50-1.52) and 40-54 years (aRR 2.03, 95% 2.00-2.05) compared with age 19-34 years; BMI 25 to <30 kg/m2 (aRR 1.32, 95% CI 1.31-1.33), 30 to <35 kg/m2 (aRR 1.57 95% CI 1.56-1.58), 35 to <40 kg/m2 (aRR 1.82, 95% CI 1.80-1.83) and ≥40 kg/m2 (aRR 2.17, 95% CI 2.15-2.19) compared with BMI 18.5-24.9 kg/m2; and pregestational diabetes (aRR 1.54, 95% CI 1.51-1.57) were all associated with increased risk. Risk factors allowed stratification of patients into high-risk versus low-risk groups. The NTSV caesarean rate was 37.9% in women who had one or more of the following characteristics: age ≥35 years, BMI ≥30 kg/m2 or pregestational diabetes. In comparison, the NTSV caesarean rate was 20.8% among women without any of these three risk factors (P < 0.01).

CONCLUSION

Among NTSV births, BMI, maternal age and medical conditions are important risk factors for caesarean delivery.

Outcomes of Neonates Born to Mothers With Severe Acute Respiratory Syndrome Coronavirus 2 Infection at a Large Medical Center in New York City

IMPORTANCE

Limited data on vertical and perinatal transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and health outcomes of neonates born to mothers with symptomatic or asymptomatic coronavirus disease 2019 (COVID-19) are available. Studies are needed to inform evidence-based infection prevention and control (IP&C) policies.

OBJECTIVE

To describe the outcomes of neonates born to mothers with perinatal SARS-CoV-2 infection and the IP&C practices associated with these outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort analysis reviewed the medical records for maternal and newborn data for all 101 neonates born to 100 mothers positive for or with suspected SARS-CoV-2 infection from March 13 to April 24, 2020. Testing for SARS-CoV-2 was performed using Cobas (Roche Diagnostics) or Xpert Xpress (Cepheid) assays. Newborns were admitted to well-baby nurseries (WBNs) (82 infants) and neonatal intensive care units (NICUs) (19 infants) in 2 affiliate hospitals at a large academic medical center in New York, New York. Newborns from the WBNs roomed-in with their mothers, who were required to wear masks. Direct breastfeeding after appropriate hygiene was encouraged.

EXPOSURES

Perinatal exposure to maternal asymptomatic/mild vs severe/critical COVID-19.

MAIN OUTCOMES AND MEASURES

The primary outcome was newborn SARS-CoV-2 testing results. Maternal COVID-19 status was classified as asymptomatic/mildly symptomatic vs severe/critical. Newborn characteristics and clinical courses were compared across maternal COVID-19 severity.

RESULTS

In total, 141 tests were obtained from 101 newborns (54 girls [53.5%]) on 0 to 25 days of life (DOL-0 to DOL-25) (median, DOL-1; interquartile range [IQR], DOL-1 to DOL-3). Two newborns had indeterminate test results, indicative of low viral load (2.0%; 95% CI, 0.2%-7.0%); 1 newborn never underwent retesting but remained well on follow-up, and the other had negative results on retesting. Maternal severe/critical COVID-19 was associated with newborns born approximately 1 week earlier (median gestational age, 37.9 [IQR, 37.1-38.4] vs 39.1 [IQR, 38.3-40.2] weeks; P = .02) and at increased risk of requiring phototherapy (3 of 10 [30.0%] vs 6 of 91 [7.0%]; P = .04) compared with newborns of mothers with asymptomatic/mild COVID-19. Fifty-five newborns were followed up in a new COVID-19 Newborn Follow-up Clinic at DOL-3 to DOL-10 and remained well. Twenty of these newborns plus 3 newborns followed up elsewhere had 32 nonroutine encounters documented at DOL-3 to DOL-25, and none had evidence of SARS-CoV-2 infection, including 6 with negative retesting results.

CONCLUSIONS AND RELEVANCE

No clinical evidence of vertical transmission was identified in 101 newborns of mothers positive for or with suspected SARS-CoV-2 infection, despite most newborns rooming-in and direct breastfeeding practices.

Coronavirus disease 2019 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals

Novel coronavirus disease 2019 is rapidly spreading throughout the New York metropolitan area since its first reported case on March 1, 2020. The state is now the epicenter of coronavirus disease 2019 outbreak in the United States, with 84,735 cases reported as of April 2, 2020. We previously presented an early case series with 7 coronavirus disease 2019-positive pregnant patients, 2 of whom were diagnosed with coronavirus disease 2019 after an initial asymptomatic presentation. We now describe a series of 43 test-positive cases of coronavirus disease 2019 presenting to an affiliated pair of New York City hospitals for more than 2 weeks, from March 13, 2020, to March 27, 2020. A total of 14 patients (32.6%) presented without any coronavirus disease 2019-associated viral symptoms and were identified after they developed symptoms during admission or after the implementation of universal testing for all obstetric admissions on March 22. Among them, 10 patients (71.4%) developed symptoms of coronavirus disease 2019 over the course of their delivery admission or early after postpartum discharge. Of the other 29 patients (67.4%) who presented with symptomatic coronavirus disease 2019, 3 women ultimately required antenatal admission for viral symptoms, and another patient re-presented with worsening respiratory status requiring oxygen supplementation 6 days postpartum after a successful labor induction. There were no confirmed cases of coronavirus disease 2019 detected in neonates upon initial testing on the first day of life. Based on coronavirus disease 2019 disease severity characteristics by Wu and McGoogan, 37 women (86%) exhibited mild disease, 4 (9.3%) severe disease, and 2 (4.7%) critical disease; these percentages are similar to those described in nonpregnant adults with coronavirus disease 2019 (about 80% mild, 15% severe, and 5% critical disease).

Antibiotics for 3rd and 4th Degree Vaginal Lacerations, Uterine Tamponade, and Manual Placental Extraction

OBJECTIVE

Trends in use of antibiotics during delivery hospitalizations complicated by (1) 3rd/4th degree vaginal lacerations, (2) manual placenta extraction, and (3) uterine tamponade are not well characterized. The objective of this study was to analyze trends in antibiotic use during vaginal delivery hospitalizations complicated by these three clinical scenarios.

STUDY DESIGN

An administrative inpatient database was used to perform a serial cross-sectional analysis of antibiotic administration during delivery hospitalizations in the United States from January 2006 to March 2015. The primary outcome was receipt of antibiotics during vaginal delivery hospitalizations complicated by (1) 3rd and 4th degree vaginal lacerations, (2) manual placenta extraction, and (3) uterine tamponade. Patients with other indications for antibiotics were excluded. The Cochran-Armitage test was used to assess trends. Adjusted log linear regression analyses including demographic, hospital, and obstetric factors were performed to analyze factors associated with antibiotic receipt for each of these three clinical scenarios in both primary and sensitivity analyses.

RESULTS

From 2006 to 2015 the rate of antibiotic administration during delivery hospitalizations decreased from 43.1% in 2006 to 25.5% for 3rd and 4th degree lacerations and from 59.6% to 49.2% for manual extraction (p < 0.01). Administration of antibiotics in the setting of uterine tamponade decreased from 48.6% in 2006 to 27.6% in 2009 before rising to 62.5% in the first quarter of 2015. In adjusted analyses, comparing the first quarter of 2015 to 2006 adjusted risk ratios for antibiotic administration were 0.61 (95% confidence interval [CI] 0.56-0.66) for 3rd and 4th degree vaginal lacerations, 0.76 (95% CI 0.53-1.09) for manual placental extraction, and 0.83 (95% CI 0.76-0.92) for uterine tamponade.

CONCLUSION

Antibiotics are not used consistently during vaginal deliveries complicated by 3rd/4th degree lacerations, manual placenta extraction, and uterine tamponade. These findings support that a significant opportunity exists for comparative effectiveness research to assist in characterizing best practices.

Maternal Age and Preeclampsia Outcomes during Delivery Hospitalizations

OBJECTIVE

To characterize risk and temporal trends for preeclampsia and related outcomes by maternal age.

STUDY DESIGN

Deliveries to women aged 15 to 54 years in the 1998 to 2014 National Inpatient Sample who had a diagnosis of preeclampsia, eclampsia, or both were included in the analysis. Age was categorized as 15 to 17, 18 to 24, 25 to 29, 30 to 34, 35 to 39, 40 to 44, and 45 to 54 years. The primary outcome was temporal trends in preeclampsia based on maternal age. Secondary outcomes analyzed included risk for severe maternal morbidity.

RESULTS

The proportion of women with preeclampsia aged 15 to 24 years decreased from 42.3% in 1998 to 30.1% in 2014, while preeclampsia among those 30 to 54 years increased from 32.9 to 43.7%. Preeclampsia risk increased for all groups over the study period. Risk for severe morbidity by age group with and without transfusion was "U-shaped," with risk highest for women 18 to 24 and 40 to 54 years. The risk for abruption, acute renal failure, acute heart failure or pulmonary edema, and stroke was lowest for women aged 15 to 24 years and increased in a "dose-dependent" manner with increasing maternal age. In contrast, eclampsia risk was highest for women aged 15 to 17 years.

CONCLUSION

With a changing demographic profile of preeclampsia, older women accounted for an increasing proportion of preeclampsia and related adverse outcomes.

Postpartum hemorrhage: early identification challenges

Postpartum hemorrhage is the leading cause of maternal morbidity and mortality worldwide. The majority of maternal deaths associated with hemorrhage could be preventable. The accurate assessment of blood loss, identification of risk factors and timely recognition of postpartum hemorrhage remain major challenges in obstetrics. It is important to review available modalities for estimation and quantification of peripartum blood loss, the value of risk assessment tools as well as the challenges in early recognition of clinical signs and symptoms of postpartum hemorrhage.

Low-dose aspirin is associated with reduced spontaneous preterm birth in nulliparous women

BACKGROUND

Preterm birth is one of the leading causes of perinatal morbidity and mortality. Clinical data suggest that low-dose aspirin may decrease the rate of overall preterm birth, but investigators have speculated that this is likely due to a decrease in medically indicated preterm birth through its effect on the incidence of preeclampsia and other placental disease. We hypothesized that low-dose aspirin may also have an impact on the mechanism of spontaneous preterm labor.

OBJECTIVE

Our objective was to determine whether low-dose aspirin reduces the rate of spontaneous preterm birth in nulliparous women without medical comorbidities.

STUDY DESIGN

This is a secondary analysis of a randomized, placebo-controlled trial of low-dose aspirin for the prevention of preeclampsia in healthy, low-risk, nulliparous women. Low-risk women were defined by the absence of hypertension, renal disease, diabetes, other endocrine disorders, seizures, heart disease, or collagen vascular disease. Our study was limited to singleton, nonanomalous gestations. Women were eligible if they had prior pregnancy terminations but not prior spontaneous pregnancy loss <20 weeks. Current pregnancies that resulted in a loss or termination <20 weeks or antepartum stillbirth or had missing follow-up data were excluded. The treatment intervention was 60 mg of aspirin, initiated at 13-25 weeks' gestation or matching placebo. The primary outcome was spontaneous preterm birth <34 weeks' gestation. Secondary outcomes included spontaneous preterm birth <37 weeks and overall preterm birth <37 and <34 weeks. Baseline demographics and primary and secondary outcomes were compared between treatment groups. A logistic regression model was used to adjust for confounders related to spontaneous preterm birth.

RESULTS

Of 2543 included women, 1262 (49.6%) received low-dose aspirin and 1281 (50.4%) placebo. Baseline characteristics were similar between groups, except for marital status. The rate of spontaneous preterm birth <34 weeks was 1.03% (n = 13) and 2.34% (n = 30) in the low-dose aspirin and placebo group, respectively (odds ratio, 0.43, 95% confidence interval, 0.26-0.84). Additionally, the rate of spontaneous preterm birth <37 weeks was 6.58% (n = 83) in the low-dose aspirin group and 7.03% (n = 90) in the placebo group (odds ratio, 0.97, 95% confidence interval, 0.71-1.33), and the rate of overall preterm birth <37 weeks was 7.84% (n = 99) in the low-dose aspirin group and 8.2% (n = 105) in the placebo group (odds ratio, 0.97, 95% confidence interval, 0.72-1.31). After adjustment for variables that were clinically relevant or statistically significant, including body mass index, race, tobacco use, marital status, and education level, there was a significant reduction in spontaneous preterm birth <34 weeks in the low-dose aspirin group (adjusted odds ratio, 0.46, 95% confidence interval, 0.23-0.89). The rates of overall preterm birth <34 and <37 weeks and spontaneous preterm birth <37 weeks were similar in women who received low-dose aspirin compared with placebo.

CONCLUSION

Low-dose aspirin is associated with a substantial decrease in spontaneous preterm birth <34 weeks in healthy nulliparous women without comorbidities. These findings suggest a new therapeutic option for preterm birth prevention that requires further study.

Second trimester marginal cord insertion is associated with adverse perinatal outcomes

Objectives: To determine the feasibility in visualizing placental cord insertion (PCI) during second-trimester fetal anatomical survey and the association between marginal cord insertion (MCI) and preterm delivery (PTD) and low birth weight (LBW). Our secondary objectives were to evaluate the association of MCI with adverse composite obstetrical and neonatal outcomes. Methods: A prospective cohort study was performed over a 28-month period. Women with singleton pregnancies presenting for routine anatomical survey between 18 and 22 weeks' gestation were included. PCI site was visualized on 2D grayscale and color Doppler and the shortest distance from the sagittal and transverse planes to the placental edge were recorded. MCI was diagnosed when any of measured distances was ≤2 cm. Correlations were assessed via bivariate chi-squared, independent t-test analyses and Fisher's exact tests. Regression models evaluated associations between MCI and adverse composite outcomes. Results: Three hundred one women were included and PCI was feasible in all cases. The incidence of MCI was 11.3% (n = 34). Baseline characteristics between those with and without MCI were similar, except for story of prior PTD, which was greater among those with MCI (17.65 versus 7.17%, p = .04). MCI was associated with increased likelihood of LBW (RR four; 95%CI, 1.46-10.99) and PTD (RR 3.2; 95%CI, 1.53-6.68); in multivariate analysis, we found associations between MCI and composite adverse obstetrical (RR 2.33; 95%CI, 1.30-4.19) and neonatal (RR 2.46; 95%CI, 1.26-4.81) outcomes. Conclusions: Evaluation of PCI is feasible in all cases. Second-trimester MCI is associated with increased likelihood for LBW, PTD, and composite adverse obstetrical and neonatal outcomes.

Cervical ripening agents in the second trimester of pregnancy in women with a scarred uterus: a systematic review and metaanalysis of observational studies

OBJECTIVE

The aim of this systematic review and metaanalysis was to determine the efficacy and safety of cervical ripening agents in the second trimester of pregnancy in patients with previous cesarean delivery.

STUDY DESIGN

Data sources were PubMed, EMBASE, CINAHL, LILACS, Google Scholar, and clinicaltrials.gov (1983 through 2015). Eligibility criteria were cohort or cross-sectional studies that reported on efficacy and safety of cervical ripening agents in patients with previous cesarean delivery. Efficacy was determined based on the proportion of patients achieving vaginal delivery and vaginal delivery within 24 hours following administration of a cervical ripening agent. Safety was assessed by the risk of uterine rupture and complications such as retained placental products, blood transfusion requirement, and endometritis, when available, as secondary outcomes. Of the 176 studies identified, 38 met the inclusion criteria. Of these, 17 studies were descriptive and 21 studies compared the efficacy and safety of cervical ripening agents between patients with previous cesarean and those with no previous cesarean. From included studies, we abstracted data on cervical ripening agents and estimated the pooled risk differences and risk ratios with 95% confidence intervals. To account for between-study heterogeneity, we estimated risk ratios based on underlying random effects analyses. Publication bias was assessed via funnel plots and across-study heterogeneity was assessed based on the I(2) measure.

RESULTS

The most commonly used agent was PGE1. In descriptive studies, PGE1 was associated with a vaginal delivery rate of 96.8%, of which 76.3% occurred within 24 hours, uterine rupture in 0.8%, retained placenta in 10.8%, and endometritis in 3.9% in patients with ≥1 cesarean. In comparative studies, the use of PGE1, PGE2, and mechanical methods (laminaria and dilation and curettage) were equally efficacious in achieving vaginal delivery between patients with and without prior cesarean (risk ratio, 0.99, and 95% confidence interval, 0.98-1.00; risk ratio, 1.00, and 95% confidence interval, 0.98-1.02; and risk ratio, 1.00, and 95% confidence interval, 0.98-1.01; respectively). In patients with history of ≥1 cesarean the use of PGE1 was associated with higher risk of uterine rupture (risk ratio, 6.57; 95% confidence interval, 2.21-19.52) and retained placenta (risk ratio, 1.21; 95% confidence interval, 1.03-1.43) compared to women without a prior cesarean. However, the risk of uterine rupture among women with history of only 1 cesarean (0.47%) was not statistically significant (risk ratio, 2.36; 95% confidence interval, 0.39-14.32), whereas among those with history of ≥2 cesareans (2.5%) was increased as compared to those with no previous cesarean (0.08%) (risk ratio, 17.55; 95% confidence interval, 3.00-102.8). Funnel plots did not demonstrate any clear evidence of publication bias. Across-study heterogeneity ranged from 0-81%.

CONCLUSION

This systematic review and metaanalysis provides evidence that PGE1, PGE2, and mechanical methods are efficacious for achieving vaginal delivery in women with previous cesarean delivery. The use of prostaglandin PGE1 in the second trimester was not associated with significantly increased risk for uterine rupture among women with only 1 cesarean; however, this risk was substantially increased among women with ≥2 cesareans although the absolute risk appeared to be relatively small.

The role of mTOR signaling pathway in premalignant and malignant cervical lesions

PURPOSE OF THE STUDY

Aberrant activation of the Akt/mTOR/pS6 signaling pathway has been identified in various types of cancer and is under investigation in cervical cancer. The purpose of this study was to assess the expression of the phosphorylated/activated forms of Akt (upstream molecule), 4E-BP1 and pS6 (downstream molecules) in biopsy samples of cervical low grade squamous intraepithelial lesions (LSIL), high grade squamous intraepithelial lesions (HSIL), and squamous cell carcinoma (Ca) compared to normal cervical epithelium.

MATERIAL AND METHODS

The study included 38 cases diagnosed as LSIL, 31 cases as HSIL, 29 cases as Ca, and eight control cases from normal cervix. Immunohistochemistry was used to assess the expression of pAkt, p4E-BP1 and pS6.

RESULTS

Statistical analysis revealed significant differences between HSIL and Ca groups compared to controls regarding intensity, positivity, and total scores for all three molecules (p < 0.001). A trend for higher expression with increasing grade of dysplasia was demonstrated.

CONCLUSION

These results strongly support the view that the mTOR signaling pathway is involved in cervical carcinogenesis.

Perinatal biomarkers in prematurity: early identification of neurologic injury

Over the past few decades, biomarkers have become increasingly utilized as non-invasive tools in the early diagnosis and management of various clinical conditions. In perinatal medicine, the improved survival of extremely premature infants who are at high risk for adverse neurologic outcomes has increased the demand for the discovery of biomarkers in detecting and predicting the prognosis of infants with neonatal brain injury. By enabling the clinician to recognize potential brain damage early, biomarkers could allow clinicians to intervene at the early stages of disease, and to monitor the efficacy of those interventions. This review will first examine the potential perinatal biomarkers for neurologic complications of prematurity, specifically, intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL) and posthemorrhagic hydrocephalus (PHH). It will also evaluate knowledge gained from animal models regarding the pathogenesis of perinatal brain injury in prematurity.

Assessment of angiogenic markers and female sex hormone receptors in pregnancy tumor of the gingiva

PURPOSE

Oral pregnancy tumors (OPTs) arise on the inflamed gingiva of women after the first trimester of pregnancy. The expression of angiogenic markers and female hormone receptors was assessed.

MATERIALS AND METHODS

Immunohistochemistry was used to analyze the expression of estrogen and progesterone receptors and the expression of angiogenic factors, such as vascular endothelial growth factor (VEGF) and its receptor, fibroblast growth factor (FGF), and hypoxia inducible factors 1α and 3α (HIF1α and HIF3α). Experimental groups included 9 OPTs, 10 oral pyogenic granulomas from nonpregnant women of the same age, and 9 oral pyogenic granulomas from postmenopausal women.

RESULTS

VEGF expression in stromal histiocytes and endothelial cells of small vessels was positively correlated in the OPT group (P < .05 by χ(2) test). VEGF receptor also was overexpressed in stromal histiocytes and endothelial cells of OPTs compared with oral pyogenic granulomas from nonpregnant and postmenopausal women (P < .005 by χ(2) test). No correlation was detected among estrogen and progesterone receptors, FGF and HIF1α and HIF3α (ER and PgR respectively) in the 3 experimental groups.

CONCLUSIONS

VEGF-associated angiogenesis is most likely involved in the pathogenesis of the lesion. These results imply that local inhibition of VEGF activity could be an adjuvant therapeutic approach for OPTs to control hemorrhage, which can be massive at the surgical excision of such lesions during pregnancy.

Impact of the Increased Use of Preoperative Imaging and Laparoscopy on Appendicectomy Outcomes

The diagnosis of appendicitis is based on clinical picture. The aim of this retrospective study was to analyse variation of outcomes and impact of increasing use of radiological investigations and laparoscopy over a 5-year period. A retrospective audit of appendicectomies over the last 5 years (01 January 2007-31 December 2011) was conducted. The negative appendicectomy rate (NAR), perforation rate and complication rate were used as outcome endpoints. A statistical analysis was performed to evaluate the difference in outcomes with surgical approach and use of radiology. One thousand fifty-five appendicectomies were performed in this period. The NAR was 22.65 % (21 % for open and 28 % for laparoscopic) and perforation rate was 14 %. There was no statistically significant difference in NAR with the use of ultrasound (P 0.3814) but there was a significant reduction in NAR with the use of computed tomography (CT) (P <0.0001). Intra-abdominal abscess (2.3 %) and wound infection (1.4 %) were the common complications with the former being higher with laparoscopy and the latter with open appendicectomy. Over 5 years, there were no significant changes in appendicectomy outcomes. The impact of diagnostic imaging on NAR varies with age, gender and the use of CT. CT can significantly reduce the negative appendicectomy rate in equivocal presentations. Complication rates vary with surgical approach.

Aortocaval fistula formation due to ruptured abdominal aortic aneurysms: a 12-year series

This study reports on the frequency and management of aortocaval fistulas (ACFs) in our department between 1998 and 2009. Overall frequency of ACFs among ruptured abdominal aortic aneurysms was 5.5%. Patients presented with low back pain (92.8%), abdominal tenderness (78.6%), hemorrhagic shock (28.6%), congestive heart failure (21.4%), dyspnea (42.8%), and palpitations (57.1%). The most reliable clinical sign was the presence of palpable pulsating abdominal mass (92.8%). Other clinical findings included increased central venous pressure (21.4%), lower extremity edema (71.4%), hematuria (21.4%), and scrotal edema (14.3%). Diagnosis was established preoperatively in 85.7% and intraoperatively in 14.3% of cases. Surgery was successful in promptly improving clinical signs and symptoms. Mortality rate was 7.1%. After a mean follow-up of 18.5 months, all surviving patients remained free from complications. In conclusion, ACFs represent a life-threatening emergency for vascular surgeons but can be successfully managed.

Characteristics of patients presenting to the vascular emergency department of a tertiary care hospital: a 2-year study

Background

The structure of health care in Greece is receiving increased attention to improve its cost-effectiveness. We sought to examine the epidemiological characteristics of patients presenting to the vascular emergency department of a Greek tertiary care hospital during a 2-year period. We studied all patients presenting to the emergency department of vascular surgery at Red Cross Hospital, Athens, Greece between 1^st January 2009 and 31st December 2010.

Results

Overall, 2452 (49.4%) out of 4961 patients suffered from pathologies that should have been treated in primary health care. Only 2509 (50.6%) needed vascular surgical intervention.

Conclusions

The emergency department of vascular surgery in a Greek tertiary care hospital has to treat a remarkably high percentage of patients suitable for the primary health care level. These results suggest that an improvement in the structure of health care is needed in Greece.

Insertion of central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations

INTRODUCTION

Central venous catheter placement is an effective alternative vascular access for dialysis in patients with chronic renal failure. The purpose of this study was to evaluate the insertion of central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations in terms of efficacy of the procedure and early complications.

MATERIALS AND METHODS

Between 2008 and 2010, the vascular access team of our hospital placed 409 central venous catheters in patients with chronic renal failure. The procedure was performed using the Seldinger blind technique. In 18 (4.4%) cases it was impossible to advance the guidewire, and so the patients were transported to the angiography suite.

RESULTS

Using the angiographic technique, the guidewire was advanced in order to position the central venous catheter. The latter was inserted into the subclavian vein in 12 (66.6%) cases, into the internal jugular vein in 4 (22.2%) and into the femoral vein in 2 (11.1%) cases. There was only one complicated case with severe arrhythmia in 1 (5.5%) patient.

CONCLUSION

Our results suggest that insertion of central venous catheters using angiographic techniques in hemodialysis patients with previous multiple catheterizations is a safe and effective procedure with few complications and high success rates.

Serum leptin levels in patients undergoing carotid endarterectomy: a pilot study

INTRODUCTION

Elevated serum leptin levels are associated with cardiovascular events. We investigated the role of serum leptin in patients undergoing carotid endarterectomy (CEA).

METHODS

A total of 74 patients (55 men; 38 symptomatic and 36 asymptomatic; mean age 66.9 +/- 8.2 years) undergoing CEA for >70% carotid artery stenosis were enrolled.

RESULTS

Serum leptin levels were lower in symptomatic compared with asymptomatic patients (7.1 +/- 1.3 vs 14.4 +/- 4.7 ng/dL; P < .001). Interleukin-6 (IL-6) levels were higher in symptomatic compared with asymptomatic patients (4.3 +/- 1.7 vs 3.3 +/- 1.1 pg/dL; P = .017). Symptomatic patients had more intense macrophage accumulation (0.7% +/- 0.1% vs 0.3% +/- 0.1%; P < .001). Serum leptin and serum IL-6 levels were independently associated with the presence of symptoms in multivariate analysis.

CONCLUSION

Serum leptin levels were decreased in symptomatic carotid artery disease. This finding requires further investigation in larger studies.