Perinatal Outcomes of Twin Gestations with and without Gestational Diabetes Mellitus

OBJECTIVE

 Existing data suggest that obstetric outcomes for individuals with twin gestations, who have gestational diabetes mellitus (GDM), may be comparable to those who do not have GDM, yet studies are limited by small sample sizes. The aim of this study was to examine differences in maternal and neonatal outcomes of individuals with twin gestations based on presence of GDM.

METHODS

 This was a population-based retrospective cohort study of individuals giving birth to twins in the United States between 2012 and 2014. Inclusion criteria were live births (≥24 weeks) and available information on GDM status; individuals with pregestational diabetes were excluded. Participants were categorized as either having had or not had GDM. Multivariable logistic regression was utilized to assess the independent association of GDM with adverse maternal outcomes, whereas generalized estimating equation models were used to estimate associations with neonatal outcomes to account for clustering.

RESULTS

 Of 173,196 individuals meeting inclusion criteria, 13,194 (7.6%) had GDM. Individuals with GDM were more likely to be older, identify as Hispanic or Asian race and ethnicity, married, college educated, privately insured, and obese than those without GDM. After adjusting for potential confounding variables, those with GDM were more likely to have hypertensive disorders (18.0 vs. 10.2%) and undergo cesarean delivery (51.2 vs. 47.3%). Neonates born to individuals with GDM were more likely to require mechanical ventilation for greater than 6 hours (6.5 vs. 5.6%) and experience neonatal intensive care unit (NICU) admission (41.1 vs. 36.2%), but were less likely to be low birth weight or have small for gestational age status (16.2 vs. 19.5%). Findings were confirmed in a sensitivity analysis of neonates born at 32 weeks of gestation or greater.

CONCLUSION

 Odds of poor obstetric and neonatal outcomes are increased for individuals with twin gestations complicated by GDM.

KEY POINTS

· Individuals with GDM and twin gestation have higher odds of developing hypertensive disorders during pregnancy and of undergoing cesarean delivery.. · Neonates of such pregnancies are less likely to be low birth weight or small for gestational age.. · Neonates of pregnancies complicated by GDM and twin gestation are more likely to require mechanical ventilation and experience NICU admission..

Prior Term Birth Decreases the Risk of Preterm Birth in a Subsequent Twin Gestation

OBJECTIVE

The aim of the study is to examine the association between the risk of preterm delivery among women with twin pregnancies and their obstetric history.

STUDY DESIGN

We designed a retrospective cohort study of live twin births in 2008 in the United States that delivered after 24^0/7 weeks. Women were categorized into nulliparas, multiparas with prior term delivery, and multiparas with prior preterm delivery. The incidence of preterm birth was compared using Chi-square test and multivariable logistic regression models.

RESULTS

A total of 32,895 nulliparous and 64,701 multiparous women with twin pregnancies were included in the study. Of the multiparous women, 2,505 (4%) had a history of a prior preterm delivery. Multiparous women with prior term birth were more likely to deliver at term (: 43%): in the index twin pregnancy than nulliparous women (40%) and multiparous women with a prior preterm birth (21%; p < 0.001). Compared with nulliparous women, prior term birth was protective against preterm delivery (adjusted odds ratio [aOR] = 0.67 [95% confidence interval: 0.60-0.74] for delivery <28 weeks and aOR = 0.79 [0.71-0.77] for delivery <34 weeks).

CONCLUSION

Among multiparous women with twins, a prior term delivery appeared to be protective against preterm delivery compared with nulliparous women with twins.

KEY POINTS

· Prior term birth is protective against preterm birth in subsequent twin pregnancy.. · A prior term birth confers an OR of 0.66 for delivery prior to 28 weeks in twin pregnancies.. · A prior preterm birth renders a twin pregnancy nearly twice as likely to deliver before 28 weeks..

Disparities in Trial of Labor among Women with Twin Gestations in the United States

OBJECTIVE

The aim of the study is to examine clinical and demographic factors associated with trial of labor (TOL) among women with twin gestations eligible for a vaginal delivery.

STUDY DESIGN

This was a population-based cohort study of women giving birth to twin gestations in the United States (2012-2014). Inclusion criteria for the analysis included live births greater than 23 weeks' gestation and a cephalic presenting twin. Women with prior cesarean delivery were excluded. Women were categorized by whether they underwent a TOL. Clinical and demographic characteristics associated with TOL status were evaluated using multivariable logistic regression analyses. Secondary analyses with stratification by parity and by second twin presentation were performed.

RESULTS

Of 90,000 women eligible for inclusion, a minority (39.3%) underwent TOL. Women who had a greater gestational age at delivery were more likely to have a TOL. In contrast, several demographic factors were associated with decreased likelihood of TOL, including maternal age >35 years and identifying as Hispanic or Asian compared with non-Hispanic White. No differences in odds of TOL were observed for women who were identified as non-Hispanic Black versus non-Hispanic White, nor were other demographic factors such as marital status, insurance status, or educational attainment associated with undergoing TOL. Clinical factors associated with decreased odds of TOL included nulliparity, obesity, and hypertensive disorders of pregnancy. Results did not substantively change when stratified by parity or second twin presentation, nor did findings differ in the subgroup who delivered at 32 weeks of gestation or greater.

CONCLUSION

In this large population of women with twins who were eligible for a TOL, a minority of individuals attempted a vaginal delivery. Demographic and clinical factors such as older maternal age, Asian or Hispanic racial or ethnic identification, nulliparity, and obesity are associated with decreased odds of undergoing TOL.

KEY POINTS

· Understanding disparities in trial of labor among patients with twins is key to promoting equity.. · Older maternal age and identifying as Hispanic or Asian were associated with lower odds of TOL.. · Nulliparity, obesity, and hypertension were associated with decreased odds of TOL..

Association between weighted adverse outcome score and race/ethnicity in women and neonates

OBJECTIVE

To examine the association between the Weighted Adverse Outcome Score (WAOS) and race/ethnicity among a large and diverse population-based cohort of women and neonates in the United States.

STUDY DESIGN

This was a retrospective cohort study of women who delivered in the United States between 2011 and 2013. We identified mother-infant pairs with adverse maternal and/or neonatal outcomes. These outcomes were assigned weighted scores to account for relative severity. The association between race/ethnicity and WAOS was examined using chi-square test and multivariable logistic regression.

RESULTS

Compared to White women and their neonates, Black women and their neonates were at higher odds of an adverse outcome.

CONCLUSION(S)

The vast majority of women and neonates had no adverse outcome. However, Black women and their neonates were found to have a higher WAOS. This tool could be used to designate hospitals or regions with higher-than-expected adverse outcomes and target them for intervention.

224 Malignancy associated pericardial effusion- do we need to drain them all?

On Behalf

Cardiac Team, Department of Medicine, Queen Elizabeth Hospital

Background

Management of significant pericardial effusion in cancer patients is controversial. These patients have poor prognosis, and avoiding unnecessary intervention is important. Close monitoring of symptoms and echocardiogram is often a reasonable option, but inherits risk of cardiac tamponade. Whether pericardial drainage by means of percutaneous pericardiocentesis or surgical pericardiotomy could prevent future deterioration or affect survival is unknown.

Purpose

To evaluate the benefit of elective pericardial drainage in malignancy associated pericardial effusion without echocardiographic or clinical evidence of tamponade effect.

Methods

From 1st Jul 2014 to 31st Dec 2017, all patients with new onset malignancy-associated pericardial effusion with size more than 1cm were retrospectively analyzed. Patients with clinical or echocardiographic evidence of cardiac tamponade were excluded. We compared pericardial drainage versus monitoring for short-term (30-day), mid-term (90-day) and long term (1 year) survival without need for drainage.

Results

101 patients were retrospectively analyzed. 40 (39.6%) patients underwent drainage. Overall median survival free from drainage was 4 months. There were no significant difference in short-term (30-day), mid-term (90-day) and long term (1-year) survival free from drainage or mortality between treatment and monitoring group. Size of pericardial effusion did not predict mortality or future need of drainage. Chemotherapy was associated with improved 30-day mortality (RR 0.53 CI 0.32-0.87 p = 0.025) but not survival free from drainage or longer term mortality.

Conclusion

Close monitoring could be a feasible strategy in cancer patients with significant pericardial effusion without tamponade effect.

Baseline characteristics Factor Drainage (n = 40) monitoring (n = 61) p-value method of drainage pericardiocentesis alone 17 NA pericardiotomy alone 13 both 10 Male 19 (47.5%) 27 (44.3%) 0.749 mean size (cm) 1.93 2.77 &lt;0.001 mean age 60.9 63.1 0.357 on chemotherapy 27 (67.5%) 38 (62.3%) 0.593

Abstract 224 Figure. Survival free from drainage

Association of Widespread Adoption of the 39-Week Rule With Overall Mortality Due to Stillbirth and Infant Death

IMPORTANCE

To improve neonatal morbidity, efforts have been made to reduce elective deliveries prior to 39 weeks' gestation, also known as the 39-week rule. Prolonging pregnancies also prolongs exposure to the risk of stillbirth. The true association of a 39-week rule with mortality is unknown and studies to date have shown conflicting results.

OBJECTIVE

To determine if widespread adoption of a 39-week rule, limiting elective deliveries prior to 39 weeks' gestation, is associated with an increase or decrease in overall mortality when considering both stillbirths and infant deaths.

DESIGN, SETTING, AND PARTICIPANTS

This historical cohort study used birth certificate and infant death certificate data in the United States to compare years before and after the adoption of the 39-week rule. Births between 2008 and 2009 were considered to be in the preadoption period (n = 7 322 234), and those between 2011 and 2012 were considered to be in the postadoption period (n = 6 972 626). Included births were singleton, nonanomalous births between 37 0/7 weeks' and 42 6/7 weeks' gestation. Statistical analysis was performed from July 19, 2016, through June 27, 2019.

EXPOSURES

The exposure of interest was the Joint Commission adoption of the 39-week rule as a quality measure.

MAIN OUTCOMES AND MEASURES

The primary outcomes of interest were stillbirth and infant death.

RESULTS

A total of 7 322 234 births (49.0% girls and 51.0% boys) were included in the preadoption period and 6 972 626 births (49.1% girls and 50.9% boys) were included in the postadoption period. Compared with the preadoption period, there was a decrease in the proportion of deliveries at 37 weeks (-0.06%) and 38 weeks (-2.5%) and an increase in the proportion of deliveries at 39 weeks (6.8%) and 40 weeks (0.2%) in the postadoption period (P < .001). The stillbirth rate increased in the postadoption cohort compared with preadoption (0.09% vs 0.10%; P < .001). The infant death rate decreased in the postadoption period compared with preadoption (0.21% vs 0.20%; P < .001). An overall mortality rate of 0.31% was calculated for the preadoption period and 0.30% for the postadoption period (P = .06). Additional analysis in a counterfactual model suggests that up to 34.2% of the difference in mortality could be associated with the 39-week rule.

CONCLUSIONS AND RELEVANCE

Stable overall perinatal mortality rates were observed in the 2-year period immediately after adoption of the 39-week rule, despite an increase in stillbirth.

Association between the Degree of Twin Birthweight Discordance and Perinatal Outcomes

BACKGROUND

Twin birthweight discordance is associated with adverse outcomes.

OBJECTIVE

To determine what degree of twin birthweight discordance is associated with adverse outcomes.

STUDY DESIGN

This is a retrospective cohort study of twins with vertex twin A delivered vaginally at 36 to 40 weeks (U.S. Vital Statistics Natality birth certificate registry data 2012-2014). The primary outcome was a composite of neonatal morbidity: 5-minute Apgar < 7, neonatal intensive care unit admission, neonatal mechanical ventilation > 6 hours, neonatal seizure, and/or neonatal transport to a higher level of care. Effect estimates were expressed as incidence rate and adjusted odds ratio (aOR) controlling for confounding using multivariate clustered analysis for between-pair effects, and multilevel random effect generalized estimating equation regressions to account for within-pair effects. We adjusted for sex discordance, breech delivery of the second twin, maternal race/ethnicity, nulliparity, age, marital status, obesity, and socioeconomic status.

RESULTS

In comparison to birthweight discordance of ≤20%, aORs with 95% confidence intervals (CIs) by weight discordance of the primary outcome among 27,276 twin deliveries were as follows: 20.01 to 25% (aOR: 1.46 [95% CI: 1.29-1.65]); 25.01 to 30% (aOR: 1.96 [95% CI: 1.68-2.29]); and 30.01 to 60% (aOR: 2.97 [95% CI: 2.52-3.50]).

CONCLUSION

Twin birthweight discordance >20% was associated with increased odds of adverse neonatal outcome.

Gestational Weight Gain during Pregnancy as an Important Factor Influencing a Successful Trial of Labor following Two Previous Cesareans

OBJECTIVE

We sought to identify factors associated with a successful trial of labor (TOL) following two cesarean deliveries (CDs) in a contemporary North American cohort.

STUDY DESIGN

This is a retrospective cohort study of term, nonanomalous, singleton, vertex pregnancies attempting a vaginal birth after cesarean (VBAC) following a history of two previous CDs in the United States from 2012 to 2014. Maternal and intrapartum factors were analyzed using chi-square tests and multivariable logistic regression.

RESULTS

A total of 22,762 women met the inclusion criteria and underwent TOL. Of these, 12,192 (53.6%) had a VBAC. Using multivariate logistic regression, previous vaginal delivery and delivery at 40 to 41 weeks' gestation were associated with VBAC; maternal age, education, Medicaid insurance, non-Caucasian race/ethnicity, weight (overweight or obese), and gestational weight gain above the Institute of Medicine guidelines (adjusted odds ratio: 0.88; 95% confidence interval: 0.81-0.95) were associated with CD. Induction of labor did not affect the VBAC rate.

CONCLUSION

For those desiring a TOL after two previous CDs, prospective studies are needed to assess interventions that limit gestational weight gain as well as the safety and optimal timing of an induction of labor. The decision to attempt a TOL should be guided by counseling regarding the risks, benefits, and chances of a successful TOL.

Evaluation of the Appropriateness of Acute Hospitalisations in Hong Kong

Objective

To test the validity of the Hong Kong version of Appropriateness Evaluation Protocol and estimate the prevalence of inappropriate acute hospitalisations in Hong Kong.

Methods

A retrospective chart review of two hundred randomly selected patients admitted to the specialty of Internal Medicine and General Surgery via the Accident & Emergency department of 2 regional hospitals in 2008. Comparison between the Hong Kong version of Appropriateness Evaluation Protocol and the consensus of an expert panel on appropriateness of admissions was made. The extent of agreement between the reviewer using the protocol and the expert panel was measured.

Results

The kappa coefficient for agreement was 0.73 (95% confidence interval: 0.63-0.83). The prevalence of inappropriate acute hospitalisations was 29%.

Conclusions

The Hong Kong version of Appropriateness Evaluation Protocol is a valid tool for assessing the appropriateness of acute hospitalisations.

Shifting Patterns in Cesarean Delivery Scheduling and Timing in Oregon before and after a Statewide Hard Stop Policy

OBJECTIVES

To assess the use and timing of scheduled cesareans and other categories of cesarean delivery and the prevalence of neonatal morbidity among cesareans in Oregon before and after the implementation of Oregon's statewide policy limiting elective early deliveries.

DATA SOURCES

Oregon vital statistics records, 2008-2013.

STUDY DESIGN

Retrospective cohort study, with multivariable logistic regression, regression controlling for time trends, and interrupted time series analyses, to compare the odds of different categories of cesarean delivery and the odds of neonatal morbidity pre- and postpolicy.

DATA COLLECTION/EXTRACTION METHODS

We analyzed vital statistics data on all term births in Oregon (2008-2013), excluding births in 2011.

PRINCIPAL FINDINGS

The odds of early-term scheduled cesareans decreased postpolicy (adjusted odds ratio [aOR], 0.70; 95 percent confidence interval [CI], 0.66-0.74). In the postpolicy period, there were mixed findings regarding assisted neonatal ventilation and neonatal intensive care unit admission, with regression models indicating higher postpolicy odds in some categories, but lower postpolicy odds after controlling for time trends.

CONCLUSIONS

Oregon's hard stop policy limiting elective early-term cesarean delivery was associated with lower odds of cesarean delivery in the category of women who were targeted by the policy; more research is needed on impact of such policies on neonatal outcomes.

Association between gestational weight gain and perinatal outcomes in women with chronic hypertension

BACKGROUND

Gestational weight gain above or below the 2009 National Academy of Medicine guidelines has been associated with adverse maternal and neonatal outcomes. Although it has been well established that excess gestational weight gain is associated with the development of gestational hypertension and preeclampsia, the relationship between gestational weight gain and adverse perinatal outcomes among women with pregestational (chronic) hypertension is less clear.

OBJECTIVE

The objective of this study was to examine the relationship between gestational weight gain above and below National Academy of Medicine guidelines and perinatal outcomes in a large, population-based cohort of women with chronic hypertension.

STUDY DESIGN

This is a population-based retrospective cohort study of women with chronic hypertension who had term, singleton, vertex births in the United States from 2012 through 2014. Prepregnancy body mass index was calculated using self-reported prepregnancy weight and height. Women were categorized into 4 groups based on gestational weight gain and prepregnancy body mass index: (1) weight gain less than, (2) weight gain within, (3) weight gain 1-19 lb in excess of, and (4) weight gain ≥20 lb in excess of the National Academy of Medicine guidelines. The χ² tests and multivariable logistic regression analysis were used for statistical comparisons. Stratified analyses by body mass index category were additionally performed.

RESULTS

In this large birth cohort, 101,259 women met criteria for inclusion. Compared to hypertensive women who had gestational weight gain within guidelines, hypertensive women with weight gain ≥20 lb over National Academy of Medicine guidelines were more likely to have eclampsia (adjusted odds ratio, 1.93; 95% confidence interval, 1.54-2.42) and cesarean delivery (adjusted odds ratio, 1.60; 95% confidence interval, 1.50-1.70). Excess weight gain ≥20 lb over National Academy of Medicine guidelines was also associated with increased odds of 5-minute Apgar <7 (adjusted odds ratio, 1.29; 95% confidence interval, 1.13-1.47), neonatal intensive care unit admission (adjusted odds ratio, 1.23; 95% confidence interval, 1.14-1.33), and large-for-gestational-age neonates (adjusted odds ratio, 2.41; 95% confidence interval, 2.27-2.56) as well as decreased odds of small-for-gestational-age status (adjusted odds ratio, 0.52; 95% confidence interval, 0.46-0.58). Weight gain 1-19 lb over guidelines was associated with similar fetal growth outcomes although with a smaller effect size. In contrast, weight gain less than National Academy of Medicine guidelines was not associated with adverse maternal outcomes but was associated with increased odds of small for gestational age (adjusted odds ratio, 1.31; 95% confidence interval, 1.21-1.52) and decreased odds of large-for-gestational-age status (adjusted odds ratio, 0.86; 95% confidence interval, 0.81-0.92). Analysis of maternal and neonatal outcomes stratified by body mass index demonstrated similar findings.

CONCLUSION

Women with chronic hypertension who gain less weight than National Academy of Medicine guidelines experience increased odds of small-for-gestational-age neonates, whereas excess weight gain ≥20 lb over National Academy of Medicine guidelines is associated with cesarean delivery, eclampsia, 5-minute Apgar <7, neonatal intensive care unit admission, and large-for-gestational-age neonates.

Induction of labor versus expectant management of large-for-gestational-age infants in nulliparous women

Background

There is no apparent consensus on obstetric management, i.e., induction of labor or expectant management of women with suspected large-for-gestational-age (LGA)-fetuses.

Methods and findings

To further examine the subject, a nationwide population-based cohort study from the Swedish Medical Birth Register in nulliparous non-diabetic women with singleton, vertex LGA (>90^th centile) births, 1992–2013, was performed. Delivery of a live-born LGA infant induced at 38 completed weeks of gestation in non-preeclamptic pregnancies, was compared to those of expectant management, with delivery at 39, 40, 41, or 42 completed weeks of gestation and beyond, either by labor induction or via spontaneous labor. Primary outcome was mode of delivery. Secondary outcomes included obstetric anal sphincter injury, 5-minute Apgar<7 and birth injury. Multivariable logistic regression analysis was performed to control for potential confounding. We found that among the 722 women induced at week 38, there was a significantly increased risk of cesarean delivery (aOR = 1.44 95% CI:1.20–1.72), compared to those with expectant management (n = 44 081). There was no significant difference between the groups in regards to risk of instrumental vaginal delivery (aOR = 1.05, 95% CI:0.85–1.30), obstetric anal sphincter injury (aOR = 0.81, 95% CI:0.55–1.19), nor 5-minute Apgar<7 (aOR = 1.06, 95% CI:0.58–1.94) or birth injury (aOR = 0.82, 95% CI:0.49–1.38). Similar comparisons for induction of labor at 39, 40 or 41 weeks compared to expectant management with delivery at a later gestational age, showed increased rates of cesarean delivery for induced women.

Conclusions

In women with LGA infants, induction of labor at 38 weeks gestation is associated with increased risk of cesarean delivery compared to expectant management, with no difference in neonatal morbidity.

Duration of Second Stage of Labour at Term and Pushing Time: Risk Factors for Postpartum Haemorrhage

BACKGROUND

Prolonged labour is associated with increased risk of postpartum haemorrhage (PPH), but the role of active pushing time and the relation with management during labour remains poorly understood.

METHODS

A population-based cohort study from electronic medical record data in the Stockholm-Gotland Region, Sweden. We included 57 267 primiparous women with singleton, term gestation, livebirths delivered vaginally in cephalic presentation in 2008-14. We performed multivariable Poisson regression to estimate the association between length of second stage, pushing time, and PPH (estimated blood loss >500 mL during delivery), adjusting for maternal, delivery, and fetal characteristics as potential confounders.

RESULTS

The incidence of PPH was 28.9%. The risk of PPH increased with each passing hour of second stage: compared with a second stage <1 h, the adjusted relative risk (RR) for PPH were for 1 to <2 h 1.10 (95% confidence interval (CI) 1.07, 1.14); for 2 to <3 h 1.15 (95% CI 1.10, 1.20); for 3 to <4 h 1.28 (95% CI 1.22, 1.33); and for ≥4 h 1.40 (95% CI 1.33, 1.46). PPH also increased with pushing time exceeding 30 min. Compared to pushing time between 15 and 29 min, the RR for PPH were for <15 min 0.98 (95% CI 0.94, 1.03); for 30-44 min 1.08 (95% CI 1.04, 1.12); for 45-59 min 1.11 (95% CI 1.06, 1.16); and for ≥60 min 1.20 (95% CI 1.15, 1.25).

CONCLUSIONS

Increased length of second stage and pushing time during labour are both associated with increased risk of PPH.

Transcriptome analysis and anthocyanin-related genes in red leaf lettuce

This study aimed to analyze the transcriptome profile of red lettuce and identify the genes involved in anthocyanin accumulation. Red leaf lettuce is a popular vegetable and popular due to its high anthocyanin content. However, there is limited information available about the genes involved in anthocyanin biosynthesis in this species. In this study, transcriptomes of 15-day-old seedlings and 40-day-old red lettuce leaves were analyzed using an Illuminia HiseqTM 2500 platform. A total of 10.6 GB clean data were obtained and de novo assembled into 83,333 unigenes with an N50 of 1067. After annotation against public databases, 51,850 unigene sequences were identified, among which 46,087 were annotated in the NCBI non-redundant protein database, and 41,752 were annotated in the Swiss-Prot database. A total of 9125 unigenes were mapped into 163 pathways using the Kyoto Encyclopedia of Genes and Genomes database. Thirty-four structural genes were found to cover the main steps of the anthocyanin pathway, including chalcone synthase, chalcone isomerase, flavanone 3-hydroxylase, flavonoid 3'-hydroxylase, flavonoid 3',5'-hydroxylase, dihydroflavonol 4-reductase, and anthocyanidin synthase. Seven MYB, three bHLH, and two WD40 genes, considered anthocyanin regulatory genes, were also identified. In addition, 3607 simple sequence repeat (SSR) markers were identified from 2916 unigenes. This research uncovered the transcriptomic characteristics of red leaf lettuce seedlings and mature plants. The identified candidate genes related to anthocyanin biosynthesis and the detected SSRs provide useful tools for future molecular breeding studies.

Planned Out-of-Hospital Birth and Birth Outcomes

BACKGROUND

The frequency of planned out-of-hospital birth in the United States has increased in recent years. The value of studies assessing the perinatal risks of planned out-of-hospital birth versus hospital birth has been limited by cases in which transfer to a hospital is required and a birth that was initially planned as an out-of-hospital birth is misclassified as a hospital birth.

METHODS

We performed a population-based, retrospective cohort study of all births that occurred in Oregon during 2012 and 2013 using data from newly revised Oregon birth certificates that allowed for the disaggregation of hospital births into the categories of planned in-hospital births and planned out-of-hospital births that took place in the hospital after a woman's intrapartum transfer to the hospital. We assessed perinatal morbidity and mortality, maternal morbidity, and obstetrical procedures according to the planned birth setting (out of hospital vs. hospital).

RESULTS

Planned out-of-hospital birth was associated with a higher rate of perinatal death than was planned in-hospital birth (3.9 vs. 1.8 deaths per 1000 deliveries, P=0.003; odds ratio after adjustment for maternal characteristics and medical conditions, 2.43; 95% confidence interval [CI], 1.37 to 4.30; adjusted risk difference, 1.52 deaths per 1000 births; 95% CI, 0.51 to 2.54). The odds for neonatal seizure were higher and the odds for admission to a neonatal intensive care unit lower with planned out-of-hospital births than with planned in-hospital birth. Planned out-of-hospital birth was also strongly associated with unassisted vaginal delivery (93.8%, vs. 71.9% with planned in-hospital births; P<0.001) and with decreased odds for obstetrical procedures.

CONCLUSIONS

Perinatal mortality was higher with planned out-of-hospital birth than with planned in-hospital birth, but the absolute risk of death was low in both settings. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.).

The risk of fetal death in nonanomalous pregnancies affected by polyhydramnios

OBJECTIVE

The objective of the study was to evaluate the ongoing risk of intrauterine fetal demise (IUFD) in nonanomalous pregnancies affected by polyhydramnios.

STUDY DESIGN

We analyzed a retrospective cohort of all singleton, nonanomalous births in California between 2005 and 2008 as recorded in a statewide birth certificate registry. We included all births between 24+0 and 41+6 weeks' gestational age, excluding multiple gestations, major congenital anomalies, and pregnancies affected by oligohydramnios. Polyhydramnios was identified by International Classification of Diseases, ninth revision, codes. χ(2) tests were used to compare the dichotomous outcomes, and multivariable logistic regression analyses were then performed to control for potential confounders. We analyzed the data for pregnancies affected and unaffected by polyhydramnios. The IUFD risk was expressed as a rate per 10,000.

RESULTS

The risk of IUFD in pregnancies affected by polyhydramnios was greater at every gestational age compared with unaffected pregnancies. The IUFD risk in pregnancies affected by polyhydramnios was more than 7 times higher than unaffected pregnancies at 37 weeks at a rate of 18.0 (95% confidence interval [CI], 9.0-32.6) vs 2.4 (95% CI, 2.0-2.5) and was 11-fold higher by 40 weeks' gestational age at a rate of 66.3 (95% CI, 10.8-68.6) vs 6.0 (95% CI, 5.1-6.3) in unaffected pregnancies. When adjusted for multiple confounding variables, the presence of polyhydramnios remained associated with an increased odds of IUFD in nonanomalous singleton pregnancies, with an adjusted odds ratio of 5.5 (95% CI, 4.1-7.6).

CONCLUSION

Ongoing risk of IUFD is greater in low-risk pregnancies affected by polyhydramnios at all gestational ages compared with unaffected pregnancies with the greatest increase in risk at term. Although further study is needed to explore the underlying etiology of polyhydramnios in these cases, the identification of polyhydramnios alone may warrant increased antenatal surveillance.

Should cell-free DNA testing be used to target antenatal rhesus immune globulin administration?

OBJECTIVE

To compare the rates of alloimmunization with the use of cell-free DNA (cfDNA) screening to target antenatal rhesus immune globulin (RhIG) prenatally, versus routine administration of RhIG in rhesus D (RhD)-negative pregnant women in a theoretic cohort using a decision-analytic model.

METHODS

A decision-analytic model compared cfDNA testing to routine antenatal RhIG administration. The primary outcome was maternal sensitization to RhD antigen. Sensitivity and specificity of cfDNA testing were assumed to be 99.8% and 95.3%, respectively. Univariate and bivariate sensitivity analyses, Monte Carlo simulation, and threshold analyses were performed.

RESULTS

In a cohort of 10,000 RhD-negative women, 22.6 sensitizations would occur with utilization of cfDNA, while 20 sensitizations would occur with routine RhIG. Only when the sensitivity of the cfDNA test reached 100%, the rate of sensitization was equal for both cfDNA and RhIG. Otherwise, routine RhIG minimized the rate of sensitization, especially given RhIG is readily available in the United States.

CONCLUSIONS

Adoption of cfDNA testing would result in a 13.0% increase in sensitization among RhD-negative women in a theoretical cohort taking into account the ethnic diversity of the United States' population.

Identification of heat shock proteins via transcriptome profiling of tree peony leaf exposed to high temperature

The tree peony leaf is an important vegetative organ that is sensitive to abiotic stress and particularly to high temperature. This sensitivity affects plant growth and restricts tree peony distribution. However, the transcriptomic information currently available on the peony leaf in public databases is limited. In this study, we sequenced the transcriptomes of peony leaves subjected to high temperature using the Illumina HiSeq TM 2000 platform. We performed de novo assembly of 93,714 unigenes (average length of 639.7 bp). By searching the public databases, 22,323 unigenes and 13,107 unigenes showed significant similarities with proteins in the NCBI non-redundant protein database and SWISS-PROT database (E-value < 1e-5), respectively. We assigned 17,340 unigenes to Gene Ontology categories, and we assigned 7618 unigenes to clusters of orthologous groups for eukaryotic complete genomes. By searching the Kyoto Encyclopedia of Genes and Genomes Pathway database, 8014 unigenes were assigned to 6 main categories, including 290 KEGG pathways. To advance research on improving thermotolerance, we identified 24 potential heat shock protein genes with complete open reading frames from the transcriptomic sequences. This is the first study to characterize the leaf transcriptome of tree peony leaf using high-throughput sequencing. The information obtained from the tree peony leaf is valuable for gene discovery, and the identified heat shock protein genes can be used to improve plant stress-tolerance.

Weight gain in pregnancy: does the Institute of Medicine have it right?

OBJECTIVE

We aimed to examine whether women who adhered to Institute of Medicine (IOM) guidelines for gestational weight gain (GWG) had improved perinatal outcomes.

STUDY DESIGN

This is a population-based retrospective cohort study of nulliparous women with term singleton vertex births in the United States from 2011 through 2012. Women with medical or obstetric complications were excluded. Prepregnancy body mass index was calculated using reported weight and height. Women were categorized into 4 groups based on GWG and prepregnancy body mass index: (1) weight gain less than, (2) weight gain within, (3) weight gain 1-19 lb in excess of, and (4) weight gain ≥20 lb in excess of the IOM guidelines. The χ(2) test and multivariable logistic regression analysis were used for statistical comparisons.

RESULTS

Compared to women who had GWG within the IOM guidelines, women with excessive weight gain, particularly ≥20 lb, were more likely to have adverse maternal outcomes (preeclampsia: adjusted odds ratio [aOR], 2.78; 95% confidence interval [CI], 2.82-2.93; eclampsia: aOR, 2.51; 95% CI, 2.27-2.78; cesarean: aOR, 2.1; 95% CI, 2.14-2.19), blood transfusion (aOR, 1.22; 95% CI, 1.11-1.33), and neonatal outcomes (5-minute Apgar <4: aOR, 1.22; 95% CI, 1.14-1.31; ventilation use >6 hours: aOR, 1.24; 95% CI, 1.15-1.33; seizure: aOR, 1.53; 95% CI, 1.24-1.89). Women who gained less than IOM guidelines had lower risks of hypertensive disorders of pregnancy and obstetric interventions but were more likely to have small-for-gestational-age neonates (aOR, 1.55; 95% CI, 1.52-1.59).

CONCLUSION

Women whose GWG is in excess of IOM guidelines have higher risk of adverse maternal and neonatal outcomes, particularly in women with ≥20 lb excess weight gain above guidelines while women who had weight gain below the IOM guidelines were less likely to have maternal morbidity but had higher odds of small for gestational age.

The impact of hospital obstetric volume on maternal outcomes in term, non-low-birthweight pregnancies

OBJECTIVE

The impact of hospital obstetric volume specifically on maternal outcomes remains under studied. We examined the impact of hospital obstetric volume on maternal outcomes in low-risk women who delivered non-low-birthweight infants at term.

STUDY DESIGN

We conducted a retrospective cohort study of term singleton, non-low-birthweight live births from 2007-2008 in California. Deliveries were categorized by hospital obstetric volume categories and separately for nonrural hospitals (category 1: 50-1199 deliveries per year; category 2: 1200-2399; category 3: 2400-3599, and category 4: ≥3600) and rural hospitals (category R1: 50-599 births per year; category R2: 600-1699; category R3: ≥1700). Maternal outcomes were compared with the use of the chi-square test and multivariable logistic regression.

RESULTS

There were 736,643 births in 267 hospitals that met study criteria. After adjustment for confounders, there were higher rates of postpartum hemorrhage in the lowest-volume rural hospitals (category R1 adjusted odds ratio, 3.06; 95% confidence interval, 1.51-6.23). Rates of chorioamnionitis, endometritis, severe perineal lacerations, and wound infection did not differ between volume categories. Longer lengths of stay were observed after maternal complications (eg, chorioamnionitis) in the lowest-volume hospitals (16.9% prolonged length of stay in category 1 hospitals vs 10.5% in category 4 hospitals; adjusted odds ratio, 1.91; 95% confidence interval, 1.01-3.61).

CONCLUSION

After confounder adjustment, few maternal outcomes differed by hospital obstetric volume. However, elevated odds of postpartum hemorrhage in low-volume rural hospitals raises the possibility that maternal outcomes may differ by hospital volume and geography. Further research is needed on maternal outcomes in hospitals of different obstetric volumes.

The mortality risk of expectant management compared with delivery stratified by gestational age and race and ethnicity

OBJECTIVE

The objective of the study was to compare the mortality risk of expectant management with the risk of delivery at each week of term pregnancy in 4 racial/ethnic groups.

STUDY DESIGN

This was a retrospective cohort study of all nonanomalous, term deliveries in California from 1997 to 2006 among white, black, Hispanic, and Asian women. In each racial/ethnic group, we compared the risk of infant death at each week with a composite risk representing the mortality risk of 1 week of expectant management.

RESULTS

The risk of stillbirth and infant death is highest in black women (stillbirth risk: 18.0 per 10,000, infant death: 24.4 per 10,000, compared with 9.4 per 10,000 and 10.8 per 10,000 in white women, respectively; P < .001). Although absolute risks differ by race/ethnicity, the composite risk of expectant management does not surpass the risk of delivery until 39 weeks in any group. At 39 weeks these absolute risk differences are low, however, with a number needed to deliver to prevent 1 death ranging from 751 (among black women) to 2587 (among Asian women).

CONCLUSION

The mortality risk of expectant management exceeds the risk of delivery at 39 weeks in all racial/ethnic groups, despite variation in absolute risks.

Intrahepatic cholestasis of pregnancy and timing of delivery

OBJECTIVE

We examined the morbidities from delivery at earlier gestational ages versus intrauterine fetal demise (IUFD) for women with intrahepatic cholestasis of pregnancy (ICP) to determine the optimal gestational age for delivery.

METHODS

A decision-analytic model was created to compare delivery at 35 through 38 weeks gestation for different delivery strategies: (1) empiric steroids; (2) steroids if fetal lung maturity (FLM) negative; (3) wait a week and retest if FLM negative; or (4) deliver immediately. Literature review identified 18 studies that estimated IUFD in ICP; we used the mean rate, 1.74%, and assumed a uniform distribution from 34 to 40 weeks gestation. Large cohort data was used to calculate neonatal morbidity rates at each gestational age. Maternal and neonatal quality-adjusted life years (QALYs) were combined. Univariate sensitivity and Monte Carlo analyses were performed to test for robustness.

RESULTS

Immediate delivery at 36 weeks without FLM testing and steroid administration was the optimal strategy as compared to delivery at 36 weeks with steroids (+47 QALYs) and as compared to immediate delivery at 35 weeks (+210 QALYs). Our results were robust up to a 30% increase in the rate of IUFD.

CONCLUSION

Immediate delivery at 36 weeks in women with ICP is the optimal delivery strategy.

Economic downturns and male cesarean deliveries: a time-series test of the economic stress hypothesis

Background

In light of the recent Great Recession, increasing attention has focused on the health consequences of economic downturns. The perinatal literature does not converge on whether ambient economic declines threaten the health of cohorts in gestation. We set out to test the economic stress hypothesis that the monthly count of cesarean deliveries (CD), which may gauge the level of fetal distress in a population, rises after the economy declines. We focus on male CD since the literature reports that male more than female fetuses appear sensitive to stressors in utero.

Methods

We tested our ecological hypothesis in California for 228 months from January 1989 to December 2007, the most recent data available to us at the time of our tests. We used as the independent variable the Bureau of Labor Statistics unadjusted total state employment series. Time-series methods controlled for patterns of male CD over time. We also adjusted for the monthly count of female CD, which controls for well-characterized factors (e.g., medical-legal environment, changing risk profile of births) that affect CD but are shared across infant sex.

Results

Findings support the economic stress hypothesis in that male CD increases above its expected value one month after employment declines (employment coefficient = -24.09, standard error = 11.88, p = .04). Additional exploratory analyses at the metropolitan level indicate that findings in Los Angeles and Orange Counties appear to drive the State-level relation.

Conclusions

Contracting economies may perturb the health of male more than female fetuses sufficiently enough to warrant more CD. Male relative to female CD may sensitively gauge the cohort health of gestations.

Inhibition of MEK sensitizes gastric cancer cells to TRAIL-induced apoptosis

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), which has long been believed to be highly selective in inducing apoptosis in cancer cells, has turned out to be a molecule that induces a far more diverse range of effects. The aim of this study was to investigate whether or not ERK1/2 pathway is involved in antitumor effects of TRAIL on gastric cancer cells. In addition to activate the extrinsic and intrinsic apoptotic pathway, TRAIL also triggered the activation of ERK1/2. Inhibition of ERK1/2 signaling by MEK inhibitor U0126 promoted cell death via increased activation of caspases, drop in mitochondrial membrane potential and downregulation of XIAP, cIAP2 and Mcl-1. These results indicate that TRAIL-induced rapid activation of ERK1/2 may be a survival mechanism to struggle against TRAIL assault at the early stage, and inhibition of ERK1/2 signaling can sensitize gastric cancer cells to TRAIL-induced apoptosis.

The effect of maternal body mass index on perinatal outcomes in women with diabetes

OBJECTIVE

To determine the effect of increasing maternal obesity, including superobesity (body mass index [BMI] ≥ 50 kg/m2), on perinatal outcomes in women with diabetes.

STUDY DESIGN

Retrospective cohort study of birth records for all live-born nonanomalous singleton infants ≥ 37 weeks' gestation born to Missouri residents with diabetes from 2000 to 2006. Women with either pregestational or gestational diabetes were included.

RESULTS

There were 14,595 births to women with diabetes meeting study criteria, including 7,082 women with a BMI > 30 kg/m2 (48.5%). Compared with normal-weight women with diabetes, increasing BMI category, especially superobesity, was associated with a significantly increased risk for preeclampsia (adjusted relative risk [aRR] 3.6, 95% confidence interval [CI] 2.5, 5.2) and macrosomia (aRR 3.0, 95% CI 1.8, 5.40). The majority of nulliparous obese women with diabetes delivered via cesarean including 50.5% of obese, 61.4% of morbidly obese, and 69.8% of superobese women. The incidence of primary elective cesarean among nulliparous women with diabetes increased significantly with increasing maternal BMI with over 33% of morbidly obese and 39% of superobese women with diabetes delivering electively by cesarean.

CONCLUSION

Increasing maternal obesity in women with diabetes is significantly associated with higher risks of perinatal complications, especially cesarean delivery.

Litigation in obstetrics: does defensive medicine contribute to increases in cesarean delivery?

OBJECTIVE

Obstetrics is one of the most sued subspecialties in the US. This study aimed to examine clinicians' medical-legal experience and its association with recommending cesarean delivery.

DESIGN

Cross-sectional convenience survey.

POPULATION OR SAMPLE

This is a survey study of clinicians in the US.

METHODS

Survey included eight common obstetric clinical vignettes and 27 questions regarding clinicians' practice environment. Chi-square test, multivariable logistic regression models were used for statistical comparisons.

MAIN OUTCOME MEASURES

Likelihood of recommending cesarean delivery.

RESULTS

There were 1486 clinicians who completed the survey. Clinicians were categorized based on answers to clinical vignettes. Having had lawsuits and daily worry of suits were associated with higher likelihood of recommending cesarean, compared to those without lawsuits (17.2 versus 11.3%, respectively; p = 0.008) as was frequent worry of lawsuits (every day, 20.3% more likely; every week/month, 12.3%; few times a year/never, 11.4%, p < 0.001).

CONCLUSION

Obstetric malpractice lawsuit and frequent worry about lawsuit are associated with higher propensity of recommending cesarean delivery in common obstetric settings.

Clinicians' practice environment is associated with a higher likelihood of recommending cesarean deliveries

OBJECTIVE

Little data exist regarding clinicians' role in the rising annual incidence rate of cesarean delivery in the US. We aimed to examine if clinicians' practice environment is associated with recommending cesarean deliveries.

STUDY DESIGN

This is a survey study of clinicians who practice obstetrics in the US. This survey included eight clinical vignettes and 27 questions regarding clinicians' practice environment. Chi-square test and multivariable logistic regression were used for statistical comparison.

RESULTS

Of 27 675 survey links sent, 3646 clinicians received and opened the survey electronically, and 1555 (43%) participated and 1486 (94%) completed the survey. Clinicians were categorized into three groups based on eight common obstetric vignettes as: more likely (n = 215), average likelihood (n = 1099), and less likely (n = 168) to recommend cesarean. Clinician environment factors associated with a higher likelihood of recommending cesarean included Laborists/Hospitalists practice model (p < 0.001), as-needed anesthesia support (p = 0.003), and rural/suburban practice setting (p < 0.001).

CONCLUSION

We identified factors in clinicians' environment associated with their likelihood of recommending cesarean delivery. The decision to recommend cesarean delivery is a complicated one and is likely not solely based on patient factors.