RESUMO
OBJECTIVE: To evaluate differences in reproductive and neonatal outcomes on the basis of the time interval from cesarean delivery to subsequent frozen embryo transfer (FET). DESIGN: Retrospective cohort. SETTING: Multicenter fertility practice. PATIENTS: Women undergoing autologous elective single embryo transfer FET after prior cesarean delivery. INTERVENTION: Time from prior cesarean delivery to subsequent FET. MAIN OUTCOME MEASURES: live birth (LB). RESULTS: A total of 6,556 autologous elective single embryo transfer FET cycles were included. Frozen embryo transfer cycles were divided into eight groups on the basis of the time interval from prior cesarean delivery to subsequent FET in months. A secondary analysis was then performed with time as a continuous variable. The proportion of LBs did not differ significantly across all time interval groups and over continuous time (range: 40.0%-45.6%). The mean gestational age at the time of delivery did not significantly differ as the time between prior cesarean delivery and subsequent FET increased (range: 37.3-38.4). When time was evaluated continuously, the proportion of preterm births was higher with a shorter time between cesarean delivery and subsequent FET. The mean birth weight ranged from 3,181-3,470g, with a statistically significant increase over time. However, the proportions of extremely low birth weight, very low birth weight, and low birth weight did not significantly differ. CONCLUSION: There were no significant differences in reproductive outcomes on the basis of the time interval from cesarean delivery to FET, including LB. The proportion of preterm deliveries decreased with a longer time between cesarean delivery and FET. Differences in mean neonatal birth weight were not clinically significant because the proportion of low birth weight neonates was not significantly different over time. Although large, this sample cannot address all outcomes associated with short interpregnancy intervals, particularly rarer outcomes such as uterine rupture. When counseling patients, the timing of FET after cesarean delivery must be balanced against the risks of increasing maternal age on reproductive and neonatal outcomes.
RESUMO
OBJECTIVE: To determine an optimal timing strategy for rescue corticosteroids in gravidas with preterm prelabor rupture of membranes (PPROM) prior to 33 0/7 weeks. METHODS: This was a retrospective cohort analysis of 109 gravidas with a singleton gestation and PPROM between 23 0/7 and 32 6/7 weeks who delivered at a single inner city tertiary care center. The time of the actual first dose of corticosteroids was chosen as Time 0. The date and time of labor onset, chorioamnionitis, heavy bleeding, cord prolapse, or fetal heart rate decelerations warranting delivery were recorded, as well as the date and time of delivery. We then compared hypothetical timing strategies for administration of the rescue course of corticosteroids at either 1, 2, or 3 weeks after the first course if still undelivered, compared to a strategy of withholding the rescue course until the recognition of spontaneous labor or the need for delivery. For each strategy, we calculated the percentage of gravidas who would have delivered within the optimal window after rescue course corticosteroids, defined as delivery at 24 h to 7 days from the first rescue dose. RESULTS: The median time from PPROM to delivery among the 109 gravidas was 8.9 days (interquartile range 4.4-17.9 days). Forty-eight (44%) gravidas delivered within the first week after initial corticosteroid administration, leaving 61 (56%) eligible for a rescue dose. In our hypothetical models, the strategy of giving rescue corticosteroids at either 1, 2, or 3 weeks from the first course would have resulted in 34.4%, 23.0%, and 19.7% of infants being born at 24 h to 7 days after the first rescue dose, respectively. These differences among the three groups or between any two groups were not statistically significant. However, all fixed interval strategies were statistically superior to the strategy of waiting for spontaneous labor or the need for delivery, in which only 4.9% would have delivered within the optimal window. CONCLUSION: In gravidas with PPROM prior to 33 0/7 weeks, giving rescue corticosteroids at a fixed interval of either 1, 2, or 3 weeks after the first course would result in a greater percentage of infants being born within the optimal 24 h to 7 day window compared to administering the rescue course at the onset of labor, infection, bleeding, or abnormal fetal heart rate tracing.