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OBJECTIVE: To determine the risk of wound complications by skin incision type in obese women undergoing cesarean delivery.Data sources: Electronic databases (MEDLINE, Scopus, and Ovid) were searched from their inception through August 2018.Methods of study selection: We included all randomized controlled trials and cohort studies reporting the placement of skin incision during cesarean section in obese women, defined as those with BMI ≥30 kg/m2. Studies were included if they compared one placement of skin incision with a different one as comparison group. The primary outcome was incidence of wound complications, while secondary outcomes included wound infection, hematoma, seroma, postpartum hemorrhage, and endometritis. Demographics and outcomes for each individual study identified were reported as part of the review. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference (MD) or relative risk (RR) with 95% confidence interval (CI). Sub-group analyses (vertical versus Pfannenstiel) were also reported.Tabulation, integration and results: Seventeen studies (including 3 RCTs; 8960 participants among the 15 non-overlapping studies) were included in the systematic review. Vertical incisions were associated with a relative risk of 2.07 (95% CI1.61-2.67) for wound complications compared to transverse incisions, however significant possible confounders were present. Studies were mildly-moderately heterogeneous (I2 44.81%, 95% CI 0.00-71.85%) with varying definitions of obesity and wound complications. High transverse incisions (3 studies, 218 participants) trend toward a lower risk of wound complications compared to low transverse incisions (RR 0.338, 95% CI 0.114-1.004). CONCLUSIONS: Vertical incisions may be associated with an increased risk for wound complications compared to transverse incisions for cesarean delivery in obese women. Randomized controlled trials are needed to evaluate optimal cesarean skin incisions for these women.
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Cesárea , Herida Quirúrgica , Cesárea/efectos adversos , Cesárea/métodos , Femenino , Humanos , Obesidad/complicaciones , Embarazo , Herida Quirúrgica/complicaciones , Dehiscencia de la Herida Operatoria/epidemiología , Dehiscencia de la Herida Operatoria/etiología , Infección de la Herida Quirúrgica/complicaciones , Infección de la Herida Quirúrgica/etiologíaRESUMEN
Chiropractic care is a commonly used treatment modality for musculoskeletal pain in pregnancy. Low back pain, pelvic pain, and other neuromuscular complaints are prevalent in pregnancy and contribute to significant maternal discomfort in many women. Nonpharmacologic therapies to relieve pain are increasingly important during pregnancy because of the opioid epidemic. Chiropractic treatment is one of the potential therapies that offers intervention without medications. This article provides an evidence-based review of the epidemiology of chiropractic use in obstetrics, commonly treated conditions, related physiology of pregnancy, and safety of spinal manipulation.
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Quiropráctica , Dolor de la Región Lumbar , Manipulación Quiropráctica , Complicaciones del Embarazo , Femenino , Humanos , Dolor de la Región Lumbar/terapia , Dolor Pélvico , Embarazo , Complicaciones del Embarazo/terapiaRESUMEN
OBJECTIVE: To compare the utility of maximum vertical pocket versus amniotic fluid index for predicting adverse perinatal outcomes. METHODS: Systematic review of randomized clinical studies comparing these two ultrasound techniques and random-effects meta-analysis to quantify a range of perinatal outcomes. RESULT: Six studies with 4278 women were eligible. Use of the maximum vertical pocket reduced the rate of diagnosis of oligohydramnios (pooled relative risk 0.38; 95% confidence interval 0.27, 0.53). Use of the maximum vertical pocket was associated with significantly lower rates of non-reassuring fetal heart tracing, cesarean delivery for fetal distress, and induction of labor for oligohydramnios. There were no differences in the rates of cesarean delivery, presence of meconium, umbilical artery pH <7.1, 5-minute Apgar score <7, or admission to the neonatal intensive care unit. CONCLUSION: The use of maximum vertical pocket is associated with a lower rate of pregnancy intervention without any worsening of adverse pregnancy outcomes.
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Trabajo de Parto , Oligohidramnios , Líquido Amniótico , Femenino , Sufrimiento Fetal , Humanos , Recién Nacido , Oligohidramnios/diagnóstico por imagen , Embarazo , Resultado del Embarazo/epidemiologíaRESUMEN
Compare echocardiographic phenotypes of women presenting with peripartum heart failure. A retrospective case-control study of pregnant women (n = 86) presenting with PP-HF symptoms (i.e., dyspnea, PND, orthopnea) and objective examination and laboratory findings (lung congestion, elevated JVP and/or HJR, elevated brain natriuretic peptide [BNP] and pulmonary edema on chest X-ray). Three distinct phenotypes based on echocardiographically-defined LVEF were identified: (a) PP-HF with preserved ejection fraction (PP HFpEF, LVEF: > 50%); (b) PP-HF with midrange ejection fraction (PP HFmrEF, LVEF: 40-50%); c) PP-HF with reduced ejection fraction (PP HFrEF, LVEF: < 40%); these were compared with 17 pregnant subjects without PP-HF symptoms/findings. Most patients were African American (n = 63; 73%), with low prevalence of hypertension (n = 15, 17%) or diabetes mellitus (n = 5, 5%); pre-eclampsia was highly prevalent (n = 52, 60%). Echocardiographically-defined phenotypes (HFpEF, n = 37; HFmrEF, n = 18; HFrEF, n = 31) showed progressively worse abnormalities in LV remodeling (LV enlargement, LV hypertrophy), LV diastolic function, and right ventricular function; the three PP-HF groups had comparable abnormalities in increased left atrial size and estimated peak tricuspid valve regurgitation velocity. Compared to controls, all three groups had significantly increased filling pressures, LV mass index and left atrial volume index. Peripartum women presenting with the clinical syndrome of heart failure exhibit a spectrum of echocardiographic phenotypes. Significant abnormalities in LV structure, diastolic function, LA size, peak TR velocity and RV function were identified in women with preserved and mid-range EFs, suggesting pregnancy-related cardiac pathophysiologic derangements.
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Ecocardiografía , Insuficiencia Cardíaca/diagnóstico por imagen , Complicaciones Cardiovasculares del Embarazo/diagnóstico por imagen , Ultrasonografía Prenatal , Adulto , Función del Atrio Izquierdo , Diabetes Mellitus/epidemiología , Femenino , Insuficiencia Cardíaca/fisiopatología , Humanos , Hipertensión/epidemiología , Fenotipo , Preeclampsia/epidemiología , Valor Predictivo de las Pruebas , Embarazo , Complicaciones Cardiovasculares del Embarazo/mortalidad , Complicaciones Cardiovasculares del Embarazo/fisiopatología , Complicaciones Cardiovasculares del Embarazo/terapia , Prevalencia , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Fumar/efectos adversos , Fumar/epidemiología , Volumen Sistólico , Factores de Tiempo , Función Ventricular Izquierda , Función Ventricular Derecha , Remodelación Ventricular , Adulto JovenRESUMEN
Objectives: While percutaneous umbilical cord blood sampling (PUBS) and intrauterine transfusion (IUT) are the standards of care for the management of significant fetal anemia, the neonatal complications resultant from these procedures remain poorly understood. Thus, we aimed to compare neonatal outcomes of the patients undergoing percutaneous umbilical cord blood sampling (PUBS) for intrauterine transfusion (IUT) to gestational age- and sex-matched controls with no indication for and not undergoing PUBS.Methods: This was a retrospective matched cohort study at a single institution from 2000 to 2017. Clinical and demographic data were abstracted from the medical record of patients undergoing PUBS. Neonatal outcomes from pregnancies undergoing PUBS for suspected fetal anemia and from randomly selected gestational age- and sex-matched controls were collected. Neonatal outcomes were compared using matched pairs analysis.Results: There were 64 patients who underwent a total of 178 PUBS with 157 IUT. The most common etiology of fetal anemia was anti-D alloimmunization. On an average, patients undergoing PUBS underwent two procedures (IQR 1,4). There were available neonatal outcomes in 40 patients. The median gestational age at delivery was 34 weeks in both neonates who underwent PUBS and controls. In matched pairs analysis, neonates who underwent PUBS were at higher risk for neonatal complications compared to control neonates (92.5 vs. 55%, OR 4.5, 95% CI 4.5, ∞) . Specifically, neonates who underwent PUBS were more likely to experience respiratory complications compared to controls despite a higher uptake of antenatal corticosteroids.Conclusions: We found that neonates who underwent PUBS experience a higher occurrence of complications which does not appear to be secondary to prematurity alone. Despite higher uptake of antenatal corticosteroids in neonates who underwent PUBS as compared to control neonates, neonates who underwent PUBS had a higher risk of respiratory complications. This study can help to inform patients undergoing PUBS/IUT on the anticipated neonatal outcomes and anticipate needed neonatology resources. While PUBS/IUT is the best treatment known to date for management of fetal anemia, our study highlights the need for further research into the subsequent neonatal complications and how to prevent them.
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Diseases of the gallbladder and biliary tract are extremely common in developed nations. Because of the physiology of pregnancy, their incidence increases during gestation. This article represents a review of the existing literature on the entire spectrum of biliary disease. The physiology, clinical presentation, and diagnostic evaluation of a variety of conditions are reviewed. Historical and contemporary data regarding pregnancy implications and treatment options are discussed.
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Enfermedades de la Vesícula Biliar/fisiopatología , Complicaciones del Embarazo/fisiopatología , Femenino , Vesícula Biliar/anatomía & histología , Vesícula Biliar/embriología , Enfermedades de la Vesícula Biliar/diagnóstico , Enfermedades de la Vesícula Biliar/epidemiología , Enfermedades de la Vesícula Biliar/terapia , Humanos , Pancreatitis/diagnóstico , Pancreatitis/fisiopatología , Pancreatitis/terapia , Embarazo , Complicaciones del Embarazo/diagnóstico , Complicaciones del Embarazo/terapiaRESUMEN
OBJECTIVE: To estimate the prevalence and characteristics of fetal thrombocytopenia at the time of percutaneous umbilical cord sampling (PUBS) in pregnancies complicated by alloimmunization and to conduct a systematic review on fetal thrombocytopenia in these pregnancies. STUDY DESIGN: Retrospective cohort study of all patients undergoing PUBS at our institution from 2000-2017. Clinical data, including fetal platelet counts, were abstracted from the medical record and analyzed with routine statistical procedures. A systematic review and meta-analysis were also conducted according to standard procedures. RESULT: At first procedure, prior to any transfusion, 13/36 fetuses (36%) had thrombocytopenia: 11/36 (31%) had moderate thrombocytopenia and 2/36 (6%) had severe thrombocytopenia (14 patients had no platelet count at first procedure). The systematic review identified six studies, and the prevalence of fetal thrombocytopenia at the time of PUBS for alloimmunization was 18% (95% confidence interval 11%, 26%). CONCLUSION: Thrombocytopenia is common and underappreciated in fetuses undergoing PUBS for alloimmunization.
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Incompatibilidad de Grupos Sanguíneos/complicaciones , Sangre Fetal , Enfermedades Fetales/etiología , Trombocitopenia/etiología , Anemia/diagnóstico , Anemia/etiología , Antígenos de Plaqueta Humana/inmunología , Femenino , Sangre Fetal/citología , Fetoscopía , Edad Gestacional , Humanos , Recuento de Plaquetas , Embarazo , Complicaciones Hematológicas del Embarazo , Estudios Retrospectivos , Trombocitopenia/diagnóstico , Trombocitopenia/inmunologíaRESUMEN
OBJECTIVE: The objective of this study was to compare the rates of spontaneous labor onset and its progression in obese and nonobese women after 37 weeks. STUDY DESIGN: We performed a secondary analysis of a retrospective cohort of all women who were admitted for delivery at ≥ 37 weeks of gestation at a university-based tertiary care center between 2004 and 2010. The cohort was stratified by weeks of gestation at which the patient presented for delivery. The rates of spontaneous labor, vaginal delivery, and augmentation with oxytocin were compared between obese (body mass index [BMI] ≥ 30) and nonobese (BMI < 30) women. RESULTS: Obese women had lower rates of spontaneous labor than nonobese women at every gestational week (37 weeks, 6.1 vs. 9.3%, p < 0.001; 38 weeks, 12.8 vs. 19.2%, p < 0.001; 39 weeks 26.0 vs. 37.0%, p < 0.001; 40 weeks, 39.6 vs. 50.2%, p < 0.001; 41 weeks, 30.8 vs. 38.0%, p < 0.012). Among women who presented in spontaneous labor, obesity was associated with higher rates of augmentation with oxytocin and lower rates of vaginal delivery. CONCLUSION: Obese women at or beyond 37 weeks are less likely to experience spontaneous labor compared with nonobese women. In addition, obese women presenting in spontaneous labor are less likely that nonobese women to have a vaginal delivery at 37 to 40 weeks, even after oxytocin augmentation.
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Índice de Masa Corporal , Inicio del Trabajo de Parto , Obesidad/fisiopatología , Adulto , Femenino , Edad Gestacional , Humanos , Trabajo de Parto Inducido/métodos , Modelos Logísticos , Missouri , Análisis Multivariante , Oxitocina/uso terapéutico , Embarazo , Estudios Retrospectivos , Nacimiento a Término , Centros de Atención Terciaria , Adulto JovenRESUMEN
BACKGROUND: Preeclampsia is a risk factor for the development of peripartum cardiomyopathy (PPCM), but it is unknown whether preeclampsia impacts clinical or left ventricular (LV) functional outcomes. This study sought to assess clinical and functional outcomes in women with PPCM complicated by preeclampsia. METHODS AND RESULTS: This retrospective cohort study included women diagnosed with PPCM delivering at Barnes-Jewish Hospital between 2004 to 2014. The primary outcome was one-year event-free survival rate for the combined end point of death and hospital readmission. The secondary outcome was recovery of LV ejection fraction. Seventeen of 39 women (44%) with PPCM had preeclampsia. The groups had similar mean LV ejection fraction at diagnosis (29.6 with versus 27.3 without preeclampsia; P=0.5). Women with preeclampsia had smaller mean LV end-diastolic diameters (5.2 versus 6.0 cm; P=0.001), greater relative wall thickness (0.41 versus 0.35 mm Hg; P=0.009), and lower incidence of eccentric remodeling (12% versus 48%; P=0.03). Clinical follow-up was available for 32 women; 5 died of cardiovascular complications within 1 year of diagnosis (4/15 with versus 1/17 without preeclampsia; P=0.16). In time to event analysis, patients with preeclampsia had worse event-free survival during 1-year follow-up (P=0.047). Echocardiographic follow-up was available in 10 survivors with and 16 without preeclampsia. LV ejection fraction recovered in 80% of survivors with versus 25% without preeclampsia (P=0.014). CONCLUSIONS: PPCM with concomitant preeclampsia is associated with increased morbidity and mortality and different patterns of LV remodeling and recovery of LV function when compared with patients with PPCM that is not complicated by preeclampsia.
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Cardiomiopatía Dilatada/fisiopatología , Preeclampsia/fisiopatología , Complicaciones Cardiovasculares del Embarazo , Adulto , Cardiomiopatía Dilatada/epidemiología , Cardiomiopatía Dilatada/etiología , Supervivencia sin Enfermedad , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Periodo Periparto , Preeclampsia/diagnóstico , Preeclampsia/epidemiología , Embarazo , Estudios Retrospectivos , Factores de Riesgo , Estados Unidos/epidemiología , Función Ventricular Izquierda/fisiologíaRESUMEN
OBJECTIVE: To estimate whether pregnancy outcomes in women with severe preeclampsia (sPE) with small for gestational age (SGA) fetuses differ from those with sPE without SGA or isolated SGA. STUDY DESIGN: We conducted a retrospective cohort study of consecutive non-anomalous, livebirths in a single tertiary care institution from 2004 to 2008. We compared pregnancy outcomes in women who had sPE with SGA (birthweight<10th percentile), and sPE without SGA to those with isolated SGA as reference. The primary outcome was a neonatal composite score including low 5-min APGAR, NICU admission and neonatal death. Secondary outcomes were components of the composite as well as placental abruption and cesarean delivery. Analysis was repeated with SGA defined as birthweight<5th percentile. Multivariable logistic regression was used to adjust for confounders. RESULTS: 1905 women met inclusion criteria: 156 sPE with SGA, 746 sPE without SGA, 1003 isolated SGA. The risk of the neonatal composite score was higher for sPE with SGA (adjusted odds ratio [aOR] 2.29; 95% confidence interval [CI] 1.39-3.79) and sPE without SGA (aOR 3.66; 95% CI 2.71-4.93) compared to isolated SGA. The risk of abruption and cesarean were similarly increased in women with sPE with SGA and sPE without SGA compared to those with isolated SGA. CONCLUSION: Similar to women with sPE without SGA fetus, women who have sPE with SGA are at a higher risk for several adverse maternal and neonatal outcomes compared to isolated SGA. These findings suggest that women with preeclampsia and SGA should be managed as sPE rather than as isolated SGA.
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Retardo del Crecimiento Fetal/fisiopatología , Recién Nacido Pequeño para la Edad Gestacional , Preeclampsia/fisiopatología , Desprendimiento Prematuro de la Placenta/etiología , Desprendimiento Prematuro de la Placenta/fisiopatología , Adulto , Puntaje de Apgar , Cesárea , Distribución de Chi-Cuadrado , Femenino , Retardo del Crecimiento Fetal/diagnóstico , Retardo del Crecimiento Fetal/etiología , Retardo del Crecimiento Fetal/mortalidad , Humanos , Lactante , Mortalidad Infantil , Unidades de Cuidado Intensivo Neonatal , Nacimiento Vivo , Modelos Logísticos , Análisis Multivariante , Oportunidad Relativa , Admisión del Paciente , Preeclampsia/diagnóstico , Embarazo , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Centros de Atención Terciaria , Adulto JovenRESUMEN
OBJECTIVE: To estimate whether marijuana use in pregnancy increases risks for adverse neonatal outcomes and clarify if any increased risk is attributable to marijuana use itself or to confounding factors such as tobacco use. DATA SOURCES: Two authors performed a search of the data through August 2015 utilizing PubMed, Embase, Scopus, Cochrane reviews, ClinicalTrials.gov, and Cumulative Index to Nursing and Allied Health. METHODS OF STUDY SELECTION: We looked at observational studies that compared rates of prespecified adverse neonatal outcomes in women who used marijuana during pregnancy with women who did not. TABULATION, INTEGRATION, AND RESULTS: Two authors independently extracted data from the selected studies. Primary outcomes were low birth weight (less than 2,500 g) and preterm delivery at less than 37 weeks of gestation. Secondary outcomes were birth weight, gestational age at delivery, small for gestational age, level II or greater nursery admission, stillbirth, spontaneous abortion, low Apgar score, placental abruption, and perinatal death. DerSimonian-Laird random-effects models were used. We assessed heterogeneity using the Q test and I statistic. Stratified analyses were performed for the primary outcomes and pooled adjusted estimates were calculated. We included 31 studies that assessed the effects of maternal marijuana use on adverse neonatal outcomes. Based on pooled unadjusted data, marijuana use during pregnancy was associated with an increased risk of low birth weight (15.4% compared with 10.4%, pooled relative risk [RR] 1.43, 95% confidence interval [CI] 1.27-1.62) and preterm delivery (15.3% compared with 9.6%, pooled RR 1.32, 95% CI 1.14-1.54). However, pooled data adjusted for tobacco use and other confounding factors showed no statistically significant increased risk for low birth weight (pooled RR 1.16, 95% CI 0.98-1.37) or preterm delivery (pooled RR 1.08, 95% CI 0.82-1.43). CONCLUSION: Maternal marijuana use during pregnancy is not an independent risk factor for adverse neonatal outcomes after adjusting for confounding factors. Thus, the association between maternal marijuana use and adverse outcomes appears attributable to concomitant tobacco use and other confounding factors.
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Peso al Nacer , Abuso de Marihuana/epidemiología , Nacimiento Prematuro/epidemiología , Factores de Confusión Epidemiológicos , Femenino , Humanos , Recién Nacido de Bajo Peso , Recién Nacido , Abuso de Marihuana/complicaciones , Embarazo , Factores de Riesgo , Fumar/epidemiologíaRESUMEN
BACKGROUND: Perineal lacerations are common at the time of vaginal delivery and may predispose patients to long-term pelvic floor disorders, such as urinary incontinence and pelvic organ prolapse. Obstetric anal sphincter injuries, which are the most severe form of perineal lacerations, result in disruption of the anal sphincter and, in some cases, the rectal mucosa during vaginal delivery. Long-term morbidity, including pain, pelvic floor disorders, fecal incontinence, and predisposition to recurrent injury at subsequent delivery may result. Despite several studies that have reported risk factors for obstetric anal sphincter injuries, no accurate risk prediction models have been developed. OBJECTIVE: The purpose of this study was to identify risk factors and develop prediction models for perineal lacerations and obstetric anal sphincter injuries. STUDY DESIGN: This was a nested case control study within a retrospective cohort of consecutive term vaginal deliveries at 1 tertiary care facility from 2004-2008. Cases were patients with any perineal laceration that had been sustained during vaginal delivery; control subjects had no lacerations of any severity. Secondary analyses investigated obstetric anal sphincter injury (3rd- to 4(th)-degree laceration) vs no obstetric anal sphincter injury (0 to 2(nd)-degree laceration). Baseline characteristics were compared between groups with the use of the chi-square and Student t test. Adjusted odds ratios and 95% confidence intervals were calculated with the use of multivariable logistic regression. Prediction models were created and model performance was estimated with receiver-operator characteristic curve analysis. Receiver-operator characteristic curves were validated internally with the use of the bootstrap method to correct for bias within the model. RESULTS: Of the 5569 term vaginal deliveries that were recorded during the study period, complete laceration data were available in 5524 deliveries. There were 3382 perineal lacerations and 249 (4.5%) obstetric anal sphincter injuries. After adjusted analysis, significant predictors for laceration included nulliparity, non-black race, longer second stage, nonsmoking status, higher infant birthweight, and operative delivery. Private health insurance, labor induction, pushing duration, and regional anesthesia were not statistically significant in adjusted analyses. Significant risk factors for obstetric anal sphincter injury were similar to predictors for any laceration; nulliparity and operative vaginal delivery had the highest predictive value. Area under the curve for the predictive ability of the models was 0.70 for overall perineal laceration, and 0.83 for obstetric anal sphincter injury. When limited to primiparous patients, 1996 term vaginal deliveries were recorded. One hundred ninety-two women sustained an obstetric anal sphincter injury; 1796 women did not. After adjusted analysis, significant predictors for laceration included non-black race, age, obesity, and nonsmoking status. In secondary analyses, significant predictors for obstetric anal sphincter injury included non-black race, nonsmoking status, longer duration of pushing, operative vaginal delivery, and infant birthweight. Area under the curve for the predictive ability of the models was 0.60 for any laceration and 0.77 for obstetric anal sphincter injury. CONCLUSIONS: Significant risk factors for sustaining any laceration and obstetric anal sphincter injury during vaginal deliveries were identified. These results will help identify clinically at-risk patients and assist providers in counseling patients about modifications to decrease these risks.
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Canal Anal/lesiones , Parto Obstétrico/efectos adversos , Perineo/lesiones , Adolescente , Adulto , Estudios de Casos y Controles , Femenino , Humanos , Paridad , Embarazo , Estudios Retrospectivos , Factores de Riesgo , Adulto JovenRESUMEN
OPINION STATEMENT: The cardiovascular risk of pregnancy among women with congenital heart disease is heterogeneous, ranging from negligible to prohibitively high. Nonetheless, many of these patients do not report being counseled about the potential risks, and the incidence of unintended pregnancy is high. These women should be counseled on safe and effective contraceptive options. Long-acting reversible contraceptives, including the intrauterine devices and etonogestrel implant, are highly effective and safe for all cardiac patients. These are good options for pregnancy planning for women at elevated risk of cardiovascular complications during pregnancy, who are taking potentially teratogenic medications, or who have contraindications to estrogen-containing methods. Pregnancy management begins with pre-conceptual risk stratification and counseling regarding individual cardiovascular and fetal risks. As significant lapse in care is common at the time of transition to adult congenital cardiology care, these discussions ideally begin in pediatric clinics and continue upon transfer of care to adult congenital cardiology clinics.
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OBJECTIVE: To systematically review the literature and synthesize data on the diagnostic performance of a 12-hour urine collection for proteinuria in pregnant women with suspected preeclampsia. DATA SOURCES: We performed a literature search of PubMed, Embase, Scopus, ClinicalTrials.gov, and CINAHL through February 2014 using key words related to gestational hypertension, preeclampsia, and proteinuria. METHODS OF STUDY SELECTION: Studies that contained results of both the 12-hour and 24-hour urine collection in the same patients were eligible. TABULATION, INTEGRATION, AND RESULTS: Three independent reviewers abstracted test performance characteristics from each study for the performance of a 12-hour urine collection for the diagnosis of proteinuria defined as 300 mg in 24 hours. Diagnostic meta-analysis was performed to obtain summary statistics. Heterogeneity was assessed using the Cochrane Q or I. Receiver operating characteristic curve analysis was used to assess the optimal diagnostic cutpoint for proteinuria from a 12-hour urine collection. Stratified analysis was performed based on whether patients were on bed rest during urine collection. A total of seven studies met inclusion criteria. The 12-hour urine protein was overall highly predictive of proteinuria on 24-hour urine collection area under receiver operating characteristic curve: 0.97 (95% confidence interval [CI] 0.95-0.98). The pooled sensitivity was 92% (95% CI 86-96) and specificity was 99% (95% CI 75-100). The optimal cutpoint based on the receiver operating characteristic curve was 150 mg of protein on 12-hour collection. CONCLUSION: A 12-hour urine collection compares favorably with a 24-hour urine collection for the diagnosis of proteinuria in women with suspected preeclampsia and has the advantage of convenience and improved clinical efficiency.
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Preeclampsia/diagnóstico , Proteinuria/diagnóstico , Toma de Muestras de Orina/normas , Femenino , Humanos , Preeclampsia/orina , Embarazo , Proteinuria/orinaRESUMEN
OBJECTIVE: Marijuana use is becoming increasingly common in the obstetric population; however, it is unknown whether it is associated with poor neonatal outcomes. We sought to determine the prevalence and risk factors for marijuana use in pregnancy and to evaluate whether marijuana use is independently associated with poor neonatal outcomes. STUDY DESIGN: This was a retrospective cohort study of all consecutive, nonanomalous, term deliveries at 1 institution over a 4-year study period. Women with marijuana use during pregnancy, either by self-report or positive urine drug screen, were compared with women who did not use marijuana. The primary outcome was a composite neonatal morbidity including birthweight less than 2500 g, neonatal intensive care unit admission, 5-minute Apgar score less than 7, and umbilical artery pH less than 7.10. Univariate, bivariate, and multiple logistic regression analyses were performed. RESULTS: Among the 8138 women in the cohort, 680 (8.4%) used marijuana during pregnancy. Women who used marijuana were younger; more likely to be of African American race; have inadequate prenatal care; and use tobacco, alcohol, and other drugs. Medical comorbidities did not differ between groups. After adjusting for smoking, other drug use, and African American race, the composite and all individual markers of poor neonatal outcome were not significantly higher among women who used marijuana during pregnancy. CONCLUSION: Marijuana use is common in pregnancy but may not be an independent risk factor for poor neonatal outcomes in term pregnancies.
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Fumar Marihuana/efectos adversos , Conducta Materna , Efectos Tardíos de la Exposición Prenatal/etiología , Adulto , Puntaje de Apgar , Estudios de Cohortes , Femenino , Humanos , Recién Nacido de Bajo Peso , Recién Nacido , Modelos Logísticos , Fumar Marihuana/epidemiología , Embarazo , Prevalencia , Estudios Retrospectivos , Factores de RiesgoRESUMEN
With the success of modern surgical techniques for congenital heart disease, the population of women of childbearing age with congenital heart disease is growing. Because of the significant hemodynamic load of pregnancy, labor, and delivery, women with congenital heart disease require preconceptual risk assessment and expert multidisciplinary care throughout pregnancy. The aim of this review is to discuss the management of cardiovascular, obstetric, and fetal care issues that are commonly encountered during pregnancy in women with congenital heart disease.
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Cardiopatías Congénitas/complicaciones , Complicaciones Cardiovasculares del Embarazo , Embarazo de Alto Riesgo/fisiología , Adulto , Parto Obstétrico , Femenino , Cardiopatías Congénitas/clasificación , Humanos , Atención Preconceptiva , Embarazo , Complicaciones Cardiovasculares del Embarazo/clasificación , Resultado del Embarazo , Medición de RiesgoRESUMEN
OBJECTIVE: The definition of postpartum hemorrhage (PPH) was developed more than 50 years ago. Since then, the obstetric population has changed dramatically. We sought to determine how well we estimated blood loss (EBL) and find thresholds predicting need for transfusion. STUDY DESIGN: We performed a prospective cohort study from 2010 to 2012, comparing those who needed transfusion postpartum and those who did not. EBL, calculated EBL (cEBL), and change in hematocrit were calculated for patients who did not receive transfusion, and EBL was calculated for those who did receive transfusion, stratified by delivery type. Receiver operator curves were created and optimal thresholds of EBL to predict transfusion were estimated. RESULTS: Among 4,804 patients, transfusion was required for 0.65% of vaginal and 8.7% of cesarean deliveries. Median EBL was higher in women requiring transfusion. A weak correlation was noted between EBL and cEBL for all deliveries. Thresholds of 500 mL blood loss for vaginal delivery and 1,000 mL for cesarean had the best predictive ability for transfusion. CONCLUSION: In this modern obstetric, cohort EBL is weakly correlated with cEBL, suggesting that accuracy of clinical estimates of blood loss is modest. However, EBL predicts need for transfusion, with optimal thresholds of 500 mL for a vaginal delivery and 1,000 mL in a cesarean. This validates the traditional definitions of PPH in our modern population.