The association of skin incision placement during cesarean delivery with wound complications in obese women: a systematic review and meta-analysis.

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.

Lower Extremity Blood Flow Velocity in Obese versus Nonobese Pregnant Women.

OBJECTIVE: Obesity and pregnancy are risk factors for venous thromboembolism (VTE). In nonpregnant individuals, abdominal obesity is associated with venous insufficiency. This study aimed to compare venous Doppler volume flow and velocity in the lower extremities of obese versus nonobese women. STUDY DESIGN: A prospective cohort study was performed. Duplex ultrasound examined bilateral lower extremity venous flow and velocity (time-averaged mean velocity, TAMV). Flow was analyzed at the superficial femoral (SFV), distal external iliac (DEI), common femoral, profunda femoris, and popliteal veins. Mann-Whitney U-test, Spearman's correlation, and chi-square tests were used, with a significance of p < 0.05. RESULTS: Left SFV TAMV and volume flow were higher in the obese group (5.1 [4.1-5.7] vs. 2.8 [1.7-3.4] cm/second; p < 0.001) and (89 [73-119] vs. 48 [26-62] cm/minute; p = 0.005). Significant differences were noted for right DEI flow (obese 326 [221-833] vs. nonobese 182 [104-355] cm/minute; p = 0.049). The right femoral profunda flow was also higher in obese (49 [40-93] cm/minute) compared with nonobese (31 [22-52] cm/minute; p = 0.041). CONCLUSION: Volume flow and TAMV in the lower extremities of obese gravidas are higher compared with nonobese ones. Thus, the increased risk of VTE among obese pregnant women may not be caused by venous stasis.

Elective Induction at 39 Weeks of Gestation and the Implications of a Large, Multicenter, Randomized Controlled Trial.

On August 8, 2018, Grobman et al published the findings from the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial, a large randomized controlled trial of elective induction of labor in nulliparous women at 39 weeks of gestation compared with expectant management. Conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, the trial found there was no difference between the two groups in the primary outcome, a composite of neonatal morbidity. Also, there was a reduction in rates of cesarean delivery and hypertensive disorders of pregnancy in the elective induction group. The topic of elective induction has been of interest to clinicians for decades, and research has yielded inconsistent results in the past. This trial offers the best evidence thus far to address this complex issue. Our objective is to briefly review the history and literature regarding elective induction of labor, discuss the recently published ARRIVE trial, and consider its implications on clinical practice and health policy.

Pfannenstiel versus Vertical Skin Incision for Cesarean Delivery in Women with Class III Obesity: A Randomized Trial.

OBJECTIVE: To compare Pfannenstiel versus vertical skin incision for the prevention of cesarean wound complications in morbidly obese women. STUDY DESIGN: Women with body mass index ≥ 40 kg/m2 undergoing cesarean delivery (CD) were randomly allocated to Pfannenstiel or vertical skin incision. The primary outcome was a wound complication within 6 weeks. Due to a low consent rate, we limited enrollment to a defined time period for feasibility. We conducted a traditional frequentist analysis with log-binomial regression to obtain relative risks (RRs), and a Bayesian analysis to estimate the probability of treatment benefit. A priori, we decided that a ≥60% probability of treatment benefit for either incision type would be convincing evidence to pursue a larger trial. RESULTS: A total of 648 women were approached, 228 were consented, and 91 were randomized. The primary outcome rate was 19% in the Pfannenstiel group and 21% in the vertical group (RR: 1.18; 95% confidence interval: 0.49-2.85). Bayesian analysis revealed a 59% probability that Pfannenstiel had a lower primary outcome rate. CONCLUSION: In the first published randomized trial to compare skin incision types for obese women undergoing CD, we were unable to demonstrate differences in clinical outcomes. Our trial suggests that a larger study would have a low probability for different findings. TRIAL REGISTRATION: NCT 01897376 (www.clinicaltrials.gov).

The association of hyperuricemia and immediate postpartum hypertension in women without a diagnosis of chronic hypertension.

Our objective was to determine if elevated uric acid (UA) is associated with postpartum hypertension (PP HTN) in women without chronic hypertension. This is a secondary analysis of a randomized trial. We compared those with elevated UA to those with normal UA. Logistic regression was conducted to determine the association of elevated UA with PP HTN. Five hundred and fifty-six women met criteria. An UA level ≥ 5.2 mg/dL was associated with immediate PP HTN (adjusted odds ratio 2.44, 95% CI 1.63-3.64). The association was stronger among overweight and obese women. We conclude that hyperuricemia is associated with PP HTN, especially among obese women.

Maternal human telomerase reverse transcriptase variants are associated with preterm labor and preterm premature rupture of membranes.

OBJECTIVE: Premature aging and short telomere lengths of fetal tissues are associated with spontaneous preterm labor (PTL) and preterm premature rupture of membranes (pPROM). Maintenance of telomere length is performed by the enzyme telomerase. Human telomerase reverse transcriptase (hTERT) is a subunit of telomerase, and its dysfunction affects telomere shortening. This study assessed whether maternal or fetal genetic variations in the hTERT gene are associated with PTL or pPROM. METHODS: A case (PTL or pPROM) control (term birth) genetic association study was conducted in 654 non-Hispanic white mothers (438 term, 162 PTL, 54 pPROM) and 502 non-Hispanic white newborns (346 term, 116 PTB, 40 pPROM). Maternal and fetal DNA samples were genotyped for 23 single nucleotide polymorphisms (SNPs) within the hTERT gene. Allele frequencies were compared between cases and controls, stratified by PTL and pPROM. Maternal and fetal data were analyzed separately. RESULTS: Allelic differences in one SNP of hTERT (rs2853690) were significantly associated with both PTL (adjusted OR 2.24, 95%CI 1.64-3.06, p = 2.32e-05) and with pPROM (adjusted OR 7.54, 95%CI 3.96-14.33, p = 2.39e-07) in maternal DNA. There was no significant association between the hTERT SNPs analyzed and PTL or pPROM in the fetal samples. CONCLUSION: hTERT polymorphisms in fetal DNA do not associate with PTL or pPROM risk; however, maternal genetic variations in hTERT may play a contributory role in risk of PTL and PPROM.

Zika in the Americas, year 2: What have we learned? What gaps remain? A report from the Global Virus Network.

In response to the outbreak of Zika virus (ZIKV) infection in the Western Hemisphere and the recognition of a causal association with fetal malformations, the Global Virus Network (GVN) assembled an international taskforce of virologists to promote basic research, recommend public health measures and encourage the rapid development of vaccines, antiviral therapies and new diagnostic tests. In this article, taskforce members and other experts review what has been learned about ZIKV-induced disease in humans, its modes of transmission and the cause and nature of associated congenital manifestations. After describing the make-up of the taskforce, we summarize the emergence of ZIKV in the Americas, Africa and Asia, its spread by mosquitoes, and current control measures. We then review the spectrum of primary ZIKV-induced disease in adults and children, sites of persistent infection and sexual transmission, then examine what has been learned about maternal-fetal transmission and the congenital Zika syndrome, including knowledge obtained from studies in laboratory animals. Subsequent sections focus on vaccine development, antiviral therapeutics and new diagnostic tests. After reviewing current understanding of the mechanisms of emergence of Zika virus, we consider the likely future of the pandemic.

Removal notice to The relationship between primary cesarean delivery skin incision type and wound complications in women with morbid obesity: Am J Obstet Gynecol 2014;210:319.e1-4.

This article has been removed: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been removed at the request of the Editors-in-Chief and Authors. The original publication reported that univariate analysis showed that a vertical skin incision in obese women undergoing Cesarean delivery was associated with a higher odds ratio for wound complications than a transverse skin incision. Multivariable analyses showed a reversal of the association (i.e. the odds of wound complications were lower in women with a vertical skin incision). However, there was an error in the way the variable was entered in the logistic analysis. Re-analysis with the correct coding of the variable indicates that a transverse skin incision is associated with decreased odds of wound complication compared to a vertical skin incision.

Should We Add Pravastatin to Aspirin for Preeclampsia Prevention in High-risk Women?

Preeclampsia is a multisystem disorder that affects 3% to 5% of pregnant women and remains a significant source of short-term and long-term maternal and neonatal mortality and morbidity. Many professional societies recommend the use of low-dose aspirin to prevent preeclampsia in high-risk women. Owing to the similarities in pathophysiology between preeclampsia and atherosclerotic cardiovascular disease, and the encouraging data from preclinical and pilot clinical studies, pravastatin has been proposed for preventing preeclampsia. However, before statin administration becomes part of routine clinical practice, a large, well-designed, and adequately powered randomized-controlled trial is needed.

Zika Virus and Pregnancy: A Review of the Literature and Clinical Considerations.

The latest Zika virus (ZIKV) outbreak has reached epidemic proportions as it spreads throughout South and Central America. In November 2015, the Brazilian Ministry of Health reported a 20-fold increase in the number of cases of neonatal microcephaly, which corresponds geographically and temporally to the ZIKV outbreak. Case reports have provided some evidence of a causal link between maternal ZIKV infection, fetal microcephaly, and intracranial calcifications. The sparse data regarding ZIKV in pregnancy come solely from case reports and personal communications, and recommendations for management of ZIKV exposure during pregnancy are rapidly evolving. Our objective is to review and synthesize the current literature regarding ZIKV as it pertains to pregnancy and provide some assistance to clinicians who may have to manage a pregnant patient with potential exposure to ZIKV. We will also explore certain aspects of related viruses in pregnancy in hopes to shed light on this little-known topic.

Infant Outcomes after Periviable Birth: External Validation of the Neonatal Research Network Estimator with the BEAM Trial.

Objective The objective of this study was to use data from the 20-center beneficial effect of antenatal magnesium sulfate (BEAM) trial to assess the external validity of the Neonatal Research Network (NRN) estimator, a widely employed web-based counseling tool to estimate the probability of an adverse outcome for periviable infants given intensive care. Study Design The probability of different adverse outcomes predicted from the NRN estimator was compared with observed rates at 18 to 22 months for ventilated, nonanomalous infants born at 23 to 25 weeks and assessed in BEAM as in the NRN. Results were assessed using rigorous validation methods for prediction models. Results Among 289 eligible infants, 26% died, 40% died or had profound neurodevelopmental impairment (PNDI), and 71% died or had NDI. The area under the receiver operating characteristic curve was 0.70 (95% confidence interval [CI], 0.63-0.78) for death, 0.64 (95% CI, 0.56-0.71) for death or NDI, and 0.71 (95% CI, 0.65-0.78) for death or PNDI. Observed and predicted rates were somewhat different for death or NDI but quite similar for death and for death or PNDI in different risk groups. Brier scores for accuracy were favorable (0.17-0.22) for all outcomes. Conclusion Our results provide external validation of the NRN estimator for assessing the probability of adverse outcomes at 18 to 22 months for periviable infants given intensive care.

Differential Morbidity in Preterm Small versus Appropriate for Gestational Age: Perhaps Unverifiable.

OBJECTIVE: The objective of this study was to determine the morbidity of preterm small for gestational age (SGA) infants compared with appropriate for GA (AGA). STUDY DESIGN: This is a secondary analysis of the randomized trial evaluating magnesium sulfate for the prevention of cerebral palsy (CP). We compared outcomes of preterm (< 37 weeks) nonanomalous infants who were SGA (birth weight < 10% for GA) versus AGA (birth weight 10-89% for GA). We compared (1) the parent trial primary outcome, a composite of stillbirth, infant death by 1 year of age, or moderate to severe CP at 2 years of age and (2) composite neonatal morbidity (CNM). RESULTS: Of the 1,948 infants who met inclusion criteria, 95% were AGA and 5% were SGA. The primary outcome was similar (10 and 15%, p = 0.08), as was the CNM (24 and 25%, p = 0.89). Sample size calculations indicate that detection of a one-third higher rate of CNM among SGA compared with AGA infants requires more than 93,900 preterm births; for a one-third difference in moderate to severe CP, more than 1.4 million infants. CONCLUSION: Owing to the prohibitive sample size required, ascertaining a difference in sequela between preterm SGA and AGA infants is possibly unverifiable.

REMOVED: The relationship between primary cesarean delivery skin incision type and wound complications in women with morbid obesity.

This article has been removed: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been removed at the request of the Editors-in-Chief and Authors. The original publication reported that univariate analysis showed that a vertical skin incision in obese women undergoing Cesarean delivery was associated with a higher odds ratio for wound complications than a transverse skin incision. Multivariable analyses showed a reversal of the association (i.e. the odds of wound complications were lower in women with a vertical skin incision). However, there was an error in the way the variable was entered in the logistic analysis. Re-analysis with the correct coding of the variable indicates that a transverse skin incision is associated with decreased odds of wound complication compared to a vertical skin incision.