Substance Use in Pregnancy and its Association With Cardiovascular Events.

Background: Substance use and cardiovascular (CV) events are increasing among pregnant women in the United States, but association between substance use in pregnancy and CV events remains unknown. Objectives: The purpose of this study was to examine the association between substance use and acute CV events in pregnancy. Methods: We identified all women with a delivery hospitalization between 2004 and 2018 in the Nationwide Inpatient Sample, stratified on the presence or absence of substance use. The primary outcome was any acute CV event, defined as the presence of: acute myocardial infarction, stroke, arrhythmia, endocarditis, acute cardiomyopathy or heart failure, or cardiac arrest. Secondary outcomes were individual acute CV events, major adverse cardiac events, and maternal mortality. The association between substance use and outcomes were examined using multivariable logistical regression. Results: A total of 60,014,368 delivery hospitalizations occurred from 2004 to 2018, with substance use complicating 955,531 (1.6%) deliveries. Substance use was independently associated with CV events (adjusted odds ratio [aOR]: 1.61; 95% CI: 1.53-1.70; P < 0.001), major adverse cardiac events (aOR: 1.53; 95% CI: 1.46-1.61; P < 0.001), and maternal mortality (aOR: 2.65; 95% CI: 2.15-3.25; P < 0.001) during delivery hospitalization. All individual substances had an increased association with CV events; however, amphetamine/methamphetamine had the strongest association (aOR: 2.71; 95% CI: 2.35-3.12; P < 0.001). All substances other than cocaine and cannabis had a significant association with maternal death. Conclusions: Substance use has a strong association with acute CV events and maternal mortality during hospitalization for delivery and women with substance use warrant increased surveillance for CV events during this time.

Cesarean wound closure in body mass index 40 or greater comparing suture to staples: a randomized clinical trial.

BACKGROUND: Cesarean delivery is the most common major surgical procedure performed in the United States. Women with class III obesity have an increased risk of cesarean delivery and have wound complication rates higher than healthy body mass index counterparts. Available evidence regarding optimal wound closure is lacking specific to the population of women with class III obesity despite a known increased rate of wound complications. OBJECTIVE: This study aimed to compare rates of postoperative wound complications among women with class III obesity (body mass index of ≥40 kg/m2) undergoing cesarean delivery with skin closure by either subcuticular suture or surgical staples. STUDY DESIGN: Patients were randomly assigned to skin closure by nonabsorbable stainless steel surgical staples or subcuticular suture of the surgeon's choice at the time of cesarean delivery at 2 university hospitals. Randomization was stratified for scheduled vs unscheduled cesarean delivery and for the 2 study sites. The primary outcome was the rate of any documented wound complication during the first 6 weeks after delivery. Any predictors of the composite outcome that in univariate analysis had a P<.20 were entered into a forward logistic regression. Sample size was calculated based on published literature and estimating the rate of wound complications within 6 weeks of follow-up at 20% with staples and 10% with sutures. For a power of 0.80 with a 2-tailed of 0.05, a total of 199 participants per group were required. RESULTS: From September 2015 to May 2019, 232 women were randomized to staples (n=117) or sutures (n=115). Nearing the planned interim analysis, enrollment in the study was concluded administratively owing to low enrollment. With loss to follow-up and exclusions, a total of 90 women were analyzed in each group. In the suture group, one-third was closed with braided suture and two-thirds were closed with monofilament suture. Median staple removal was 5 days postoperatively. Fewer composite wound complications were noted in the surgical staples group than the subcuticular suture group (20.0% vs 27.6%), although this difference was not statistically significant (P≥.5). The rate of surgical site infection was significantly lower in the staples group (10.5% vs 22.7%; P=.041). In the multiple logistic regression, the 3 significant independent predictors of the outcome were body mass index (odds ratio, 1.08; P=.004), scheduled vs unscheduled cesarean delivery (odds ratio, 0.40; P=.018), and study site (odds ratio, 0.36; P=.028). CONCLUSION: Surgical staples or subcuticular suture for skin closure at the time of cesarean delivery in women with a body mass index of ≥40 kg/m2 resulted in similar composite wound complication rates; however, lower cesarean wound infection rates were noted among wounds closed with staples.

Robotic Transabdominal Cerclage vs Laparotomy: A Comparison of Obstetric and Surgical Outcomes.

STUDY OBJECTIVE: To compare obstetric and surgical outcomes of transabdominal cerclage (TAC) via laparotomy (TAC-LAP) versus robotic-assisted (TAC-RA) approaches. DESIGN: Retrospective cohort study. SETTING: An academic medical center. PATIENTS: Sixty-nine women with acquired or congenital cervical insufficiency. INTERVENTIONS: All women underwent TAC either by laparotomy or robotic-assisted approaches by 2 primary surgeons between January 2003 and July 2018. Women with a preconceptional TAC without a subsequent pregnancy were excluded. MEASUREMENTS AND MAIN RESULTS: A total of 69 women met inclusion criteria in the 15-year study period with 40 in the historical TAC-LAP group and 29 in the TAC-RA group. Gestational age at delivery was similar in the 2 groups (36 weeks 3 days vs 37 weeks; median difference -1 day, 95% confidence interval [CI] -6 to 2, p = .36). There were no differences in birth weight, Apgar scores, neonatal intensive care unit admission, or neonatal survival. Estimated blood loss and length of stay were significantly greater in the TAC-LAP group (50 mL vs 20 mL; median difference 25, 95% CI 5-40, p = .007 and 76 hours vs 3 hours; median difference 71, 95% CI 65-75, p <.001, respectively). Operative time was significantly shorter in the TAC-LAP group (65 minutes vs 132 minutes; median difference -64.7, 95% CI -79 to -49, p <.001). There was one intra-operative complication and 4 minor postoperative complications in the TAC-LAP group and none observed in the TAC-RA group. All outcomes were similar when comparing postconceptional TAC alone, except there was no longer a difference in blood loss. When comparing pre- versus postconceptional robotic TAC, there were no differences in surgical outcomes. CONCLUSION: Robotic TAC has similar favorable obstetric outcomes to traditional laparotomy and is associated with reduced blood loss and shorter hospital stays. Despite longer operative times, the robotic group did not experience any intra-operative or postoperative complications, which speaks to the benefits of this minimally invasive approach to TAC.

Vasa previa: diagnosis and management.

BACKGROUND: Vasa previa is a rare condition that is associated with a high rate of fetal or neonatal death when not diagnosed antenatally. The majority of available studies are either small, do not include antepartum data, limited to single institutions, or are biased by inclusion of patients from registries and online vasa previa support groups. OBJECTIVE: The purpose of this study was to investigate the diagnostic and management strategies for this potentially catastrophic entity and to describe further maternal and placental risk factors that may aid in the establishment of a screening protocol for vasa previa. STUDY DESIGN: This was a retrospective multicenter descriptive study that included all pregnancies that were complicated by vasa previa that delivered between January 1, 2000, and December 31, 2012. Nine maternal fetal medicine practices and the hospitals in which they practice participated in data collection of diagnosis, treatment, and maternal-neonatal outcomes. RESULTS: Sixty-eight pregnancies were identified that included the diagnosis of vasa previa or "possible vasa previa" either in the ultrasound record or in the hospital record at the time of delivery. Four cases (5.8%) appeared to resolve on repeat ultrasound examination. Fifteen of the 64 cases that were suspected of having vasa previa could not be verified or were not documented at delivery. Of the remaining 49 cases, where vasa previa was documented, 47 cases (96%) were diagnosed by ultrasound scanning antenatally. Known risk factors for vasa previa were present in 41 of 47 cases (87%). Of the 49 cases, 41 were delivered by planned cesarean delivery at a mean gestational age of 34.7 weeks, and 8 cases required emergent cesarean delivery at a mean gestational age of 34.6 weeks (range, 32.4-36.0 weeks gestation). Seven of these emergent cesarean deliveries had been diagnosed previously; 1 case had not. All of the emergent cesarean deliveries were for vaginal bleeding; 1 case was also for a concerning fetal heart rate, but only 1 of the known cases had a documented ruptured fetal vessel. None of these cases were found to have cervical shortening before the onset of bleeding. One of the undiagnosed cases resulted in a ruptured fetal vessel and a baby with no heart beat at birth who survived but had periventricular leukomalacia at 1 month of age with mild white-matter atrophy. Of the remaining neonates in this group, there were no deaths and no major complications beyond mild respiratory distress syndrome in 9 cases. There were no other major neonatal complications, which included no cases of periventricular leukomalacia, neonatal sepsis, necrotizing enterocolitis, or any grade of intraventricular hemorrhage in the confirmed cases of vasa previa. CONCLUSION: This study confirms most current recommendations that include risk-based ultrasound screening, early hospitalization at 30-34 weeks gestation, antenatal corticosteroids at 30-32 weeks gestation, and elective delivery at 33-34 weeks gestation. Thus, with these recommendations for current identification and management of vasa previa in this series of geographically diverse mostly private practice maternal fetal medicine practices, we have confirmed recent reports that show a dramatic improvement in neonatal survival and complications compared with earlier reports.

Umbilical artery aneurysm: a case report, literature review, and management recommendations.

BACKGROUND: Umbilical artery aneurysm is a rare and often lethal condition frequently associated with fetal anomalies, fetal demise, and neonatal complications. CASE: We report a case of umbilical artery aneurysm discovered at 21 weeks 2 days of gestation in a fetus of normal karyotype. Maternal hospitalization occurred at 28 weeks for antenatal testing, betamethasone administration, and monitoring for expansion of the aneurysm. Delivery of a live neonate by repeat cesarean delivery was performed at 32 weeks 2 days. Pathology confirmed a 3-vessel cord with an umbilical artery aneurysm. Neonatal course was complicated by respiratory distress of the newborn, hyperbilirubinemia, anemia, difficulty feeding, and cardiac defects. The newborn was discharged from the neonatal intensive care unit on day of life 19. CONCLUSIONS: Umbilical artery aneurysm is highly associated with fetal complications including trisomy 18, single umbilical artery, cardiac anomalies, and intrauterine fetal demise. A normal karyotype, antenatal monitoring, and early delivery have been suggested to impact the likeliness of survival. Antenatal management strategies include consideration of nonstress testing 3 times daily, serial ultrasound assessments, testing to identify intrauterine growth restriction, and delivery by planned cesarean delivery between 32 and 34 weeks. We recommend that patients be counseled on the high risks associated with umbilical artery aneurysm and be included in discussions regarding antenatal management and delivery planning.

Obesity and pregnancy: clinical management of the obese gravida.

In recent years, the prevalence of obesity in the United States has risen dramatically, especially among women of reproductive age. Research that has specifically evaluated pregnancy outcomes among obese parturients has allowed for a better understanding of the myriad adverse perinatal complications that are observed with significantly greater frequency in the obese pregnant population. The antepartum, intrapartum, intraoperative, postoperative, and postpartum periods are all times in which the obese pregnant woman is at greater risk for adverse maternal-fetal outcomes, compared with her ideal bodyweight counterpart. Comorbid medical conditions that commonly are associated with obesity further accentuate perinatal risks. All obese pregnant women should be counseled regarding these risks, and strategies should be used to improve perinatal outcome whenever possible. Obese women of reproductive age ideally should be counseled before conception and advised to achieve ideal bodyweight before pregnancy.

Umbilical artery aneurysm.

BACKGROUND: Umbilical artery aneurysm is a rare condition associated with increased risk for aneuploidy and fetal demise. CASE: We report a case of umbilical artery aneurysm discovered at 27 weeks of gestation in one fetus of a dichorionic, diamniotic twin pregnancy. The patient was hospitalized to monitor for expansion of the aneurysm. Corticosteroids were administered, and, after genetic amniocentesis revealed a normal karyotype, cesarean delivery was performed at 28 2/7 weeks of gestation. Pathologic examination confirmed an umbilical artery aneurysm in the cord of the affected fetus. CONCLUSION: Given the high incidence of aneuploidy associated with umbilical artery aneurysm, it is important to consider karyotype analysis of the affected fetus. If a normal karyotype is identified, early delivery may be warranted to decrease the risk of fetal demise.

Blunt suture needle use in laceration and episiotomy repair at vaginal delivery.

OBJECTIVE: By surveying obstetricians regarding the use of blunt suture needles for laceration and episiotomy repair, the purpose of this study was to determine whether blunt suture needles represent a safe and effective alternative to sharp needles. STUDY DESIGN: Blunt suture needles were made available at our institution for repairs at vaginal delivery. Participating physicians indicated their personal history of needlestick injuries and rated the blunt suture needle after completing the repair. Categorical variables were analyzed using Fisher's exact test and a 2-tailed P < .05 was considered significant. RESULTS: Attending and resident physicians completed 80 surveys, and 83% reported previous needlestick injuries. Blunt suture needles were rated as excellent or good by 92.5% (95% confidence interval 84.6 to 96.5%). No needlestick injuries occurred. CONCLUSION: In an effort to reduce needlestick injuries, the use of blunt suture needles is safe and effective for repairs at vaginal delivery.

Patients' knowledge of umbilical cord blood banking.

OBJECTIVE: To determine patients' knowledge of umbilical cord blood banking (UCBB). METHODS: A questionnaire was administered. Part 1 queried issues of familiarity with the term UCBB. Those patients with any awareness of UCBB were provided with part 2, asking more detailed questions that assessed knowledge. RESULTS: Four hundred twenty-five patients completed the survey; 37% had no knowledge of UCBB. Older patients and those with higher degrees of education were more aware of UCBB, and the greatest disparity of knowledge was noted among Native American patients (p < 0.001). Of patients indicating familiarity with UCBB, 2.6% felt "extremely knowledgeable," while 74% felt "minimally informed." Fifty percent of the patients were misinformed that UCBB was only for "the child that I will deliver." Seventy-one percent of patients were not planning UCBB, with "expense" and "insufficient knowledge" as the primary reasons cited. Only 14% of patients were educated about UCBB by their nurse or obstetrician, although 90% of patients expected their obstetrician to answer their questions on UCBB. CONCLUSIONS: Patients are poorly informed about UCBB, especially ethnic minorities, younger patients and those with lesser degrees of education. Few patients receive UCBB education from health care providers, yet most patients expect their obstetrician to be able to answer questions on UCBB. Lack of knowledge and expense remain barriers to UCBB. Opportunities to educate patients and obstetric providers on UCBB should be pursued.

Klippel-Trenaunay-type syndrome in pregnancy.

INTRODUCTION: Klippel-Trenaunay-Type Syndrome (KTTS) is a rare congenital anomaly with variable expression and an unknown etiology characterized by capillary and venous malformations and hypertrophy of bone and soft tissue. Pregnancy has been rarely reported in patients with KTTS and since 1989 there have been only 13 case reports of pregnancy in women with KTTS reported in the literature. Concurrent pregnancy is associated with adverse perinatal outcomes. To the best of our knowledge this is the second reported, and largest, series of cases. STUDY DESIGN: After a thorough review of the literature, the medical records of four obstetrical patients with KTTS were reviewed. RESULTS: The obstetrical course of women with KTTS varies. Complications include bleeding, DIC, thromboembolic events, and pain. CONCLUSIONS: The maternal and fetal risks associated with pregnancy in women with KTTS are proportional to the severity of disease, which can be exacerbated by pregnancy. Thoughtful preconceptional counseling, along with methodical and systematic intrapartum and postpartum care are keys to reducing mortality and morbidity.

Association of vasa previa at delivery with a history of second-trimester placenta previa.

OBJECTIVE: To evaluate whether vasa previa at delivery is associated with a history of second-trimester placenta previa. STUDY DESIGN: Retrospective, case-control study of all vasa previa cases at Good Samaritan Regional Medical Center from January 1, 1991, to May 1, 2001. Cases were identified by ICD-9 codes and confirmed by chart review. Each case was matched in a 1:4 ratio with controls based upon normal placentation at delivery, ultrasound documentation of midtrimester placental location, maternal parity and gestational age at delivery. RESULTS: During the study period, 13 cases of vasa previa were identified. Nine cases (9/13, 69.2%) of vasa previa at delivery had a second-trimester placenta previa as documented by midtrimester ultrasonography, whereas 2 controls (2/52, 3.8%) had a second-trimester placenta previa (P < .000001, OR = 56.3, 95% CI = 8.9-354.1). CONCLUSION: There is a highly significant association between vasa previa at delivery and a history of second-trimester placenta previa.

Complications associated with peripherally inserted central catheter use during pregnancy.

OBJECTIVE: The purpose of this study was to evaluate the complications of peripherally inserted central catheter use in an obstetrics population at a single institution over a 5-year period. STUDY DESIGN: We conducted a descriptive retrospective review of all obstetrics patients with peripherally inserted central catheter insertion during the antepartum period at Good Samaritan Regional Medical Center, from January 1, 1997, through September 30, 2001. RESULTS: During the 5 years of the study, complete data regarding the primary admission diagnoses for peripherally inserted central catheter placement and associated complications were available for 52 cases. An associated complication rate of 50% (n = 26 cases) was noted. The complications included culture-proved line infection (n = 9/52 complications, 17%), presumed line infection (n = 6/52 complications, 12%), cellulitis (n = 4/52 complications, 8%), mechanical line failure (n = 4/52 complications, 8%), pain that required line discontinuation (n = 2/52 complications, 4%), and superficial thrombophlebitis (n = 1/52 complications, 2%). A chi(2) analysis was performed, and preterm labor may be associated with an increased risk for peripherally inserted central catheter complication (P =.012). CONCLUSION: Patients who receive a peripherally inserted central catheter during pregnancy are at significant risk for infectious complications. Alternative treatment approaches are suggested, where appropriate.