Routine Postoperative Complete Blood Counts Are Not Necessary After Most Primary Total Hip and Knee Arthroplasties.

BACKGROUND: Routine postoperative complete blood count tests are commonplace after total joint arthroplasty. The goal of this study was to identify if these result in any clinically meaningful action and if it would be safe to forego this testing in a population without known risk factors for transfusion. METHODS: A retrospective review of 1060 patients undergoing a total knee or total hip arthroplasty at a single institution was performed. Data points including patient demographics, preoperative and postoperative laboratory results, tranexamic acid use, preoperative and postoperative medication for venous thromboembolism prophylaxis and anticoagulation, as well as 90-day readmission related to anemia were collected. RESULTS: The transfusion rate for all patients was 0.66% (7/1060) and there was only one transfusion for a patient with a preoperative hemoglobin (Hb) greater than 12 g/dL (1/976; 0.1%). There was no difference in the change from preoperative to postoperative day 1 Hb levels in patients treated with aspirin compared with those on direct oral anticoagulation (P = .73). There were no 90-day readmissions related to acute blood loss anemia. CONCLUSIONS: This study demonstrates that routine postoperative complete blood count testing is not absolutely necessary and does not provide additional value in the vast majority of patients with preoperative Hb levels equal to or greater than 12 g/dL when tranexamic acid is administered. This could avoid unnecessary testing in patients and increased savings to the health care system. LEVEL OF EVIDENCE: Level 3, retrospective cohort.

Does the etiology of a failed hemiarthroplasty affect outcomes when revised to a reverse shoulder arthroplasty?

BACKGROUND: The purposes of this study were to evaluate patient outcomes after revision of hemiarthroplasty to reverse shoulder arthroplasty (RSA) based on initial pathology, to determine the re-revision rate, and to identify characteristics that may predict subsequent re-revision. METHODS: A total of 207 shoulder hemiarthroplasty, bipolar prosthesis, and humeral resurfacing cases revised to RSA between January 2004 and January 2017 were reviewed. Outcome measures included shoulder motion and American Shoulder and Elbow Surgeons and Simple Shoulder Test (SST) scores. Sixteen RSAs underwent re-revision. A case-control study with each revised RSA matched to 4 controls based on age, sex, and minimum 2-year follow-up was performed to evaluate for factors predicting re-revision. RESULTS: The mean time from initial hemiarthroplasty to RSA was 3.6 years (range, 0.1-20 years). There were 114 patients with a minimum of 2 years' follow-up (mean, 57 months; range, 24-144 months). The most common initial diagnoses for hemiarthroplasty were fracture (n = 72), cuff tear arthropathy (CTA) (n = 22), and osteoarthritis (OA) (n = 20). Overall mean scores and range-of-motion values were as follows: American Shoulder and Elbow Surgeons score, 59 (95% confidence interval [CI], 54-64); SST score, 4 (95% CI, 4-5); forward flexion, 106° (95% CI, 96°-116°); and abduction, 95° (95% CI, 85°-105°). Compared with fracture cases, CTA cases had better forward flexion (P = .01) and abduction (P = .006) and OA cases had better SST scores (P = .02) and abduction (P = .04). The re-revision rate was 7.7% at a mean of 31 months (range, 0-116 months), with the most common diagnosis being fracture (10 of 16 cases). Humeral loosening (8 of 16 cases) was the most common failure mechanism, and larger glenosphere sizes were more likely to be revised. CONCLUSION: Functional outcome scores of hemiarthroplasty cases revised to RSA were better for patients with OA than for patients with CTA or fracture. Cases of hemiarthroplasty for fracture had decreased motion after revision to RSA compared with CTA and OA. Humeral loosening was the most common failure mechanism.

Defining the younger patient: age as a predictive factor for outcomes in shoulder arthroplasty.

BACKGROUND: The purpose of this study was to define an age cutoff at which clinical outcomes and revision rates differ for patients undergoing primary anatomic total shoulder arthroplasty (TSA) and patients undergoing primary reverse shoulder arthroplasty (RSA). METHODS: This retrospective cohort study included 1250 primary shoulder arthroplasties (1131 patients) with minimum 2-year clinical follow-up (mean, 50 months [range, 24-146 months]). TSA (n = 518; mean age, 68.1 years [range, 28-90 years]) was performed for osteoarthritis in most cases (99%), whereas the primary diagnoses for RSA (n = 732; mean age, 70.8 years [range, 22-91 years]) included rotator cuff arthropathy (35%), massive cuff tear without osteoarthritis (29.8%), and osteoarthritis (20.5%). Outcomes included range of motion, the American Shoulder and Elbow Surgeons (ASES) score, and the revision rate. The relationship between age at the time of surgery in 5-year increments (46-50 years, 51-55 years, and so on) and the revision rate was examined to identify the age cutoff; this was then used to assess clinical outcomes. RESULTS: In patients younger than 65 years, TSA was associated with a 3.4-fold increased risk of revision (P = .01). RSA performed in patients younger than 60 years was associated with a 4.8-fold increased risk of revision (P < .001). TSA patients aged 65 years or older and RSA patients aged 60 years or older had better total ASES scores (82 vs. 77 [P = .03] and 72 vs. 62 [P = .002], respectively) and better internal rotation (interquartile range, TSA 5-6 vs. 4-5 [P = .002] and RSA 4-5 vs 3-4 [P = .04])-where 6 represents T4 to T6 and 4 represents T11 to L1-than their younger counterparts. CONCLUSION: Age at index arthroplasty affects outcomes and the risk of revision. Primary TSA patients younger than 65 years and RSA patients younger than 60 years have a significantly increased revision risk. These age cutoffs are also correlated with differences in ASES scores and internal rotation.

Using the Probability of Cesarean from a Validated Cesarean Prediction Calculator to Predict Labor Length and Morbidity.

OBJECTIVE: To determine if increasing predicted risk of cesarean was associated with longer labor length and increased morbidity among women undergoing induction with an unfavorable cervix. STUDY DESIGN: Using a publically available database, we evaluated whether a previously validated prediction model for cesarean delivery after induction was associated with labor length, maternal morbidity (third-/fourth-degree lacerations, endometritis, blood transfusion, wound infection, venous thromboembolism, hysterectomy, intensive care unit admission, and death), and neonatal morbidity (blood transfusion, encephalopathy, intraventricular hemorrhage, severe respiratory distress syndrome, necrotizing enterocolitis, and sepsis). Full-term (≥37 weeks) singleton gestations with intact membranes and an unfavorable cervix (Bishop score ≤6 and dilation ≤2 cm) undergoing induction of labor were included. RESULTS: A total of 8,466 women met the inclusion criteria. Each category increase in cesarean probability (<20, 20-39.9, 40-59.9, ≥60%) was associated with an increase in labor length (9.6, 10.8, 11.7, and 11.9 hours, respectively; p < 0.001). With increasing predicted probability of cesarean there, was also a significant increase in maternal morbidity with each category (2.6, 4.7, 5.1, 6.1%; p = 0.001) and increase in neonatal morbidity (0.9, 1.5, 2, 2.2%; p = 0.002). CONCLUSION: Using a validated prediction model for cesarean delivery among women induced with an unfavorable cervix, increasing predicted probability of cesarean is associated with longer labor length and increased maternal and neonatal morbidity.

A validated calculator to estimate risk of cesarean after an induction of labor with an unfavorable cervix.

BACKGROUND: Induction of labor occurs in >20% of pregnancies, which equates to approximately 1 million women undergoing an induction in the United States annually. Regardless of how common inductions are, our ability to predict induction success is limited. Although multiple risk factors for a failed induction have been identified, risk factors alone are not enough to quantify an actual risk of cesarean for an individual woman undergoing a cesarean. OBJECTIVE: The objective of this study was to derive and validate a prediction model for cesarean after induction with an unfavorable cervix and to create a Web-based calculator to assist in patient counseling. STUDY DESIGN: Derivation and validation of a prediction model for cesarean delivery after induction was performed as part of a planned secondary analysis of a large randomized trial. A predictive model for cesarean delivery was derived using multivariable logistic regression from a large randomized trial on induction methods (n = 491) that took place from 2013 through 2015 at an academic institution. Full-term (≥37 weeks) women carrying a singleton gestation with intact membranes and an unfavorable cervix (Bishop score ≤6 and dilation ≤2 cm) undergoing an induction were included in this trial. Both nulliparous and multiparous women were included. Women with a prior cesarean were excluded. Refinement of the prediction model was performed using an observational cohort of women from the same institution who underwent an induction (n = 364) during the trial period. An external validation was performed utilizing a publicly available database (Consortium for Safe Labor) that includes information for >200,000 deliveries from 19 hospitals across the United States from 2002 through 2008. After applying the same inclusion and exclusion criteria utilized in the derivation cohort, a total of 8466 women remained for analysis. The discriminative power of each model was assessed using a bootstrap, bias-corrected area under the curve. RESULTS: The cesarean delivery rates in the derivation and external validation groups were: 27.7% (n = 136/491) and 26.4% (n = 2235/8466). In multivariable modeling, nulliparity, gestation age ≥40 weeks, body mass index at delivery, modified Bishop score, and height were significantly associated with cesarean. A nomogram and calculator were created and found to have an area under the curve in the external validation cohort of 0.73 (95% confidence interval, 0.72-0.74). CONCLUSION: A nomogram and user-friendly Web-based calculator that incorporates 5 variables known at the start of induction has been developed and validated. It can be found at: http://www.uphs.upenn.edu/obgyn/labor-induction-calculator/. This calculator can be used to augment patient counseling for women undergoing an induction with an unfavorable cervix.

Neonatal Outcomes Associated With Placental Abruption.

Placental abruption (early separation of the placenta) is associated with preterm birth and perinatal mortality, but associations with other neonatal morbidities remain understudied. We examined the association between abruption and newborn outcomes. We analyzed 223,341 singleton deliveries from the Consortium on Safe Labor study, a retrospective, multisite, observational study (2002-2008) of electronic medical records in the United States. Adjusted relative risks, incidence rate ratios, and 99% confidence intervals were estimated. Direct effects attributable to abruption were examined by conditioning on intermediates (preterm birth and small for gestational age) with sensitivity analyses. Incidence of abruption was 1.6% (n = 3,619). Abruption was associated with an elevated risk of newborn resuscitation (relative risk (RR) = 1.5, 99% confidence interval (CI): 1.5, 1.6), apnea (RR = 5.8, 99% CI: 5.1, 6.5), asphyxia (RR = 8.5, 99% CI: 5.7, 11.3), respiratory distress syndrome (RR = 6.5, 99% CI: 5.9, 7.1), neonatal intensive care unit admission (RR = 3.4, 99% CI: 3.2, 3.6), longer intensive care length of stay (incidence rate ratio = 2.0, 99% CI: 1.9, 2.2), stillbirth (RR = 6.3, 99% CI: 4.7, 7.9), and neonatal mortality (RR = 7.6, 99% CI: 5.2, 10.1). In sensitivity analyses, there was a direct effect of abruption associated with increased neonatal risks. These findings expand our knowledge of the association between abruption and perinatal and neonatal outcomes.

Maternal, Labor, Delivery, and Perinatal Outcomes Associated with Placental Abruption: A Systematic Review.

Objective Risk factors for placental abruption have changed, but there has not been an updated systematic review investigating outcomes. Methods We searched PubMed, EMBASE, Web of Science, SCOPUS, and CINAHL for publications from January 1, 2005 through December 31, 2016. We reviewed English-language publications reporting estimated incidence and/or risk factors for maternal, labor, delivery, and perinatal outcomes associated with abruption. We excluded case studies, conference abstracts, and studies that lacked a referent/comparison group or did not clearly characterize placental abruption. Results A total of 123 studies were included. Abruption was associated with elevated risk of cesarean delivery, postpartum hemorrhage and transfusion, preterm birth, intrauterine growth restriction or low birth weight, perinatal mortality, and cerebral palsy. Additional maternal outcomes included relaparotomy, hysterectomy, sepsis, amniotic fluid embolism, venous thromboembolism, acute kidney injury, and maternal intensive care unit admission. Additional perinatal outcomes included acidosis, encephalopathy, severe respiratory disorders, necrotizing enterocolitis, acute kidney injury, need for resuscitation, chronic lung disease, infant death, and epilepsy. Conclusion Few studies examined outcomes beyond the initial birth period, but there is evidence that both mother and child are at risk of additional adverse outcomes. There was also considerable variation in, or absence of, the reporting of abruption definitions.

Previous prelabor or intrapartum cesarean delivery and risk of placenta previa.

OBJECTIVE: The purpose of this study was to examine the association between previous cesarean delivery and subsequent placenta previa while distinguishing cesarean delivery before the onset of labor from intrapartum cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study of electronic medical records from 20 Utah hospitals (2002-2010) with restriction to the first 2 singleton deliveries of nulliparous women at study entry (n=26,987). First pregnancy delivery mode was classified as (1) vaginal (reference), (2) cesarean delivery before labor onset (prelabor), or (3) cesarean delivery after labor onset (intrapartum). Risk of second delivery previa was estimated by previous delivery mode with the use of logistic regression and was adjusted for maternal age, insurance, smoking, comorbidities, previous pregnancy loss, and history of previa. RESULTS: Most first deliveries were vaginal (82%; n=22,142), followed by intrapartum cesarean delivery (14.6%; n=3931), or prelabor cesarean delivery (3.4%; n=914). Incidence of second delivery previa was 0.29% (n=78) and differed by previous delivery mode: vaginal, 0.24%; prelabor cesarean delivery, 0.98%; intrapartum cesarean delivery, 0.38% (P<.001). Relative to vaginal delivery, previous prelabor cesarean delivery was associated with an increased risk of second delivery previa (adjusted odds ratio, 2.62; 95% confidence interval, 1.24-5.56). There was no significant association between previous intrapartum cesarean delivery and previa (adjusted odds ratio, 1.22; 95% confidence interval, 0.68-2.19). CONCLUSION: Previous prelabor cesarean delivery was associated with a >2-fold significantly increased risk of previa in the second delivery, although the approximately 20% increased risk of previa that was associated with previous intrapartum cesarean delivery was not significant. Although rare, the increased risk of placenta previa after previous prelabor cesarean delivery may be important when considering nonmedically indicated prelabor cesarean delivery.

United states medical licensing examination scores as a predictor of performance on the annual council of resident education in obstetrics and gynecology examinations.

OBJECTIVE: To determine how well the United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores predict the performance of residents on the annual Council of Resident Education in Obstetrics and Gynecology (CREOG) examination given to the residents at the second and third years of their residency. STUDY DESIGN: USMLE Steps 1 and 2 scores from medical school were compared to the resident CREOG examination scores at the second and third years of training for 61 residents from 2000 to 2011. RESULTS: A strong, statistically significant (p < 0.001) correlation was found between the USMLE and CREOG scores, ranging between r = 0.588 and r = 0.667 for the USMLE 1 scores and r = 0.630 and r = 0.640 for the USMLE 2 scores. CONCLUSION: This observation should be useful for program directors in selecting the future medical students for their residency program since those with high USMLE Steps 1 and 2 scores typically do very well on their objective testing during and after the residency.

Factors that predict postoperative motion in patients treated with reverse shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has proven to be a useful yet inconsistent tool to manage a variety of pathologic conditions. Factors believed to lead to poor postoperative range of motion (ROM) may be associated with preoperative diagnosis, poor preoperative ROM, and surgical factors such as inability to lengthen the arm. The purpose of this study was to analyze multiple factors that may be predictive of motion after RSA. Our hypothesis is that intraoperative ROM is most predictive of postoperative ROM. METHODS: Between February 2003 and April 2011, 540 patients (217 men and 323 women) treated with RSA were evaluated with measurements of preoperative, intraoperative, and postoperative ROM at a follow-up, where ROM was found to have plateaued at 1 year as determined by a pilot study. A regression analysis was performed to define independent predictive factors of postoperative active ROM. RESULTS: Intraoperative forward flexion was the strongest predictor of final postoperative ROM, followed by gender and preoperative ROM. Age and arm lengthening were not significant independent predictors. Controlling for gender and preoperative ROM, patients with an intraoperative elevation of 90° gained 29° in postoperative forward elevation (P < .001), 120° gained approximately 40° in postoperative forward elevation (P < .001), 150° gained approximately 56° in postoperative forward elevation (P < .001) and 180° gained approximately 62° in postoperative forward flexion (P < .001). CONCLUSIONS: Intraoperative forward flexion is the strongest predictor of postoperative ROM. Surgeons may use intraoperative motion as a powerful decision-making tool regarding soft tissue tension in RSA.

Knee strength retention and analgesia with continuous perineural fentanyl infusion after total knee replacement: randomized controlled trial.

PURPOSE: Despite providing adequate pain relief, a femoral nerve block can induce postoperative muscle weakness after total knee arthoplasty (TKA). Fentanyl has been shown to have peripheral effects but has not been used as a perineural infusate alone after TKA. METHODS: Sixty patients scheduled for TKA were randomized to one of three blinded groups: a continuous 24 h infusion of either fentanyl 3 µg/ml, ropivacaine 0.1%, or 0.9% normal saline through a femoral nerve sheath catheter at 10 ml/h. The main outcome was maximum voluntary isometric contraction (MVIC) in the quadriceps femoris (knee extension), measured by a handheld dynamometer (Nm/kg). Other variables assessed were preoperative and postoperative visual analog scale (VAS) scores, hamstrings MVIC (knee flexion), active range of motion of the operative knee, distance ambulated, incidence of knee buckling, supplemental morphine usage, postoperative side effects, and serum fentanyl levels. RESULTS: Quadriceps MVIC values were significantly greater in the fentanyl group compared to the group that received ropivacaine (median values, 0.08 vs. 0.03 Nm/kg; p = 0.028). The incidence of postoperative knee buckling upon ambulation was higher in the ropivacaine group compared to the fentanyl group, although not statistically significant (40% vs. 15 %, respectively; p = 0.077). VAS scores while ambulating were not significantly different between the fentanyl group and the ropivacaine group (p = 0.270). Postoperative morphine consumption, nausea and vomiting, and resting VAS scores were similar among the three groups. CONCLUSIONS: A continuous perineural infusion of fentanyl produced greater strength retention than ropivacaine post-TKA.

Preparing for the bundled-payment initiative: the cost and clinical outcomes of reverse shoulder arthroplasty for the surgical treatment of advanced rotator cuff deficiency at an average 4-year follow-up.

BACKGROUND: The purpose of this study is to report on cost, outcomes, reliability, and safety of reverse shoulder arthroplasty (RSA) in patients with symptomatic advanced rotator cuff deficiency. METHODS: Fifty-five primary RSA patients operated on at a single institution by a single surgeon were prospectively studied for a mean of 48 months (range, 31-71 months). For each patient, validated subjective and independently evaluated objective outcome data were collected to determine clinical reliability. In addition, safety, defined as major complications, as well as direct costs specific to each patient, were collected and analyzed. RESULTS: There were significant improvements (P < .05) in all clinical measures with the exception of the general health and vitality components as well as the mental component summary scores of the Short Form 36 version 2 (SF-36v2). In addition, the majority of the patients met the criteria set forth for clinical reliability (53 of 55 [96%]) and safety (49 of 55 [89%]). The mean total 4-year cost was $24,661, with the hospitalization accounting for 92% of this cost. Fiscal year was found to be responsible for the greatest fluctuation in total cost (P < .001). In addition, a lower comorbidity burden (P < .001), a higher preoperative extremity impairment rating (P < .001), higher postoperative role-emotional component scores on the SF-36v2 (P = .001), and lower postoperative social functioning component scores on the SF-36v2 (P = .005) were correlated with less cost. CONCLUSION: The mean 4-year total cost of $24,661 allowed the purchase of treatment with RSA, leading to a greater than 5-fold reduction in pain and a 70% improvement in shoulder function with a small risk of harm.

Preparing for the bundled-payment initiative: the cost and clinical outcomes of total shoulder arthroplasty for the surgical treatment of glenohumeral arthritis at an average 4-year follow-up.

BACKGROUND: The purpose of this study is to report on cost, outcomes, reliability, and safety of total shoulder arthroplasty (TSA) in patients with symptomatic glenohumeral joint arthritis. MATERIALS AND METHODS: Eighty-three primary TSA patients operated on at a single institution by a single surgeon were prospectively studied for a mean of 48 months (range, 32-69 months). For each patient, validated subjective and independently evaluated objective outcome measures were collected to determine clinical reliability of TSA. In addition, safety-defined as the lack of major complications-and direct costs specific to each patient were collected and analyzed. RESULTS: There were significant improvements (P < .01) in all clinical measures with the exception of the general health component of the Short Form 36 version 2. In addition, the majority of the patients met the criteria set forth for clinical reliability (76 of 83 [92%]) and safety (80 of 83 [96%]). The mean 4-year cost was $17,587, with the hospitalization accounting for 88% of this cost. Fiscal year was found to be responsible for the greatest fluctuation in total cost (P < .001). In addition, greater improvements in American Shoulder and Elbow Surgeons function scores (P = .022), higher preoperative social functioning scores on the Short Form 36 version 2 (P < .001), and female gender (P = .001) were correlated with lower cost. CONCLUSION: Before operative treatment, patients had moderate to severe shoulder pain and were limited in performing their activities. The mean 4-year cost of $17,587 allowed the purchase of treatment with TSA, leading to a greater than 5-fold reduction in pain and a nearly double improvement in shoulder function with a small risk of harm.

A retrospective study evaluating silver-impregnated dressings on cesarean wound healing.

OBJECTIVE: This retrospective study was designed to assess the effectiveness of silver-impregnated dressings in reducing postoperative wound care visits. DESIGN: A retrospective chart review of 72 patients was conducted to compare the effectiveness of silver-impregnated dressings with traditional wound dressings in reducing additional postoperative visits associated with surgical site infections (SSIs) in patients undergoing cesarean delivery: Prior to October 1, 2009, incisions of 36 women were covered with gauze pads. Subsequent to that date, Silverlon dressings (Cura Surgical, Geneva, Illinois) were applied to the wounds of the remaining 36 women. MAIN RESULTS: Two patients whose incisions were covered with a gauze pad and 2 patients who received the silver-impregnated dressings developed an SSI requiring additional wound care visits. Silver-impregnated dressings did not significantly reduce the rate of wound care-related postoperative visits, but the experimental group had a higher rate of comorbidities. CONCLUSIONS: Although there was no observed difference in the number of women requiring additional wound care visits, the significantly greater number of comorbidities noted in the silver-impregnated dressing group should have theoretically placed them at increased risk for SSIs and additional postoperative wound care visits, suggesting that silver-impregnated dressings may have more of a protective effect than is appreciated in this study. A randomized prospective study is planned to further assess its usefulness in decreasing the incidence of wound infections along with its potential benefits regarding wound appearance.

Outcomes of Various Antibiotic Cement-Coated Intramedullary Implants on the Treatment of Long Bone Septic Nonunion.

OBJECTIVE: To determine the effectiveness of various types of antibiotic-coated intramedullary implants in the treatment of septic long bone nonunion. DESIGN: Retrospective chart review. SETTING: Level 1 trauma center. PARTICIPANTS: Forty-one patients with septic long bone nonunion treated with an antibiotic cement-coated intramedullary implant. INTERVENTION: Surgical debridement and placement of a type of antibiotic-coated intramedullary implant. MAIN OUTCOME MEASUREMENTS: Union and need for reoperation. RESULTS: At an average 27-month follow-up (6-104), 27 patients (66%) had a modified radiographic union score of the tibia of 11.5 or greater, 12 patients (29%) a score lower than 11.5, and 2 patients (5%) underwent subsequent amputation. Six patients underwent no further surgical procedures after the index operation. Patients treated with a rigid, locked antibiotic nail achieved earlier weight-bearing (P = 0.001), less frequently required autograft (P = 0.005), and underwent fewer subsequent procedures (average 0.38 vs. 3.60, P = 0.004) than those treated with flexible core antibiotic rods. CONCLUSIONS: Antibiotic-coated intramedullary implants are successful in the treatment of septic nonunions in long bones. In our cohort, rigid, statically locked nails allowed faster rehabilitation, decreased the need for autograft, and decreased the number of additional surgical procedures. Further study is needed to confirm these findings. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluating the impact of a standardized induction protocol to reduce adverse perinatal outcomes: a prospective cohort study.

OBJECTIVE: Our objective was to evaluate the impact of a standardized induction protocol on reducing maternal and neonatal morbidity in women undergoing an induction with an unfavorable cervix. STUDY DESIGN: We performed a prospective cohort study of women undergoing an induction from May 2013 to June 2015. Women who were ≥18 years, ≥37 weeks with intact membranes and an unfavorable cervix (Bishop score of ≤6 and cervical dilation ≤2 cm) with no prior cesarean were included. We compared the following outcomes between women managed with the labor protocol versus women in an observation group, managed at the discretion of the provider: Labor length, cesarean delivery, maternal and neonatal morbidity, and neonatal intensive care unit admission for >48 hours. Multivariable models incorporated confounders specific to each outcome. RESULTS: 855 women were included (491: labor protocol group; 364: observational group). Women in the labor protocol group had a shorter time to delivery (15.7 hours vs. 18.0 hours, p < .001), a decrease in maternal morbidity (7.3% vs. 11.5%, p = .04), lower rates of NICU admission >48 hours (3.5% vs 8%, p = .005), and a lower neonatal morbidity (3.0% vs. 7.7%, p = .003) compared to women in the observational group. There was no difference in rate of cesarean between the labor protocol and observational groups (27.7% vs. 32.7%, p = .13). When adjusting for confounders, women in the labor protocol group had a 60% reduction in NICU admission >48 hours (RR: 0.41, 95% CI: 0.22-0.76) and a 70% reduction in neonatal morbidity (RR: 0.31, 95% CI: 0.13-0.70). Time to delivery and maternal morbidity were not significantly different in adjusted models. CONCLUSION: Utilization of a standardized induction protocol was associated with a significant reduction in neonatal morbidity without increasing the risk of cesarean or maternal morbidity.

Fetal umbilical cord blood erythropoietin, interleukin-6, pH, pO(2), pCO(2), and base excess levels in histologic and/or clinical chorioamnionitis: is the response only inflammatory?

OBJECTIVE: To determine the correlation of histological chorioamnionitis (CA) with and without clinical CA with umbilical cord blood gases, erythropoietin (EPO), and interleukin-6 (IL-6) levels. METHODS: Umbilical artery blood gas analysis (pH, pO(2), pCO(2), BE) and umbilical vein EPO and IL-6 levels were measured in 202 infants from normal, histological, and no clinical CA and histological plus clinical CA pregnancies. RESULTS: Umbilical artery blood gas analyses were not different between normal controls and histological and clinical CA groups. Blanc Stage 1 histological CA had no abnormal EPO or IL-6 umbilical blood results. EPO in umbilical venous blood was elevated only in those infants with both histological and clinical CA. Umbilical vein IL-6 levels were elevated in all advanced microscopic and clinical CA. High and low EPO groups also have corresponding high and low IL-6 levels suggesting a common stimulus for these substances. CONCLUSIONS: Blanc stage I histological CA is probably clinically insignificant. CA is infrequently associated with abnormal umbilical artery blood gas levels. Advanced histological and clinical CA can elevate both EPO and IL-6 in umbilical blood and these may be key elements of mechanisms that effect fetal brain function.