Caesarean Delivery Surgical Site Infection: What are Expected Rates and Potentially Modifiable Risk Factors?

OBJECTIVE: This study sought to determine baseline Caesarean delivery (CD) surgical site infection (SSI) rates in various patient subgroups and to identify potentially modifiable and non-modifiable risk factors for SSI. METHODS: This is a secondary analysis of a multicentre CD registry. Women who underwent CD were divided into SSI versus no SSI. SSI was defined as an infection that occurred in the part of the body where the surgery took place, within 30 days of surgery. Clinical characteristics and potential risk factors were compared between groups. RESULTS: Of 57 182 women, 3696 (6.5%) had SSI. SSI rates were higher in primary versus repeat CD (9.7% vs. 4.2%; P <0.001), and in CD after labour vs. no labour (9.5% vs. 3.8%; P <0.001). After adjustment for confounding factors, low transverse CD (adjusted OR [aOR] 0.7 [0.6-0.9]), CD performed between 7 pm and 7 am (aOR 0.9 [0.83-0.98]), primary CD (aOR 0.5 [0.5-0.6]), and intrapartum antibiotics (aOR 0.3 [0.1-0.4]) were associated with a decreased in the rate of SSI. Black race (aOR 1.9 [1.7-2.1]), tobacco use (aOR 1.4 [1.2-1.6]), increasing American Society of Anesthesiologists category (aOR 1.3 [1.1-1.6]), vertical skin incision (aOR 1.2 [1.1-1.3], emergency CD (aOR 1.3 [1.1-1.5]), and postpartum transfusion (aOR 2.7 [2.1-3.6]) were associated with an increase in the rate of SSI. CONCLUSION: This study estimates the CD SSI rates in different subgroups and serves as a baseline for future trials designed to develop preventive guidelines and protocols.

The Relationship of Assisted Reproductive Technology on Perinatal Outcomes in Triplet Gestations.

OBJECTIVE: To assess whether assisted reproductive technology (ART) is associated with increased risk of adverse perinatal outcomes in triplet gestations compared with spontaneous conception. STUDY DESIGN: Secondary analysis of a multicenter randomized trial for the prevention of preterm birth in multiple gestations. Triplets delivered at ≥ 24 weeks were studied. The primary outcome was the rate of composite neonatal morbidity (CNM) that included one or more of the following: bronchopulmonary dysplasia, respiratory distress syndrome, necrotizing enterocolitis, culture proven sepsis, pneumonia, retinopathy of prematurity, intraventricular hemorrhage, periventricular leukomalacia, or perinatal death. RESULTS: There were 381 triplets (127 women) of which 89 patients conceived via ART and 38 patients spontaneously. Women with ART were more likely to be older, Caucasian, married, nulliparous, have higher level of education, and develop pre-eclampsia. Spontaneously conceived triplets were more likely to delivery at an earlier gestation (31.2 ± 3.5 vs 32.8 ± 2.7 weeks) (p = 0.009) with a lower birth weight (p < 0.001). After adjusting for confounders, no differences were noted in culture proven sepsis, perinatal death, CNM, respiratory distress syndrome, or Apgar score < 7 at 5 minutes. All remaining perinatal outcomes were similar. CONCLUSION: Triplets conceived by ART had similar perinatal outcomes compared with spontaneously conceived triplets.

Can 3-dimensional power Doppler indices improve the prenatal diagnosis of a potentially morbidly adherent placenta in patients with placenta previa?

BACKGROUND: Traditionally, 2-dimensional ultrasound parameters have been used for the diagnosis of a suspected morbidly adherent placenta previa. More objective techniques have not been well studied yet. OBJECTIVE: The objective of the study was to determine the ability of prenatal 3-dimensional power Doppler analysis of flow and vascular indices to predict the morbidly adherent placenta objectively. STUDY DESIGN: A prospective cohort study was performed in women between 28 and 32 gestational weeks with known placenta previa. Patients underwent a two-dimensional gray-scale ultrasound that determined management decisions. 3-Dimensional power Doppler volumes were obtained during the same examination and vascular, flow, and vascular flow indices were calculated after manual tracing of the viewed placenta in the sweep; data were blinded to obstetricians. Morbidly adherent placenta was confirmed by histology. Severe morbidly adherent placenta was defined as increta/percreta on histology, blood loss >2000 mL, and >2 units of PRBC transfused. Sensitivities, specificities, predictive values, and likelihood ratios were calculated. Student t and χ2 tests, logistic regression, receiver-operating characteristic curves, and intra- and interrater agreements using Kappa statistics were performed. RESULTS: The following results were found: (1) 50 women were studied: 23 had morbidly adherent placenta, of which 12 (52.2%) were severe morbidly adherent placenta; (2) 2-dimensional parameters diagnosed morbidly adherent placenta with a sensitivity of 82.6% (95% confidence interval, 60.4-94.2), a specificity of 88.9% (95% confidence interval, 69.7-97.1), a positive predictive value of 86.3% (95% confidence interval, 64.0-96.4), a negative predictive value of 85.7% (95% confidence interval, 66.4-95.3), a positive likelihood ratio of 7.4 (95% confidence interval, 2.5-21.9), and a negative likelihood ratio of 0.2 (95% confidence interval, 0.08-0.48); (3) mean values of the vascular index (32.8 ± 7.4) and the vascular flow index (14.2 ± 3.8) were higher in morbidly adherent placenta (P < .001); (4) area under the receiver-operating characteristic curve for the vascular and vascular flow indices were 0.99 and 0.97, respectively; (5) the vascular index ≥21 predicted morbidly adherent placenta with a sensitivity and a specificity of 95% (95% confidence interval, 88.2-96.9) and 91%, respectively (95% confidence interval, 87.5-92.4), 92% positive predictive value (95% confidence interval, 85.5-94.3), 90% negative predictive value (95% confidence interval, 79.9-95.3), positive likelihood ratio of 10.55 (95% confidence interval, 7.06-12.75), and negative likelihood ratio of 0.05 (95% confidence interval, 0.03-0.13); and (6) for the severe morbidly adherent placenta, 2-dimensional ultrasound had a sensitivity of 33.3% (95% confidence interval, 11.3-64.6), a specificity of 81.8% (95% confidence interval, 47.8-96.8), a positive predictive value of 66.7% (95% confidence interval, 24.1-94.1), a negative predictive value of 52.9% (95% confidence interval, 28.5-76.1), a positive likelihood ratio of 1.83 (95% confidence interval, 0.41-8.11), and a negative likelihood ratio of 0.81 (95% confidence interval, 0.52-1.26). A vascular index ≥31 predicted the diagnosis of a severe morbidly adherent placenta with a 100% sensitivity (95% confidence interval, 72-100), a 90% specificity (95% confidence interval, 81.7-93.8), an 88% positive predictive value (95% confidence interval, 55.0-91.3), a 100% negative predictive value (95% confidence interval, 90.9-100), a positive likelihood ratio of 10.0 (95% confidence interval, 3.93-16.13), and a negative likelihood ratio of 0 (95% confidence interval, 0-0.34). Intrarater and interrater agreements were 94% (P < .001) and 93% (P < .001), respectively. CONCLUSION: The vascular index accurately predicts the morbidly adherent placenta in patients with placenta previa. In addition, 3-dimensional power Doppler vascular and vascular flow indices were more predictive of severe cases of morbidly adherent placenta compared with 2-dimensional ultrasound. This objective technique may limit the variations in diagnosing morbidly adherent placenta because of the subjectivity of 2-dimensional ultrasound interpretations.

Successful Management of a Periviable Pregnancy with Morbidly Adherent Placenta after Uterine Rupture.

BACKGROUND: Although rare, trauma in pregnancy can cause uterine rupture. In a periviable pregnancy, uterine rupture can lead to premature delivery and significant morbidity. CASE: A 29-year-old woman with four prior CSs presented with uterine rupture and a protruding morbidly adherent placenta at 23+4 weeks of gestation. Since the pregnancy was highly desired, the defect was repaired and the decision made to continue with the pregnancy. The patient presented at 29+3 weeks of gestation with preterm labour and subsequently delivered a healthy male infant of 1130 grams. CONCLUSION: Expectant management followed by CS can be beneficial in certain cases of uterine rupture with morbidly adherent placenta following trauma. This is especially the case in a periviable pregnancy, since prolonging the pregnancy will improve neonatal outcomes. We recommend individualized management based on clinical presentation, imaging findings, and the patient's wishes.

Rate of Gestational Diabetes Mellitus and Pregnancy Outcomes in Patients with Chronic Hypertension.

Objective This study aims to determine the rate of gestational diabetes mellitus (GDM) in pregnancies complicated by chronic hypertension and to compare the adverse outcomes in chronic hypertensive pregnancies with and without GDM. Study Design A secondary analysis from a multicenter trial of low-dose aspirin for preeclampsia prevention in women with chronic hypertension. The rate of GDM was evaluated among singleton pregnancies complicated with chronic hypertension and grouped according to their GDM status. Pregnancy outcomes and rates of preterm delivery < 35 weeks and < 32 weeks, preeclampsia, indicated preterm birth, small for gestational age, abruptio placentae, and perinatal death were compared between those with and without GDM. A subgroup analysis comparing women who developed superimposed preeclampsia with and without GDM was studied. Multivariate logistic-regression analysis was used to adjust for potentially confounding factors. Results A total of 763 women met the inclusion criteria: 129 (17%) developed GDM. Parity, race, maternal baseline blood pressure, antihypertensive drug use, and assignment to low-dose aspirin were not significantly different between the groups with and without GDM. Using univariate analysis, maternal age (33 vs. 24%, p = 0.03) and body mass index (88 vs. 57%, p < 0.001) were higher in those who had GDM, whereas the rate of preterm delivery < 32 weeks (12 vs. 5%, p = 0.02) was higher among those without GDM. Using logistic-regression analysis, the rate of composite adverse outcomes (adjusted odds ratio [aOR], 0.77; 95% confidence interval [CI], 0.41-1.47) that included indicated preterm birth, small for gestational age, abruptio placentae, and perinatal death showed no significant differences.Superimposed preeclampsia developed in 34 (26%) women with GDM and in 182 (29%) without GDM. When superimposed preeclampsia was present, it developed at an earlier gestational age among the group without GDM (35 ± 5 vs. 37 ± 3 weeks, p = 0.003), and had higher rates of small for gestational age infants (18 vs. 3%, p = 0.03). After adjustment for confounders, only length of stay in neonatal intensive care unit was longer for those without GDM who developed superimposed preeclampsia (aOR, 0.42; 95% CI, 0.2-0.93). Conclusion Women with chronic hypertension are at a high risk for developing GDM. Outcomes in patients with chronic hypertension and GDM are not significantly different from those with chronic hypertension only.

Effect of Tocolytics on Surfactant Secretion When Administered with Betamethasone: An in Vitro Study.

OBJECTIVE: To analyze the amount of surfactant protein (SP)-B and lecithin/sphingomyelin (L/S) ratio in response to betamethasone (BMS) alone as compared with magnesium sulfate (Mg(2+)), indomethacin (Indo), and nifedipine (Nif) with or without BMS. STUDY DESIGN: NCI-H441 human lung cells were grown and distributed into eight plates. BMS and tocolytics were added and the final plates were: control, BMS only, and each tocolytic ± BMS. Cells were stained with SP-B antibodies and relative fluorescence was measured. Lipids were also extracted, identified, and examined for relative densities. The L/S ratio was calculated. RESULTS: Nine independent measurements were obtained for each plate. The protein analysis revealed that among all eight plates, SP-B levels were highest among BMS only. There was a nonsignificant decrease in SP-B in each of the combinations of tocolytics + BMS as compared with BMS only. Compared with BMS only, L/S ratio was decreased in Mg(2+) + BMS (p = 0.041), Indo + BMS (p = 0.042), and Nif + BMS (p = 0.025). CONCLUSION: In our in vitro human lung cell model, SP-B and L/S ratio increased in response to BMS administration alone. The addition of tocolytics to BMS resulted in no increase in L/S ratio and no changes seen in SP-B production compared with BMS alone.

Composite neonatal and maternal morbidities with small- versus appropriate- for gestational age among uncomplicated obese women undergoing repeat cesarean delivery.

PURPOSE: Our goal was to compare composite neonatal and maternal morbidities (composite neonatal morbidity (CNM), composite maternal morbidity (CMM)) among deliveries with small for age (SGA) versus appropriate for gestational age (AGA; birthweight 10-89%) among obese versus non-obese women undergoing repeat cesarean delivery (CD). STUDY DESIGN: This is a secondary analysis of a prospective observational study. Women who had elective CD ≥37 weeks were studied. We excluded multiple gestations, fetal anomalies, > 1 prior CD, and medical diseases. Patients were divided into BMI ≥30 versus <30 kg/m2. CNM included respiratory distress syndrome, necrotizing enterocolitis, severe intraventricular hemorrhage, seizure, or death; CMM included transfusion, hysterectomy, operative injury, coagulopathy, thromboembolism, pulmonary edema, or death. Multivariate logistic regression was used to control for confounding factors. RESULTS: Of 7561 women, we included 65% were obese and 35% were not. SGA rates differed significantly: 8 versus 12% (p < .001). Overall, CNM was significantly higher in patients with SGA versus AGA (adjusted odds ratio (aOR) 2.04, 95% CI 1.19-3.49). CMM of SGA in obese versus non-obese was statistically different (aOR 0.11, 95% CI 0.02-0.68). Among obese mothers, SGA neonates had significantly higher CNM compared with AGA ones (aOR 2.17, 95% CI 1.03-4.59). CONCLUSIONS: SGA occurred in 8% of low-risk obese women with prior CD. CNM of SGA babies in obese versus non-obese women were similar. Paradoxically, CMM was lower in obese cases, possibly reflecting the caution that obese patients receive preoperatively. Our findings may assist in counseling patients and designing trials.

Adverse pregnancy outcomes in deliveries prior to, at and beyond 39 weeks; low- and high-risk women.

BACKGROUND: Hypertensive disorders are associated with maternal and neonatal complications. Though they are more common in women with history of prior preeclampsia, they can occur in uncomplicated pregnancies. OBJECTIVE: To determine the proportion of adverse pregnancy outcomes in deliveries prior to or at ≥39 weeks, in uncomplicated singleton nulliparous women (low-risk), as well as women with history of preeclampsia in a prior gestation (high-risk). STUDY DESIGN: This was a secondary analysis from the multicenter trials of low dose aspirin for preeclampsia prevention in low and high-risk pregnancies. The proportion of adverse pregnancy outcomes including hypertensive disorders in pregnancy, small for gestational age, placental abruption, neonatal intensive critical unit admission, and respiratory distress syndrome were evaluated in the two groups. Adverse pregnancy outcomes were stratified by gestational age at delivery (<39 weeks and ≥39 weeks). Descriptive statistics were performed, and results reported as percentages. RESULTS: Three thousand twenty-one pregnancies were included in the low risk group, and 600 in the high risk one. In the low risk group 362 (12%) had hypertensive disorders, with 58% occurring at ≥39 weeks. In the low risk group, the rate of small for gestational age was of 5.9%, placental abruption 0.4%, neonatal intensive care unit admission 9%, and respiratory distress syndrome 3.5%. Sixty percent of all small for gestational age, 31% of all placenta abruptions, 44% of all neonatal intensive care unit admissions and 33% of respiratory distress syndrome cases, occurred at ≥39 weeks in the low risk group. In contrast in the high risk group, 197 (33%) patients developed a hypertensive disorder, with 35.5% occurring at ≥39 weeks. The overall rate of small for gestational age was 9.2%, abruption 2%, neonatal intensive care unit admission 15.5%, and respiratory distress syndrome 5%. In this group, 24% of all small for gestational age, 8.3% of all placental abruptions, 16% of all neonatal intensive care unit admissions and 3% of respiratory distress syndrome cases, were at ≥39 weeks. CONCLUSIONS: We found that in low-risk women, the majority of hypertensive disorders occur at ≥39 weeks, whereas in women with prior preeclampsia the majority develops at <39 weeks. Moreover, a third of all placental abruption occurred at or beyond 39 weeks in the low risk group. Our findings suggest that in low-risk women, a policy of delivery at 39 weeks may prevent most of the adverse outcome that occurs beyond that gestational age cutoff.

Effect of partial compliance on the prevention of recurrent preterm birth in women receiving weekly 17 alpha-hydroxyprogesterone caproate injections.

PURPOSE: To analyze the effect of partial compliance on preterm birth (PTB) prevention among women with previous PTB and receiving 17 alpha-hydroxyprogesterone caproate (17-OHPC). STUDY DESIGN: This is a secondary analysis of a multicenter trial for the prevention of recurrent PTB. Women with prior PTB were randomly assigned between 15 0/7 and 20 3/7 weeks to weekly injections of either 17-OHPC or placebo. Full 100% compliance (group 1) was compared to 40-80% (group 2). Recurrent PTB rates and odds ratios were calculated. Student's t, Chi-square, Wilcoxon Rank-Sum, multivariate logistic regression and Breslow-Day tests were used. RESULTS: Group 1 included 370 women versus 35 in group 2. In each group, the PTB rate was significantly reduced in pregnancies receiving 17-OHPC compared to placebo. The adjusted odds ratio for PTB rate in group 1 was 0.48 (95% CI 0.31-0.75) versus 0.18 (95% CI 0.04-0.92) in group 2. Comparing the homogeneity of both odds ratios, the rates of recurrent PTB prevention in both groups were not statistically different (Breslow-Day test; p= .15). CONCLUSION: A compliance rate of 40-80% did not significantly reduce 17-OHPC's efficacy. If confirmed, our findings could lead to a dramatic decrease in costs related to prevention of recurrent PTB.

Folic acid supplementation: what is new? Fetal, obstetric, long-term benefits and risks.

The association between folic acid supplementation, prior to conception and/or during pregnancy and pregnancy outcomes, has been the subject of numerous studies. The worldwide recommendation of folic acid is at least 0.4 mg daily for all women of reproductive age, and 4-5 mg in high-risk women. In addition, evidence shows that folic acid supplementation could modulate other adverse pregnancy outcomes, specifically, in pregnancies complicated by seizure disorders, preeclampsia, anemia, fetal growth restriction and autism. This review summarizes the available national and international guidelines, concerning the indications and dosage of folic acid supplementation during pregnancy. In addition, it describes the potential preventive benefits of folic acid supplementation on multiple maternal and fetal outcomes, as well as potential risks.

Safety of anticonvulsant agents in pregnancy.

INTRODUCTION: Seizures in pregnancy are particularly challenging, as their management requires careful consideration of not only the etiology of the seizure, but also the physiologic changes of pregnancy as well as potential adverse effects on the developing embryo or fetus. Newer antiepileptic drugs (AEDs) have increasingly shown promising results of lower rate of teratogenesis, as well as better seizure control during pregnancy. AREAS COVERED: We performed a review of the scientific literature of seizures in pregnancy including status epilepticus as well as eclampsia, with a focus on safety of currently used AEDs. This covers the different generations of antiepileptic medications, their interactions and seizure recurrence preventative measures. In addition, we summarized our personal approach to the care for these women. EXPERT OPINION: In summary, morbidity associated with seizure in pregnancy is decreasing as treatments and supportive therapies have improved. The understanding of teratogenesis as well as novel targeted therapeutics will allow women on AEDs during their pregnancy, to receive the safest drug for their developing fetus as well as themselves.

Chronic granulomatous disease carrier with recurrent poor obstetric outcome.

BACKGROUND: Chronic granulomatous disease is a primary immunodeficiency disorder characterized by severe recurrent bacterial and fungal infections. Female carriers of the X-linked form of the disorder usually are unaffected and rarely have serious infections. CASE: A 22-year-old pregnant patient known to be a carrier of the X-linked form of chronic granulomatous disease had a history of chorioamnionitis during her two previous pregnancies. During her third pregnancy, she presented again with the same diagnosis, which resulted in delivery at 25 weeks of gestation. CONCLUSION: Carriers of chronic granulomatous disease should be monitored closely during pregnancy, as if they have the disease. To decrease the risk of infectious morbidity and mortality, obstetricians should have a low threshold for starting prophylactic antibiotics early during pregnancy, even if the patient is asymptomatic.