Prevalence and Risk Factors for New-Onset Hypertension in Labor.

OBJECTIVE: Little is known about prevalence, risk factors, rate of treatment, or adverse outcomes associated with intrapartum hypertension. Thus, our objective was to describe these findings. STUDY DESIGN: This was a retrospective study of laboring term gestations with no history of hypertensive disorders. Intrapartum blood pressures were reviewed, and women were subdivided based on blood pressures: normal (<140 mm Hg systolic and <90 mm Hg diastolic), mild hypertension (140-159 or 90-109), and severe hypertension (≥ 160 or ≥ 110). Groups were compared using chi-square test and analysis of variance. RESULTS: A total of 724 women were studied during 4 months: 248 (34%) had mild and 69 (10%) had severe hypertension. Severe hypertensives were more likely to be nulliparous, obese, or have received an epidural or oxytocin. There were no cases of eclampsia, stroke, or pulmonary edema in severe hypertensives (95% confidence interval, 0-5). Despite severely elevated pressures, only 4/69 (6%) patients received intravenous antihypertensive therapy, and 3 (4%) required medications at discharge. CONCLUSION: One in 3 women exhibits mild hypertension and 1 in 10 develop severe hypertension in labor. Only 6% of patients received treatment for severe blood pressures. This study highlights lack of treatment of hypertension in labor and further investigation into causes and outcomes of intrapartum elevations of blood pressures.

Erratum: Persistence of Neonatal Brachial Plexus Palsy among Nulliparous Versus Parous Women.

[This corrects the article DOI: 10.1055/s-0038-1677051.].

Persistence of Neonatal Brachial Plexus Palsy among Nulliparous Versus Parous Women.

Objective Our objective was to compare persistence of neonatal brachial plexus palsy (NBPP) at 1 and 2 years in children of nulliparous versus parous women. Study Design We conducted a retrospective cohort study of children diagnosed with NBPP followed at the University of Michigan, Interdisciplinary Brachial Plexus Program (UM-BPP). Self-reported demographics, delivery history, including birth weight (BW) < versus ≥ 9 lbs, and presence of shoulder dystocia (SD) were recorded. Student's t -test and Chi-square test with odds ratio (OR) with 95% confidence intervals (CI) were calculated for comparisons of maternal, neonatal, and peripartum characteristics. Results Of 337 children with NBPP, 43% (146) were of nulliparas and 57% (191) of multiparas. At 1 year, children with persistent NBPP were similar in both groups (87% vs. 88%, aOR 1.357, 95% CI: 0.297-6.208). Persistent NBPP was not significantly different among nulliparous and multiparous women at 2 years (97% vs. 92% respectively, aOR 0.079, 95% CI: 0.006-1.050). Conclusion In one of the largest cohorts of NBPP, maternal parity did not influence the likelihood of NBPP persistence at 1 and 2 years.

Twin transvaginal cervical length at 16-20 weeks and prediction of preterm birth.

OBJECTIVE: Our objective was to determine if transvaginal cervical length at 16-20 weeks is predictive of preterm birth <34 weeks in a large cohort of twin pregnancies. STUDY DESIGN: This is a secondary analysis from a randomized trial of 17 alpha-hydroxyprogesterone caproate in twins to prevent preterm birth. Transvaginal cervical length was performed at 16-20-week gestation. The inclusion criteria were non-anomalous twins with transvaginal cervical length at 16-20 weeks. Receiver-operating characteristic (ROC) curves were generated to determine the transvaginal cervical length associated with preterm birth. RESULTS: Of 655 pregnancies, 27% (N = 178) women met our inclusion criteria. The rate of spontaneous preterm birth before 34 weeks was 16% (N = 29). A receiver operator characteristic curve was generated for all preterm birth <34 weeks (spontaneous and indicated) which demonstrated an area under the curve of 0.51, 95% CI (0.41-0.61). When indicated preterm birth (n = 15) were excluded, the area under the curve was 0.59 (95% CI 0.47-0.70), indicating that transvaginal cervical length values were not a clinically useful test for the prediction of spontaneous preterm birth. A transvaginal cervical length of 30 mm from this model would produce a sensitivity of detecting spontaneous preterm birth of 95% and a specificity of 14%. CONCLUSION: In an asymptomatic twin population, a single transvaginal cervical length between 16 and 20 weeks was not predictive of spontaneous preterm birth before 34 weeks. Thus, our findings suggest that routine transvaginal cervical length screening of twins should not be performed between 16-20 weeks.

Adherence to Consensus Guidelines for the Management of Labor Arrest Disorders in a Single Academic Tertiary Care Medical Center.

OBJECTIVE: To evaluate the degree of adherence to the new the American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine guidelines in labor arrest management. STUDY DESIGN: A retrospective study of term, live, singleton deliveries with intrapartum primary cesarean delivery solely for failed induction of labor or labor arrest. Adherence was defined according to the Safe Prevention of the Primary Cesarean Delivery 2014 criteria. We evaluated adherence and compared maternal and perinatal outcomes, delivery time frame, and billing provider. Multivariable Poisson regression models with robust error variance were used to calculate adjusted relative risk (aRR) and 95% confidence interval (CI). RESULTS: Two-hundred six deliveries met the inclusion criteria; 73% were deemed not adherent to the guidelines. The majority of cases were under the care of nonacademic private practice OB/GYN physicians. The adherence rate was higher in the active phase of labor (45%) than in second stage (17%) and latent phase (14%). There were no differences in perinatal outcomes between the two groups. The adherence to guidelines was higher among academic OB/GYN physicians (aRR, 2.24, 95% CI, 1.49-3.36) and during the weekday-night shift (aRR, 1.81, 95% CI, 1.10-2.98). CONCLUSION: Despite recent guidelines aimed to reduce the primary cesarean delivery rate, most cesarean deliveries performed for labor arrest disorders were not adherent to the guidelines.

Liberal versus Indicated Maternal Oxygen Supplementation in Labor: A Before-and-After Trial.

BACKGROUND: Although supplemental oxygen (SO2) is routinely administered to laboring gravidas, benefits and harms are not well studied. OBJECTIVE: This article compares strategies of liberal versus indicated SO2 therapy during labor on cesarean delivery (CD) rate and neonatal outcomes. STUDY DESIGN: A controlled, before-and-after trial of laboring women with term, singleton pregnancies. During an initial 8-week period, maternal SO2 was administered at the discretion of the provider followed by an 8-week period where SO2 was to be given only for protocol indications. RESULTS: Our study included 844 women. There was no difference in number of women receiving SO2 (53% liberal vs. 50% indicated; p = 0.33). For those receiving SO2, there was no difference in SO2 duration (median, 89 minutes [interquartile range, 42-172] vs. 87 minutes [36-152]; p = 0.42). There were no differences in overall CD rate (20% vs. 17%; p = 0.70), CD for nonreassuring fetal status, or use of intrauterine resuscitative measures. There were more 5-minute APGAR < 7 in the indicated group, but no difference in umbilical artery pH < 7.1 or neonatal intensive care unit (NICU) admission. CONCLUSION: Approximately half of women receive SO2 intrapartum regardless of a strategy of liberal or indicated oxygen use. There were no clinically significant differences in outcomes between strategies.

Chronic Hypertension in Pregnancy: Diagnosis, Management, and Outcomes.

Chronic hypertension affects up to 5% of pregnancies. Women can be stratified into low-risk or high-risk chronic hypertension based on baseline laboratory and diagnostic work-up, comorbid conditions, and outcomes in prior pregnancies. Pregnancies complicated by chronic hypertension are at risk for increased adverse maternal and neonatal outcomes including superimposed preeclampsia, fetal growth restriction, placental abruption, and perinatal death. Mainstays of management include blood pressure control, close monitoring for development of superimposed preeclampsia, serial ultrasound assessment of fetal growth, and antenatal testing after 32 weeks.

Neonatal brachial plexus palsy: obstetric factors associated with litigation.

OBJECTIVE: Our objective was to compare characteristics between neonatal brachial plexus palsy (NBPP) cases that were litigated versus those that were not. STUDY DESIGN: From May to December 2012, the University of Michigan Interdisciplinary Brachial Plexus Program surveyed 51 consecutive families whose children were treated for NBPP. Obstetric data was self-reported. Unless NBPP resolved, children were followed for at least two years. Student's t-test and Chi-square test with odds ratio and 95% confidence intervals were calculated. RESULTS: Among 51 families surveyed, obstetric data were available for 98% (n = 50). Litigation was pursued by 48% (n = 24). Comparing families that litigated versus those that did not, there were no differences in demographics, peripartum characteristics, operative versus spontaneous vaginal birth, shoulder dystocia in current pregnancy (65% versus 54%; p = 0.56) or birth weight above 9 lbs. The number of children having brachial nerve surgery was significantly higher among families that litigated (46%) versus those that did not (8%; p = 0.002). CONCLUSION: Though there were no differences in peripartum events, almost 1 out of 2 children managed by interdisciplinary team had concomitant litigation. The only factor associated with litigation was having brachial nerve surgery. Efforts are warranted to avert NBPP and mitigate litigations.

Intravenous Acetaminophen versus Morphine for Analgesia in Labor: A Randomized Trial.

Objective To compare the effectiveness of intravenous acetaminophen with that of morphine in reducing pain in the first stage of labor. Methods An open-label, randomized controlled trial of women ≥ 34 weeks gestation in the first stage of labor, assigned to either intravenous acetaminophen or morphine. The primary outcome was improved analgesia measured by difference of visual analog scale (VAS) score at 120 minutes from baseline. Secondary outcomes were request for rescue analgesia, maternal side effects, and fetal heart rate changes. Statistical analyses performed were chi-square, Student's t-test, and Kaplan-Meier survival analysis. Results Of 40 women randomized, 18 received acetaminophen (2 did not receive study drug), and 20 received morphine. Because of difficulties in recruitment, the sample size of 88 was not achieved. The primary outcome was similar between groups (p = 0.53). Within 120 minutes of initial treatment, more women receiving intravenous acetaminophen required rescue analgesia (acetaminophen: 52.9% vs. morphine: 17.6%, p < 0.01). Maternal and fetal side effects were similar between groups. Conclusion There was no difference in VAS scores between groups. However, as half of women receiving intravenous acetaminophen required rescue analgesia within 120 minutes of treatment, intravenous acetaminophen may be less effective for analgesia in early labor compared with intravenous morphine.

Persistence of Neonatal Brachial Plexus Palsy Associated with Maternally Reported Route of Delivery: Review of 387 Cases.

Objective The factors associated with persistent neonatal brachial plexus palsy (PNBPP) are unknown. Our objectives are to compare PNBPP at 1 and 2 years in children delivered via vaginal delivery (VD) versus cesarean delivery (CD) and in children delivered via VD with or without reported shoulder dystocia (SD). Study Design Retrospective cohort of children diagnosed with neonatal brachial plexus palsy (NBPP). Maternally reported delivery history and presence of SD were recorded with Student t-test, chi-square test, and odds ratio (OR) with 95% confidence intervals (CI) calculated for comparisons. Results Of 387 cases of NBPP, 8% (30) delivered via CD. Rates of PNBPP were higher in the VD group at 1 and 2 years (60% of CD and 85% of VD; OR, 0.26; 95% CI, 0.11-0.62 at 1 year; 33% of CD and 73% of VD; OR, 0.15; 95% CI, 0.05-0.39 at 2 years). There was no difference in PNBPP in women with VD with or without maternally reported SD (87 vs. 85%, p = 0.68 at 1 year; 64 vs. 61%, p = 0.61 at 2 years). Conclusion PNBPP is possible with CD, and there is no difference in PNBPP in VD with or without maternally reported SD. A prospective study is warranted to ascertain associative factors.

Pregnancy Outcomes in Women with 1-Hour Glucose Challenge Test ≥ 200 mg/dL.

OBJECTIVE: Many protocols diagnose gestational diabetes mellitus (GDM) solely on a 1-hour glucose challenge test (GCT) ≥ 200 mg/dL. However, pregnancy outcomes in these women compared with women diagnosed with a 3-hour glucose tolerance test (GTT) has not been adequately evaluated. We hypothesize that a 1-hour GCT ≥ 200 mg/dL is associated with worse pregnancy outcomes as compared with a GCT 135 to 199 mg/dL with positive GTT. STUDY DESIGN: A retrospective cohort of singleton pregnancies complicated by GDM. Maternal outcomes included A2DM, preeclampsia, primary cesarean, and failed trial of labor after cesarean. Perinatal outcomes were large/small for gestational age, shoulder dystocia, and birth injury. Groups were compared with t-test and chi-square test, and logistic regression to adjust for confounders. RESULTS: A total of 602 women diagnosed with GDM by 1-hour GCT 135 to 199 mg/dL and confirmatory 3-hour GTT (< 200 group) and 225 women diagnosed with 1-hour GCT ≥ 200 alone (≥ 200) were included. The ≥ 200 group had a higher incidence of preeclampsia (16.4 vs. 10.6%) and shoulder dystocia (3.1 vs. 1.0%). Adjusted odds ratio and 95% confidence interval were 1.80 (1.10-2.94) and 5.10 (1.25-20.76), respectively. CONCLUSION: Preeclampsia and shoulder dystocia are more frequent in women with GCT ≥ 200 mg/dL than those with a positive GTT following a GCT of 135 to 199 mg/dL.

Nulliparous Women in the Second Stage of Labor: Changes in Delivery Outcomes Between Two Cohorts From 2000 and 2011.

OBJECTIVE: To evaluate changes over the past decade in the mode of delivery and second-stage duration in nulliparous women. METHODS: We conducted a retrospective cohort study at a single institution of nulliparous women reaching complete cervical dilation with singleton gestations 36 weeks or greater from January 1, 2011, to December 31, 2012, and compared these with a prior cohort prospectively collected from July 28, 2000, to February 28, 2003. We excluded pregnancies with prenatally diagnosed fetal anomalies. The primary outcome was cesarean delivery. Secondary outcomes included second-stage duration, rates of operative vaginal delivery (forceps and vacuum collectively), and indications for cesarean delivery and operative vaginal delivery. RESULTS: There were 1,023 mother-neonate pairs in the prior cohort and 1,476 in the current cohort. In the prior and current cohorts, respectively, 2% compared with 6% underwent cesarean delivery, 21% compared with 10% underwent operative vaginal delivery, and 77% compared with 84% had spontaneous vaginal delivery (all P<.01). Compared with the prior cohort, the adjusted odds (OR) of cesarean delivery (compared with any vaginal birth) for current patients was 1.74 (95% confidence interval [CI] 1.04-2.91), and in a separate regression model, the adjusted OR of operative vaginal delivery (compared with spontaneous vaginal delivery or cesarean delivery) was 0.42 (95% CI 0.33-0.54). Median (25th, 75th percentile) second-stage duration significantly increased from 38 (20, 71) to 42 (22, 87) minutes (P<.01), but this difference was nullified after adjusting for confounders. CONCLUSION: Comparing cohorts from 2000 and 2011, although the second-stage duration has not changed appreciably, nulliparous women in the second stage of labor at our institution are twice as likely to undergo cesarean delivery and half as likely to undergo operative vaginal delivery. LEVEL OF EVIDENCE: II.

Risk of adverse pregnancy outcomes in women with mild chronic hypertension before 20 weeks of gestation.

OBJECTIVE: To evaluate whether blood pressure (BP) less than 140/90 mm Hg is associated with lower risk of adverse pregnancy outcomes in women with mild chronic hypertension. METHODS: This was a secondary analysis of women with chronic hypertension diagnosed before 20 weeks of gestation (either BP 140/90 mm Hg or greater on two occasions at least four hours apart or previously diagnosed and on antihypertensive therapy) enrolled in the Maternal-Fetal Medicine Units Network's High-risk Aspirin preeclampsia prevention trial. Outcomes including a primary composite (perinatal death, severe preeclampsia, placental abruption, and indicated preterm birth less than 35 weeks of gestation) and small for gestational age (SGA) were compared by study preenrollment BP analyzed as a categorical (less than 140/90, 140-150/90-99, or 151-159/100-109 mm Hg) and as a continuous variable. RESULTS: Among 759 women with singleton pregnancy and preenrollment BP less than 160/110 mm Hg, the incidence of the primary composite outcome (10.7%, 19.0%, 30%) and SGA (8.8%, 12.3%, 23.7%) increased with increasing BP category (P values≤.001). The adjusted odds ratio (95% confidence interval) for the primary composite was 2.0 (1.3-3.2) for 140-150/90-99 mm Hg and 3.2 (1.6-6.3) for 151-159/100-109 mm Hg compared with BP less than 140/90 mm Hg. The results for SGA were 1.6 (0.9-2.8) and 3.8 (1.8-7.9), respectively. Models including continuous systolic and diastolic BP revealed increasing adverse outcomes per 5-mm Hg rise in diastolic but not systolic BP: primary composite (19% per 5 mm Hg) and SGA (22% per 5 mm Hg). CONCLUSION: The risks of adverse pregnancy outcomes in women with chronic hypertension are lower with preenrollment BP less than 140/90 mm Hg as compared with higher BP categories and increase with increasing BP. LEVEL OF EVIDENCE: II.