Outcomes of Uterine Rupture in the Setting of the Unscarred Compared With the Scarred Uterus.

Uterine rupture is a rare obstetric complication that is associated with maternal and neonatal morbidity and mortality. The aim of this study was to examine uterine rupture and its outcomes in the setting of the unscarred compared with the scarred uterus. A retrospective observational cohort study was performed examining all cases of uterine rupture in three tertiary care hospitals in Dublin, Ireland, over a 20-year period. The primary outcome was perinatal mortality rate with uterine rupture, which was 11.02% (95% CI 6.5-17.3). There was no significant difference in perinatal mortality between cases of scarred and unscarred uterine rupture. Unscarred uterine rupture was associated with higher maternal morbidity , defined as major obstetric hemorrhage or hysterectomy.

Assessment of antenatal anxiety, depression and obsessive-compulsive disorder in pregnant women in the COVID-19 era.

OBJECTIVE: To assess the mental health of pregnant women, with reference to anxiety, depression and obsessive-compulsive (OC) symptoms, during the COVID-19 pandemic. METHODS: A cross-sectional survey was conducted in Ireland during the third wave of the pandemic between February and March 2021. Psychiatric, social and obstetric information was collected from pregnant women in a Dublin maternity hospital, alongside self-reported measures of mental health status. RESULTS: Of 392 women responding, 23.7% had anxiety, scoring >9 for GAD-7 (7-item generalised anxiety disorder), 20.4% had depression, scoring >9 for PHQ-9 (9-item depression screening tool: Patient health questionnaire) and 10.3% had obsessive-compulsive disorder (OCD), scoring >13 for Yale-Brown obsessive-compulsive scale symptom checklist (Y-BOCS). Amongst self-reported OCD symptoms, there was a preponderance for obsessions rather than compulsions. Of 392 women, 36.2% described their mental health as worse during the pandemic, most frequently describing symptoms of anxiety and sleep disturbance. When analysed against test scores, self-reported worsening of mental health was significantly associated with higher scores on the GAD-7, PHQ-9 and Y-BOCS scales. The three scores were positively interrelated. Poor mental health scores were associated with self-reported strain in relationship with the baby's father, and current or previous history of mental illness. CONCLUSION: This study found high levels of depression, anxiety and OC symptoms amongst pregnant women during COVID-19. This highlights the vulnerability of this group to mental illness and the importance of enhanced screening and support during pandemics.

Use of the Robson Ten Group Classification System to categorise operative vaginal delivery.

BACKGROUND: Operative vaginal delivery (OVD), either vacuum or forceps, can be used to expedite vaginal delivery. While rates of OVD have been reducing worldwide, rates in Ireland remain high. The Robson Ten Group Classification System (TGCS) was originally created to compare rates of caesarean delivery between healthcare units, although no similar system exists for the analysis of OVD. AIMS: We sought to examine rates of OVD using the TGCS in an effort to understand which patient groups make significant contributions to the overall rate of OVD. MATERIALS AND METHODS: This is a retrospective cohort study of all women delivering in a tertiary-level university institution in Dublin, Ireland, from 2007 to 2016. Mode of delivery for all patients was extracted from contemporaneously recorded hospital records. Rates of OVD were analysed according to the TGCS, and the contribution of each group to the overall hospital population was calculated. RESULTS: There were 86 191 deliveries of women in our institution, of which 19.3% (16 673/86 191) had an OVD. Women in Group 1 (singleton, cephalic, nulliparous women at term in spontaneous labour) contributed the most to the overall rate of OVD, accounting for almost half of all OVDs (46.1% (7679/16 673)). Nulliparous women with a singleton, cephalic fetus at term who were induced (Group 2) were more likely to have an OVD than similar patients who laboured spontaneously (Group 1). CONCLUSION: OVD accounts for almost one in five deliveries in our population and is predominately performed in nulliparous women. These groups may be the subject of interventions to lower rates of OVD. The Robson TGCS is a freely available tool to hospitals and birthing centres to facilitate comparison of rates of OVD on local and national levels.

Influence of mode of delivery on outcomes in preterm breech infants presenting in labor.

Objective: Rates of vaginal breech delivery at term have fallen significantly. We sought to examine rates of preterm vaginal breech delivery and outcomes associated with delivery route.Methods: This retrospective cohort study was carried out at a large tertiary referral center serving an urban population, from 2001 to 2011. The primary objective was to compare outcomes of breech presenting preterm infants according to mode of delivery. The incidence of preterm breech delivery was examined as well as maternal and neonatal outcomes associated with vaginal and abdominal delivery of preterm breech infants.Results: A total of 15% (413/2759) of breech presenting infants delivered prior to 37-week gestation. In extreme prematurity (<28 weeks) the majority (88%; 37/42) of those who presented in labor delivered vaginally, this rate fell to 47% (63/134) after 28 weeks. Infants delivered vaginally after 28 weeks were more likely to have an Apgar <7 at 5 min, than those who had a cesarean delivery (22.5% [16/71] versus 9% [25/278], p = .002; numbers needed to treat (NNT) = 4). Maternal blood loss >500 ml was more likely in those patients delivered by cesarean section (24.2% [74/305] versus 3.7% [4/108]; p < .0001; NNT =2).Conclusion: These results demonstrate that vaginal delivery of a preterm breech - presenting infant is a necessary skill for all birth attendants in contemporary practice, particularly prior to 28-week gestation.

Anal Sphincter Injury Associated with Vaginal Twin Delivery.

OBJECTIVE: Obstetric anal sphincter injury remains the most common cause of fecal incontinence in women, and research in twin pregnancies is sparse. This study aimed to examine risk factors for sphincter injury in twin deliveries over a 10-year period. STUDY DESIGN: This was a retrospective study of twin vaginal deliveries in a tertiary-level hospital over 10 years. We examined the demographics of women who had a vaginal delivery of at least one twin. Logistic regression analysis was used to examine risk factors. RESULTS: There were 1,783 (2.1%) twin pregnancies, of which 556 (31%) had a vaginal delivery of at least one twin. Sphincter injury occurred in 1.1% (6/556) women with twins compared with 2.9% (1720/59,944) singleton vaginal deliveries. Women with sphincter injury had more instrumental deliveries (83.3 vs. 27.6%; p = 0.008). On univariate analysis, only instrumental delivery was a significant risk factor (odds ratio: 2.93; p = 0.019). CONCLUSION: Sphincter injury occurs at a lower rate in vaginal twin pregnancies than in singletons. No twin-specific risk factors were identified. Discussion of the risk of sphincter injury should form part of patient counseling with regard to the mode of delivery.

Antecedents of red cell transfusion in a large contemporary obstetric cohort.

Background Hemorrhage is a critical contributor to maternal morbidity but estimation of blood loss at delivery is frequently inaccurate. Due to this inaccuracy we sought to examine blood transfusion as a surrogate marker for morbidity in a large non-population based consecutive cohort. Methods A retrospective analysis of prospectively gathered data was carried out at two university institutions serving a heterogeneous urban obstetric population from January to December 2016. Data were analyzed to determine whether individual characteristics were associated with perinatal transfusion. Hematological indices and requirement for other blood products were also characterized. Results A total of 16,581 deliveries were recorded during the study and 1.7% (289/16,581) of the cohort required red cell transfusion. Those who received transfusion were more likely to be nulliparous, and to deliver <37 weeks' or >42 weeks' gestation. They were also more likely to have a macrosomic infant (birthweight >4 kg) and to have had a multiple pregnancy. Characteristics not associated with risk of transfusion included obesity [18% (52/289) vs. 15% (2445/16,292); P=0.18], and maternal age ≥35 years [28% (82/289) vs. 33% (5537/16,292); P=0.05]. Additional blood products were necessary in a small number of patients who received red cells. Conclusion The rate of transfusion in a contemporary Irish cohort has risen compared with previous data. Several variables associated with transfusion are consistent with older studies but importantly; maternal obesity and advanced maternal age are not associated with transfusion. These data may encourage the investment of resources in a population previously considered low-risk and, following future studies, to improve strategies aimed at limiting blood transfusion.

Cesarean delivery in the United States 2005 through 2014: a population-based analysis using the Robson 10-Group Classification System.

BACKGROUND: Cesarean delivery has increased steadily in the United States over recent decades with significant downstream health consequences. The World Health Organization has endorsed the Robson 10-Group Classification System as a global standard to facilitate analysis and comparison of cesarean delivery rates. OBJECTIVE: Our objective was to apply the Robson 10-Group Classification System to a nationwide cohort in the United States over a 10-year period. STUDY DESIGN: This population-based analysis applied the Robson 10-Group Classification System to all births in the United States from 2005 through 2014, recorded in the 2003 revised birth certificate format. Over the study 10-year period, 27,044,217 deliveries met inclusion criteria. Five parameters (parity including previous cesarean, gestational age, labor onset, fetal presentation, and plurality), identifiable on presentation for delivery, were used to classify all women included into 1 of 10 groups. RESULTS: The overall cesarean rate was 31.6%. Group-3 births (singleton, term, cephalic multiparas in spontaneous labor) were most common, while group-5 births (those with a previous cesarean) accounted for the most cesarean deliveries increasing from 27% of all cesareans in 2005 through 2006 to >34% in 2013 through 2014. Breech pregnancies (groups 6 and 7) had cesarean rates >90%. Primiparous and multiparous women who had a prelabor cesarean (groups 2b and 4b) accounted for over one quarter of all cesarean deliveries. CONCLUSION: Women with a previous cesarean delivery represent an increasing proportion of cesarean deliveries. Use of the Robson criteria allows standardized comparisons of data and identifies clinical scenarios driving changes in cesarean rates. Hospitals and health organizations can use the Robson 10-Group Classification System to evaluate quality and processes associated with cesarean delivery.

Second-Stage Duration and Outcomes Among Women Who Labored After a Prior Cesarean Delivery.

OBJECTIVE: To characterize probabilities of vaginal delivery based on second-stage duration along with maternal and neonatal risks for women undergoing labor after cesarean delivery. METHODS: This unplanned secondary analysis of the Maternal-Fetal Medicine Units Cesarean Registry, a prospective observational cohort, assessed outcomes in women with a prior uterine scar and included women with a previous cesarean delivery without prior vaginal delivery who reached the second stage of labor. The primary outcome was mode of delivery by second-stage duration. Secondary outcomes included assessment of individual adverse maternal (chorioamnionitis, atony, endometritis, hysterectomy, uterine rupture or dehiscence, and red cell transfusion) and neonatal (cord pH less than 7.10, Apgar score less than 6 at 5 minutes, neonatal intensive care unit admission, and ventilatory support) outcomes. RESULTS: Of 4,579 women with a previous cesarean delivery who reached the second stage of labor, 4,147 (90.6%) delivered vaginally. As second stage increased, successful vaginal delivery rates decreased: 97.3% at less than 1 hour (95% CI 96.6-97.9%), 91.5% at 1 to less than 2 hours (95% CI 89.8-93.1%), 78.5% at 2 to less than 3 hours (95% CI 74.5-82.1%), 62.3% at 3 to less than 4 hours (95% CI 55.2-69.1%), and 45.6% at 4 hours or greater (95% CI 37.7-53.7%). Risk of all adverse maternal outcomes increased with the length of the second stage. Specifically, risk of uterine rupture or dehiscence increased with second-stage length from less than 1 hour (0.7%), 1 to less than 2 hours (1.4%), 2 to less than 3 hours (1.5%), to 3 hours or greater (3.1%) (P<.001 for differential risk across the second stage). Risk of neonatal outcomes did not differ significantly by second-stage length. CONCLUSION: Although many women with a longer second stage (greater than 3 hours) will achieve successful vaginal delivery, these patients may be at increased risk for adverse maternal outcomes and should have close observation of fetal heart rate monitoring, maternal vital signs, and symptoms suggestive of uterine rupture or dehiscence.

The presentation and management of platelet disorders in pregnancy.

Thrombocytopenia, defined as a platelet count less than 150 000 per microlitre, occurs in 7%-12% of all pregnancies. Apart from anaemia, it is the most common haematological disorder in pregnancy. Despite its frequent occurrence, thrombocytopenia often leads to difficulties of diagnosis and management in pregnancy. Typically, a pregnant woman will have platelet counts of 150 000 to 450 000 per microlitre and platelet counts may be slightly lower than those of healthy, non-pregnant controls. Approximately, 8% of pregnant women will develop mild thrombocytopenia (100 000-150 000 per microlitre) and while 65% of these women will have no underlying pathology, all pregnant women with platelet counts of less than 100 000 per microlitre should undergo further clinical and laboratory assessment. Thrombocytopenia in pregnancy occurs as a result of multiple distinct conditions, we present four cases of thrombocytopenia in pregnancy encountered in our unit over a 12-month period. These include gestational thrombocytopenia, immune thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura (TTP) and thrombocytopenia absent radius (TAR) syndrome. The literature review of these cases highlights the significance of identification, understanding pathophysiology and a multidisciplinary approach to these conditions. We refresh knowledge on these conditions and emphasise the importance of thrombocytopenia in pregnancy.

Anal sphincter injury in vaginal deliveries complicated by shoulder dystocia.

INTRODUCTION AND HYPOTHESIS: Shoulder dystocia is an obstetric emergency that occurs in 0.2-3% of all cephalic vaginal deliveries. We hypothesized that because of the difficult nature of deliveries complicated by shoulder dystocia, the condition may be associated with anal sphincter injury. We sought to identify risk factors for obstetric anal sphincter injury in women with shoulder dystocia. METHODS: This retrospective analysis included all cases of shoulder dystocia from 2007 to 2011 at two large tertiary referral centers, in the USA and Ireland. Details of maternal demographics, intrapartum characteristics, and delivery outcomes in cases of shoulder dystocia were analyzed. Univariate and multivariate analyses were used to describe the association between shoulder dystocia and anal sphincter injury. RESULTS: There were 685 cases of shoulder dystocia, and the rate of shoulder dystocia was similar at both institutions. The incidence of anal sphincter injury was 8.8% (60 out of 685). The rate was 14% (45 out of 324) in nulliparas and 4.2% (15 out of 361) in multiparas. Women with sphincter injury were more likely to be nulliparous (75% [45 out of 60] vs 45% [279 out of 625]; p < 0.0001), have had an operative vaginal delivery (50% [30 out of 60] vs 36% [226 out of 625]; p = 0.03) and require internal maneuvers (50% [30 out of 60] vs 32% [198 out of 625], p = 0.004) than those with an intact sphincter. On multivariate regression analysis, these predictors of sphincter injury remained significant when adjusted for other risk factors. Episiotomy was negatively associated with sphincter injury on multivariate regression analysis. CONCLUSIONS: In a retrospective cohort of 685 women with shoulder dystocia, the risk of anal sphincter injury is 9%. Risk factors include nulliparity, operative vaginal delivery, and use of internal maneuvers, whereas episiotomy was found to have a protective effect against anal sphincter injury during cases of shoulder dystocia.

Prenatal prediction of significant intertwin birthweight discordance using standard second and third trimester sonographic parameters.

INTRODUCTION: Our study aim was to evaluate standard ultrasound-derived fetal biometric parameters in the prediction of clinically significant intertwin birthweight discordance defined as ≥18%. MATERIAL AND METHODS: This was a secondary analysis of a prospective cohort study of 1028 unselected twin pairs recruited over a two-year period. Dichorionic twins underwent two-weekly ultrasonographic surveillance from 24 weeks' gestation, with surveillance of monochorionic twins two-weekly from 16 weeks. Ultrasonographic biometric data from 24 to 36 weeks were evaluated for the prediction of an intertwin birthweight discordance threshold ≥18%. Umbilical artery Doppler waveform data was also analyzed to evaluate whether it was predictive of birthweight discordance. RESULTS: Of the 956 twin pairs analyzed for discordance, 208 pairs were found to have a clinically significant birthweight discordance ≥18%. All biometric parameters were predictive of significant inter-twin birthweight discordance at low cut-offs, with low discriminatory powers when ROC curves were analyzed. Discordance in estimated fetal weight was predictive of a significant birthweight discordance at all gestational categories with cut-offs between 8 and 11%. A low-discriminatory power and poor sensitivity and specificity were also observed. An abnormal umbilical artery Doppler was predictive of birthweight discordance ≥18% between 28 and 32 weeks' gestation, although with poor sensitivity and specificity. CONCLUSIONS: Calculation of estimated fetal weight and birthweight discordance between twins allows minimal margin for error. These margins make it difficult to accurately predict those who are at or above the discordance threshold of 18%. These findings highlight that small intertwin discrepancies in weight and biometry should not be overlooked and merit further investigation.

Severe maternal morbidity and comorbid risk in hospitals performing <1000 deliveries per year.

BACKGROUND: While research has demonstrated increasing risk for severe maternal morbidity in the United States, risk at lower volume hospitals remains poorly characterized. More than half of all obstetric units in the United States perform <1000 deliveries per year and improving care at these hospitals may be critical to reducing risk nationwide. OBJECTIVE: We sought to characterize maternal risk profiles and severe maternal morbidity at low-volume hospitals in the United States. STUDY DESIGN: We used data from the Nationwide Inpatient Sample to evaluate trends in severe maternal morbidity and comorbid risk during delivery hospitalizations in the United States from 1998 through 2011. Comorbid maternal risk was estimated using a comorbidity index validated for obstetric patients. Severe maternal morbidity was defined as the presence of any 1 of 15 diagnoses representative of acute organ injury and critical illness. RESULTS: A total of 2,300,279 deliveries occurred at hospitals with annual delivery volume <1000, representing 20% of delivery hospitalizations overall. There were 7849 cases (0.34%) of severe morbidity in low-volume hospitals and this risk increased over the course of the study from 0.25% in 1998 through 1999 to 0.49% in 2010 through 2011 (P < .01). The risk in hospitals with ≥1000 deliveries increased from 0.35-0.62% during the same time periods. The proportion of patients with the lowest comorbidity decreased, while the proportion of patients with highest comorbidity increased the most. The risk of severe morbidity increased across all women including those with low comorbidity scores. Risk for severe morbidity associated with obstetric hemorrhage, infection, hypertensive diseases of pregnancy, and medical conditions all increased during the study period. CONCLUSION: Our findings demonstrate increasing maternal risk at hospitals performing <1000 deliveries per year broadly distributed over the patient population. Rates of morbidity in centers with ≥1000 deliveries have also increased. These findings suggest that maternal safety improvements are necessary at all centers regardless of volume.

Perinatal death associated with umbilical cord prolapse.

OBJECTIVE: Umbilical cord prolapse occurs when the cord prolapses ahead of or alongside the presenting part. It is an acute obstetric emergency with potential catastrophic effects. We set out to assess incidence of cord prolapse, as well as rates and characteristics of perinatal death associated with the condition. STUDY DESIGN: This was a retrospective cohort study. All recorded cases of cord prolapse were included, and rates of perinatal death and encephalopathy, as well as intrapartum and maternal characteristics were examined. RESULTS: There were 156,130 deliveries at the hospital over the 20-year study period. Three hundred and seven cases of cord prolapse were identified (1.9/1000 deliveries). There was a decrease in the incidence of cord prolapse over the course of the study. The rate peaked in 1999 at 3.9/1000 and was just 0.8/1000 of all deliveries in 2007. The majority of cases (216/307, 70%) occurred in multiparas; however, nulliparous parturients were more likely to have a perinatal death [12% (11/91) vs. 4.6% (10/216)]. The rate of perinatal death in cases of cord prolapse was 6.8% (21/307). Over half of perinatal deaths (11/21) occurred in infants of mothers who presented with ruptured membranes, seven of these infants were already dead on reaching hospital. There was just one case of neonatal encephalopathy associated with cord prolapse, giving an incidence of 0.32%. CONCLUSION: Cord prolapse carries a significant risk of perinatal death, approximately 7%. The corresponding rate of encephalopathy is low. A significant number of deaths were diagnosed on presentation to hospital and were not deemed preventable.

Simplified and standardized intrapartum management can yield high rates of successful VBAC in spontaneous labor.

OBJECTIVE: To examine the outcomes of vaginal birth after cesarean (VBAC) in women, in spontaneous labor, delivering after 37 weeks' gestation at an institution where trial of labor after a previous cesarean delivery (TOLAC) is encouraged and management of labor is standardized. METHODS: This retrospective cohort study included 3071 women with one previous cesarean only and no vaginal delivery who underwent a trial of labor from 2001 to 2011. Women were managed using the standardized "active management of labor" intrapartum protocol. Outcomes and characteristics of women who delivered vaginally were compared with those who required cesarean delivery. RESULTS: In spontaneous labor in their second pregnancy, those who attempted TOLAC had a 72.5% (1611/2222) rate of successful VBAC. Women who had a successful VBAC had smaller babies (3584 ± 452 g versus 3799 ± 489 g; p < 0.0001) at earlier gestations than those who had a repeat intrapartum cesarean delivery. They also required less intrapartum intervention, such as oxytocin augmentation (14.5% [234/1611] versus 41% [251/611]; p < 0.0001) and epidural anesthesia (64.8% [1044/1611] versus 82.8% [506/611]; p < 0.0001). The rate of uterine rupture was 0.54% (12/2222), while the rate of peri-partum hysterectomy was 0.18% (4/2222). CONCLUSION: This study shows that serious complications associated with TOLAC are rare providing intrapartum care and decision-making is made simple for the benefit of staff and patients alike. This is achieved through a standardized labor management protocol.

Gestational hypertensive disease in twin pregnancy: Influence on outcomes in a large national prospective cohort.

OBJECTIVE: Gestational hypertensive disease (GHD) is associated with pregnancy-related complications and poor maternal and fetal outcomes in singleton pregnancies. We sought to examine the influence of GHD in a large prospective cohort of twin pregnancies. STUDY DESIGN: The ESPRIT study was a national multicenter observational cohort study of 1028 structurally normal twin pregnancies. Each pregnancy underwent sonographic surveillance with two-week ultrasound from 24 weeks for dichorionic and from 16 weeks for monochorionic gestations. Characteristics and demographics as well as labour and delivery outcome data were prospectively recorded. Perinatal mortality, admission to the neonatal intensive care unit (NICU) and a composite of morbidity of respiratory distress syndrome, hypoxic ischaemic encephalopathy, periventricular leukomalacia, necrotising enterocolitis and sepsis were documented for all cases. Outcomes for patients with documented GHD (pre-eclampsia and gestational hypertension) were compared with those without GHD. RESULTS: Perinatal outcome data were recorded for 977 patients. Women with GHD had a higher body mass index (27.1 ± 6.4 vs 25.2 ± 4.5, P < 0.0001) than those without and were more likely to be nulliparous (65% (59/92) vs 46% (407/885), P = 0.001). Both groups had similar mean birthweights, but those with GHD were more likely to have a birthweight discordance ≥18% (35% (32/92) vs 20% (179/885), P = 0.001). Rates of caesarean delivery were higher in those twin pregnancies affected by GHD, and while the rate of composite morbidity was similar in both groups, twins in the GHD group had higher rates of NICU admission. CONCLUSION: In twin gestations, gestational hypertension independently confers an increased risk for emergency caesarean delivery, birthweight discordance and NICU admission, such that intensive maternal-fetal monitoring is justified when hypertension develops in a twin pregnancy.