Embryo culture media and neonatal birthweight following IVF.

BACKGROUND: Infants conceived from IVF are at increased risk for low birthweight. Animal studies suggest that embryo culture medium influences birthweight but it is unknown whether this association exists in humans. This study examines the relationship between culture medium and birthweight following IVF. METHODS: We identified all IVF cycles with start dates between 1 January 1999 and 31 December 2008 that used autologous oocytes with resulting embryos cultured in G1.3, Global or G1.5 medium. The population was restricted to singleton deliveries following Day 3, fresh single embryo transfer, or twin deliveries following Day 3, fresh double embryo transfer, at a gestational age of ≥ 34 weeks. Only the first cycle during the study period was included for each woman. Women were excluded if the number of gestational sacs on ultrasound differed from the number of infants born. Variables were evaluated with the χ²-test or analysis of variance. Multiple linear regressions controlled for potential confounders. RESULTS: Of the 198 women with singleton deliveries, 102 embryos were cultured in G1.3, 53 in Global and 43 in G1.5 medium. Of the 303 twin deliveries, 172 pairs of embryos were cultured in G1.3, 58 in Global and 73 in G1.5 medium. No significant association between culture medium and birthweight was observed, even when controlling for potential confounders. CONCLUSIONS: This retrospective study demonstrated no significant association between embryo culture medium and birthweight following IVF. Although our careful selection of patients minimized the influence of potential confounders, further research is required to elucidate this issue with larger numbers of patients.

Use of a random urinary protein-to-creatinine ratio for the diagnosis of significant proteinuria during pregnancy.

OBJECTIVE: The purpose of this study was to evaluate whether a random urinary protein-to-creatinine ratio is a clinically useful predictor of significant proteinuria (300 mg/24 hour). STUDY DESIGN: The medical records of 138 women who completed both a random urinary protein-to-creatinine ratio and a 24-hour urine collection for the evaluation of preeclampsia were reviewed. Urine samples for the random protein-to-creatinine ratio were collected before the 24-hour urine collection. With the use of a protein level of at least 300 mg in the 24-hour urine sample as the gold standard, the sensitivity and specificity of the random protein-to-creatinine ratio for the diagnosis of significant proteinuria were determined with a range of cutoffs. RESULTS: Fifty percent of the study population had significant proteinuria. The data suggest that a cutoff below 0.14 ruled out significant proteinuria. The best cutoff of > or = 0.19 yields a sensitivity of 90% and a specificity of 70%. All of the false-negative test results had 24-hour urine protein levels below 400 mg; 13 of the 21 false-positive results had levels that ranged from 250 to 300 mg. CONCLUSION: The random urinary protein-to-creatinine ratio is strongly associated with the 24-hour total protein excretion. A level below 0.14 can rule out significant proteinuria. A best cutoff of > or = 0.19 is a good predictor of significant proteinuria. With further study, the random urinary protein-to-creatinine ratio could replace the 24-hour urine collection as a simpler, faster, more useful method for the diagnosis of significant proteinuria.

Increased risk of cesarean delivery with advancing maternal age: indications and associated factors in nulliparous women.

OBJECTIVE: To investigate factors that contribute to the increased risk of cesarean delivery with advancing maternal age. STUDY DESIGN: We reviewed demographic and ante- and intrapartum variables from a data set of term, nulliparous women who delivered at Brigham and Women's Hospital in 1998 (n = 3715). RESULTS: Cesarean delivery rates increased with advancing maternal age (< 25 years, 11.6%; > or = 40 years, 43.1%). Older women were more likely to have cesarean delivery without labor (< 25 years, 3.6%; > or = 40 years, 21.1%). Malpresentation and prior myomectomy were the indications for cesarean delivery without labor that were more prevalent in our older population as compared to our younger population. Even among women with spontaneous or induced labor, cesarean delivery rates increased with maternal age (< 25 years, 8.3%; > or = 40 years, 30.6%). Cesarean delivery rates were higher with induced labor, and rates of induction rose directly and continuously with maternal age, especially the rate of elective induction. Cesarean delivery for failure to progress or fetal distress was more common among older parturients, regardless of whether labor was spontaneous or induced. Among women who underwent cesarean delivery because of failure to progress, use of oxytocin and length of labor did not vary with age. CONCLUSIONS: Older women are at higher risk for cesarean delivery in part because they are more likely to have cesarean delivery without labor. However, even among those women who labor, older women are more likely to undergo cesarean delivery, regardless of whether labor is spontaneous or induced. Part of the higher rate among older women who labor is explained by a higher rate of induction, particularly elective induction. Among women in both spontaneous and induced labor, cesarean delivery for the diagnoses of failure to progress and fetal distress was more frequent in older patients, although management of labor dystocia for these patients was similar to that for younger patients.

Prenatal ultrasonography and the diagnosis of fetal cleft lip.

OBJECTIVE: To determine the efficacy of obstetric ultrasonography in the detection of fetal cleft lip. METHODS: The study population included all women who had a fetal anatomic survey with adequate visualization of the face and who gave birth at Brigham and Women's Hospital between January 1, 1990, and January 31, 2000. All neonates born with cleft lip were identified from the Brigham and Women's Active Malformation Surveillance Program. Confirmation of the anatomic defect was obtained from the pediatric record or from the pathologic report if the pregnancy was terminated or ended in miscarriage. Cases of isolated cleft palate were excluded. An ultrasonography database was used to identify all cases of cleft lip diagnosed before delivery. Maternal information regarding the pregnancy was abstracted from the medical record. Statistical significance was determined using the chi2 statistic for categorical variables and the t test for continuous variables. RESULTS: A total of 56 confirmed cases of cleft lip were identified in the study population. Overall, 73% of the cases (41 of 56) were identified antenatally. Additional fetal anomalies were present in 54% of the cases (30 of 56). A comparison between those cases that were detected and those in which the diagnosis was missed showed that there was a significantly lower detection rate if the ultrasonography was performed before 20 weeks (12 [57%] of 21 versus 29 [83%] of 35; P = .035). There was no difference between the 2 groups in terms of maternal age or weight. Maternal parity, prior maternal abdominal surgery, the presence of a multiple gestation, or coexisting fetal anomalies did not significantly affect the detection rate. There was no difference in detection rate in the first half of the study period (1990-1995; 23 [72%] of 32) compared with the second half (1996-2000; 18 [76%] of 24; P = .79). CONCLUSIONS: In this cohort of women, the rate of detection of fetal cleft lip was significantly lower when the anatomic survey was performed before 20 weeks' gestation. This difference could not be accounted for by such variables as prior maternal abdominal surgery, coexisting fetal anomalies, or improvements in ultrasonographic detection with time. We recommend that the anatomic survey for fetuses at high risk for this condition be performed after 20 weeks' gestation.

Management of cervical cerclage and preterm premature rupture of the membranes: should the stitch be removed?

OBJECTIVE: Our aim was to determine whether retention of cerclage after preterm premature rupture of the membranes occurring before 34 completed weeks' gestation influences pregnancy outcome. STUDY DESIGN: Singleton pregnancies with cerclage and premature rupture of the membranes between 24.0 and 34.9 weeks were reviewed. Women were excluded if they were first seen in labor, had chorioamnionitis, or were delivered within 48 hours. Control subjects consisted of women with premature rupture of the membranes without cerclage. RESULTS: Eighty-one cases of cerclage with premature rupture of the membranes met criteria for inclusion: 30 women (37%) had their cerclage removed at presentation, and 51 (63%) retained the cerclage until delivery. Cases were similar in terms of gestational age at placement and gestational age at premature rupture of the membranes. There was no significant difference between the retained, removed, or control groups in terms of latency, gestational age at delivery, chorioamnionitis, or neonatal morbidity and mortality. CONCLUSIONS: Retention of cervical cerclage after premature rupture of the membranes occurring before 34 completed weeks' gestation is associated with comparable clinical outcomes with respect to latency and perinatal outcome, when compared with removal of the cerclage.

Differences in TDx fetal lung maturity assay values between twin and singleton gestations.

OBJECTIVE: The purpose of this study was to quantify differences in indexes of pulmonary maturity between singleton and twin gestations by means of the TDx fetal lung maturity assay. STUDY DESIGN: We identified records of a total of 830 singleton and twin pregnancies not complicated by diabetes and delivered between 28 and 37 weeks' gestation from December 1994 through August 1995. Among these, 170 (20%) had TDx fetal lung maturity measurements performed within 72 hours of delivery. Linear regression was used to assess differences in TDx fetal lung maturity assay values between singleton gestations (n = 143 gestations) and twin gestations (n = 27 gestations) while controlling for potential confounding factors. RESULTS: Twin gestations were no more likely than singleton gestations to undergo TDx fetal lung maturity screening (odds ratio, 1.3; 95% confidence interval, 0.8-2.2). Pregnancy complications and corticosteroid treatment were similar in the two groups. After 31 weeks' gestation the twin gestations had significantly higher TDx fetal lung maturity values. Linear regression with controls for gestational age indicated that twin gestations on average had a TDx fetal lung maturity value that was 22.0 mg/g (95% confidence interval, 9.8-34.6 mg/g) higher than that of gestational age-matched singleton gestations. CONCLUSION: Beyond 31 weeks' gestation twin pregnancies appeared to have a TDx fetal lung maturity value that was 22 mg/g higher than that of singleton pregnancies. If the underlying incidences of respiratory distress syndrome are similar between twin and singleton gestations, then the potential exists for false-positive prediction of adequate lung maturity values among twin gestations.

Episiotomy, operative vaginal delivery, and significant perinatal trauma in nulliparous women.

OBJECTIVES: The aim of this study was to determine whether choice of obstetric instrument at operative vaginal delivery is associated with any differences in the rate of significant perineal trauma and whether this rate is modified by the use of episiotomy. STUDY DESIGN: The occurrence of significant perineal trauma among 323 consecutive operative vaginal deliveries was evaluated according to type of instrument used and performance of episiotomy. These findings were compared with spontaneous vaginal deliveries during the same period. RESULTS: Among forceps deliveries the use of episiotomy was not associated with a difference in the occurrence of significant perineal trauma (55% vs 46%; relative risk, 1.2; 95% confidence interval, 0.8-1.9). Among vacuum extraction deliveries an increased rate of such trauma was noted when episiotomy was used (34.9% vs 9. 4%; relative risk, 3.7; 95% confidence interval, 1.2-11.2). There was no difference in the rate of significant perineal trauma according to type of forceps used. In a logistic regression analysis forceps delivery with or without episiotomy was associated with an increase of >10-fold in the rate of significant perineal trauma with respect to vacuum extraction deliveries without episiotomy. CONCLUSIONS: Our data suggest that in forceps delivery neither the type of forceps nor episiotomy influences the risk of significant perineal trauma. When vacuum extraction delivery is performed, the use of episiotomy is associated with a higher risk of significant perineal trauma.

Epidural analgesia and third- or fourth-degree lacerations in nulliparas.

OBJECTIVE: To determine if epidural analgesia is associated with differences in rates of severe perineal trauma during vaginal deliveries. METHODS: We studied 1942 consecutive, low-risk, term, vaginal deliveries in nulliparas, including spontaneous and induced labors, at a single institution from December 1994 to August 1995. The rate of third- and fourth-degree lacerations was compared for women who had and did not have epidural analgesia for labor-pain relief. Statistical significance was determined using chi2. Logistic regression analyses were used to evaluate associations while controlling for possible confounding variables. RESULTS: Overall rates of third- and fourth-degree lacerations were 10.8% (n = 210) and 3.4% (n = 63), respectively. Epidural analgesia was given to 1376 (70.9%) women. Among women who had epidurals, 16.1% (221 of 1376) had severe perineal lacerations compared with 9.7% (n = 55) of the 566 women who did not have epidurals (P < .001; odds ratio [OR] 1.8, 95% confidence interval [CI] 1.3, 2.4). When controlling for birth weight, use of oxytocin, and maternal age in logistic regression analysis, epidural remained a significant predictor of severe perineal injury (OR 1.4, 95% CI 1.0, 2.0). Epidural use is consistently associated with increased operative vaginal deliveries and consequent episiotomies, so we constructed a logistic regression model to evaluate whether the higher rates of those procedures were responsible for the effect of epidurals on severe perineal traumas. With operative vaginal delivery and episiotomy in the model, epidural was no longer an independent predictor of perineal injury (OR 0.9, 95% CI 0.6, 1.3). CONCLUSION: Epidural analgesia is associated with an increase in the rate of severe perineal trauma because of the more frequent use of operative vaginal delivery and episiotomy.

The value of elevated second-trimester beta-human chorionic gonadotropin in predicting development of preeclampsia.

OBJECTIVE: Our purpose was to investigate the association of an elevated second-trimester serum beta-human chorionic gonadotropin concentration with the subsequent development of hypertension in pregnancy and to evaluate its utility as a screening test for preeclampsia. STUDY DESIGN: We examined 6286 nondiabetic women with singleton pregnancies who, as part of triple-screen testing, had a serum beta human chorionic gonadotropin level drawn between 15 and 22 weeks' gestation between November 1, 1991, and November 30, 1994. Medical records of women with hypertension (n = 675) were reviewed, patients with chronic hypertension were excluded, and the remainder were classified as having gestational hypertension (n = 333), mild preeclampsia (n = 110), or severe preeclampsia (n = 84). The beta-human chorionic gonadotropin level expressed as multiples of the median adjusted for maternal weight and gestational age was compared between normotensive and hypertensive complicated pregnancies. RESULTS: In the overall population beta-human chorionic gonadotropin levels > or = 2.0 multiples of the median during the second trimester were significantly associated with development of hypertension in pregnancy. The rate ratio for development of overall hypertension was 1.6 (95% confidence interval 1.3 to 2.0) and for preeclampsia 1.8 (95% confidence interval 1.3 to 2.6). When stratified by parity, a statistically significant association remained only among multiparous women, for overall hypertension (rate ratio 2.2, 95% confidence interval 1.6 to 3.2) and for preeclampsia (rate ratio 3.4, 95% confidence interval 2.1 to 5.6). Adjusting for confounding factors did not alter the results. In the overall population, with the use of 2.0 multiples of the median of beta-human chorionic gonadotropin as a cutoff value, the sensitivity of beta-human chorionic gonadotropin as a screen for development of hypertension was 15.6%, the specificity was 90.0%, and the positive predictive value was 12.8%. CONCLUSION: Overall, second-trimester serum beta-human chorionic gonadotropin levels were elevated among women who had hypertension during pregnancy. In our population this association was statistically significant only among multiparous women. The utility of an elevated second-trimester beta-human chorionic gonadotropin level as a screening test for preeclampsia is limited.

Age, sex, and road-use patterns of motor vehicular trauma in Rhode Island: A population-based hospital emergency department study.

Population-based hospital emergency department data on motor vehicle traffic trauma in Rhode Island, 1984-85, are analyzed by age, sex, and road-use status. Annualized rates of overall and severe trauma were 1,195 cases (95% confidence interval [CI] = 1,164, 1,225) and 102 cases (95% CI = 94, 111) per 100,000 population, respectively. Overall and severe rates peaked at ages 15-24 years. Male rate excesses were most pronounced for motor-cycle and pedal cycle trauma.