Maternal cardiac disease and perinatal outcomes in a single tertiary care center.

OBJECTIVE: Maternal mortality in the U.S. has increased, with a substantial contribution from maternal cardiac disease. As a result of improved childhood survival, more women with congenital heart disease are reaching reproductive age leading to a growing high-risk obstetric population. We sought to determine the obstetrical and neonatal outcomes of women with maternal cardiac disease, including acquired cardiovascular disease and congenital heart disease. METHODS: We studied a retrospective cohort study of women that delivered from 2008 to 2013 (N = 9026). Singleton pregnancies without preexisting conditions were established as the unexposed group for this study. Maternal and neonatal outcomes were compared between the unexposed group (N = 7277) and women exposed to maternal (acquired or congenital) cardiac disease (N = 139) as well as only congenital heart disease (N = 85). Statistical comparisons used univariate/multivariable logistic and linear regression analysis controlling for confounders with p < .05 and 95% confidence intervals indicating statistical significance. RESULTS: Pregnancies complicated by maternal cardiac disease were associated with increased odds of preterm birth (<34 weeks, <37 weeks), intrauterine growth restriction (IUGR), need for assisted vaginal delivery, maternal ICU admission, and prolonged maternal hospitalization (>7 d). Neonatal outcomes including small for gestational age and Apgar score <7 at 5 min were increased in the pregnancies complicated by maternal cardiac disease. When pregnancies complicated by congenital heart disease were analyzed as a sub-group of the cohort, the results were similar. There were increased odds of preterm birth (<37 weeks), early-term delivery, need for assisted vaginal delivery, and prolonged hospitalization. Neonatal outcomes were only significant for small for gestational age. CONCLUSION: We observed that in a select cohort of pregnancies complicated by maternal cardiac diseases (acquired or congenital), there were significant increases of adverse perinatal outcomes. Therefore, a multidisciplinary approach including maternal-fetal medicine specialists, cardiologists, obstetric anesthesia, and dedicated ancillary support is imperative for optimal care of this high-risk obstetrics population.

Effect of a Patient-Centered Decision Support Tool on Rates of Trial of Labor After Previous Cesarean Delivery: The PROCEED Randomized Clinical Trial.

Importance: Reducing cesarean delivery rates in the US is an important public health goal; despite evidence of the safety of vaginal birth after cesarean delivery, most women have scheduled repeat cesarean deliveries. A decision support tool could help increase trial-of-labor rates. Objective: To analyze the effect of a patient-centered decision support tool on rates of trial of labor and vaginal birth after cesarean delivery and decision quality. Design, Setting, and Participants: Multicenter, randomized, parallel-group clinical trial conducted in Boston, Chicago, and the San Francisco Bay area. A total of 1485 English- or Spanish-speaking women with 1 prior cesarean delivery and no contraindication to trial of labor were enrolled between January 2016 and January 2019; follow-up was completed in June 2019. Interventions: Participants were randomized to use a tablet-based decision support tool prior to 25 weeks' gestation (n=742) or to receive usual care (without the tool) (n=743). Main Outcomes and Measures: The primary outcome was trial of labor; vaginal birth was the main secondary outcome. Other secondary outcomes focused on maternal and neonatal outcomes and decision quality. Results: Among 1485 patients (mean age, 34.0 [SD, 4.5] years), 1470 (99.0%) completed the trial (n = 735 in both randomization groups) and were included in the analysis. Trial-of-labor rates did not differ significantly between intervention and control groups (43.3% vs 46.2%, respectively; adjusted absolute risk difference, -2.78% [95% CI, -7.80% to 2.25%]; adjusted relative risk, 0.94 [95% CI, 0.84-1.05]). There were no statistically significant differences in vaginal birth rates (31.8% in both groups; adjusted absolute risk difference, -0.04% [95% CI, -4.80% to 4.71%]; adjusted relative risk, 1.00 [95% CI, 0.86-1.16]) or in any of the other 6 clinical maternal and neonatal secondary outcomes. There also were no significant differences between the intervention and control groups in the 5 decision quality measures (eg, mean decisional conflict scores were 17.2 and 17.5, respectively; adjusted mean difference, -0.38 [95% CI, -1.81 to 1.05]; scores >25 are considered clinically important). Conclusions and Relevance: Among women with 1 previous cesarean delivery, use of a decision support tool compared with usual care did not significantly change the rate of trial of labor. Further research may be needed to assess the efficacy of this tool in other clinical settings or when implemented at other times in pregnancy.

Correction to: The association of patient preferences and attitudes with trial of labor after cesarean.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

The association of patient preferences and attitudes with trial of labor after cesarean.

OBJECTIVE: To evaluate the association of patient preferences and attitudes with TOLAC. STUDY DESIGN: Prospective observational study of TOLAC-eligible women at 26-34 weeks gestation. Preferences (utilities) were elicited using the time trade-off and standard gamble metrics. Logistic regression was used to identify preference- and attitude-based factors associated with TOLAC. RESULTS: Of the 231 participants, most (n = 197, 85%) preferred vaginal delivery, but only 40% (n = 93) underwent TOLAC. Utilities for uterine rupture outcomes did not differ based on delivery approach. In multivariable analysis, strength of preference for vaginal delivery, value for the experience of labor, and the opinion of the person whom the participant thought of as most important to this decision were associated with TOLAC. CONCLUSIONS: Future decision support interventions incorporating individualized information regarding the likelihood of vaginal birth and empowering patients to express their preferences and engage their families in the decision-making process may improve decision quality and increase TOLAC rates.

Women's Preferences Regarding the Processes and Outcomes of Trial of Labor After Cesarean and Elective Repeat Cesarean Delivery.

Background: The decrease in trial of labor after cesarean (TOLAC) at institutions that offer this option suggests that patient preference could be a factor in the declining TOLAC rate. However, data regarding how women value the potential processes and outcomes of TOLAC and elective repeat cesarean delivery (ERCD) are limited. We sought to determine how women view the processes and outcomes of TOLAC and ERCD and identify sociodemographic and clinical factors associated with these preferences. Materials and Methods: This is a multicenter cross-sectional study of mode of delivery preferences among TOLAC-eligible women at 26-34 weeks gestation. The time tradeoff metric was used to obtain utilities for the processes and outcomes of TOLAC and ERCD. Multivariable regression analysis was utilized to identify independent predictors of utilities. Results: The 299 study participants constituted a geographically and racially/ethnically diverse group. Although uncomplicated TOLAC resulting in vaginal birth after cesarean and uncomplicated ERCD resulted in high utility values, any alteration in either the process or outcome resulted in substantial utility decrements. In multivariable regression analysis, race/ethnicity, insurance status, and order of scenario presentation emerged as statistically significant predictors. Conclusions: Information regarding both maternal and infant implications is important to women in discussions about approach to delivery. Both the way in which information regarding labor interventions and potential complications is presented and the characteristics of the women contemplating this information affect its impact. These findings underscore the need for evidence-based decision support to help create realistic expectations and incorporate informed patient preferences into decision-making to optimize both clinical outcomes and individual patient experience for women with a prior cesarean delivery.

The association between nitroglycerin use and adverse outcomes in women undergoing cesarean delivery in the second stage of labor.

OBJECTIVE: To identify predictors of hysterotomy extension in women undergoing cesarean delivery (CD) in the second stage of labor, and whether use of nitroglycerin (NTG) during CD has a protective effect. METHODS: We conducted a retrospective cohort study of women undergoing CD in the second stage of labor from 2012 to 2015. Some women received NTG at the obstetrician's request. Logistic regression was used to examine the relationship between second stage duration and NTG administration on maternal and neonatal outcomes. RESULTS: Of the 391 women in the sample, 27% had an extension and 12% received NTG. Second stage ≥4 h was associated with a 2.14-fold higher risk of extension (95% CI 1.22-3.75), a 2.00-fold higher risk of hemorrhage (95% CI: 1.20-3.33) and 2.42-fold higher risk of blood transfusion during delivery hospitalization (95% CI: 0.99-5.91). Intravenous (IV) and sublingual-spray (SL-spray) NTG administration were not associated with an increased risk of hemorrhage or extension. SL-NTG was associated with 4.68-fold increased odds of 5-min Apgar <7 (95% CI 1.42-15.41) and 3.36-fold greater odds of NICU admission (95% CI 1.20-9.41). CONCLUSION: We found no evidence that NTG protects against extension, and SL-NTG use was associated with adverse neonatal outcomes. Clinical trials should be conducted to evaluate risk and benefits of NTG use.

Perinatal neuroprotection update.

Antepartum, intrapartum, and neonatal events can result in a spectrum of long-term neurological sequelae, including cerebral palsy, cognitive delay, schizophrenia, and autism spectrum disorders [1]. Advances in obstetrical and neonatal care have led to survival at earlier gestational ages and consequently increasing numbers of periviable infants who are at significant risk for long-term neurological deficits. Therefore, efforts to decrease and prevent cerebral insults attempt not only to decrease preterm delivery but also to improve neurological outcomes in infants delivered preterm. We recently published a comprehensive review addressing the impacts of magnesium sulfate, therapeutic hypothermia, delayed cord clamping, infections, and prevention of preterm delivery on the modification of neurological risk [2]. In this review, we will briefly provide updates to the aforementioned topics as well as an expansion on avoidance of toxin and infections, specifically the Zika virus.

Retained Placenta Accreta Mimicking Choriocarcinoma.

This case demonstrates a rare event of retained invasive placenta masquerading as choriocarcinoma. The patient presented with heavy vaginal bleeding following vaginal delivery complicated by retained products of conception. Ultrasound and computed tomography demonstrated a vascular endometrial mass, invading the uterine wall and raising suspicion for choriocarcinoma. Hysterectomy revealed retained invasive placenta.

Effect of stage of initial labor dystocia on vaginal birth after cesarean success.

OBJECTIVE: The objective of the study was to examine whether the stage of labor dystocia causing a primary cesarean delivery (CD) affects a trial of labor after cesarean (TOLAC) success. STUDY DESIGN: This was a retrospective cohort study of women who had primary CD of singleton pregnancies for first- or second-stage labor dystocia and attempted TOLAC at a single hospital between 2002 and 2014. We compared TOLAC success rates between women whose primary CD was for first- vs second-stage labor dystocia and investigated whether the effect of prior dystocia stage on TOLAC success was modified by previous vaginal delivery (VD). RESULTS: A total of 238 women were included; nearly half (49%) achieved vaginal birth after cesarean (VBAC). Women with a history of second-stage labor dystocia were more likely to have VBAC compared with those with first-stage dystocia, although this trend was not statistically significant among the general population (55% vs 45%, adjusted odds ratio, 1.4, 95% confidence interval, 0.8-2.5]). However, among women without a prior VD, those with a history of second-stage dystocia did have statistically higher odds of achieving VBAC than those with prior first-stage dystocia (54% vs 38%, adjusted odds ratio, 1.8 [95% confidence interval, 1.0-3.3], P for interaction = .043). CONCLUSION: Nearly half of women with a history of primary CD for labor dystocia will achieve VBAC. Women with a history of second-stage labor dystocia have a slightly higher VBAC rate, seen to a statistically significant degree in those without a history of prior VD. TOLAC should be offered to all eligible women and should not be discouraged in women with a prior second-stage arrest.

Human Chorionic Gonadotropin Partially Mediates Phthalate Association With Male and Female Anogenital Distance.

CONTEXT: Prenatal exposure to phthalates disrupts male sex development in rodents. In humans, the placental glycoprotein hormone human chorionic gonadotropin (hCG) is required for male development, and may be a target of phthalate exposure. OBJECTIVE: This study aimed to test the hypothesis that phthalates disrupt placental hCG differentially in males and females with consequences for sexually dimorphic genital development. DESIGN: The Infant Development and Environment Study (TIDES) is a prospective birth cohort. Pregnant women were enrolled from 2010-2012 at four university hospitals. PARTICIPANTS: Participants were TIDES subjects (n = 541) for whom genital and phthalate measurements were available and who underwent prenatal serum screening in the first or second trimester. MAIN OUTCOME MEASURES: Outcomes included hCG levels in maternal serum in the first and second trimesters and anogenital distance (AGD), which is the distance from the anus to the genitals in male and female neonates. RESULTS: Higher first-trimester urinary mono-n-butyl phthalate (MnBP; P = .01), monobenzyl phthalate (MBzP; P = .03), and mono-carboxy-isooctyl phthalate (P < .01) were associated with higher first-trimester hCG in women carrying female fetuses, and lower hCG in women carrying males. First-trimester hCG was positively correlated with the AGD z score in female neonates, and inversely correlated in males (P = 0.01). We measured significant associations of MnBP (P < .01), MBzP (P = .02), and mono-2-ethylhexyl phthalate (MEHP; P < .01) with AGD, after adjusting for sex differences. Approximately 52% (MnBP) and 25% (MEHP) of this association in males, and 78% in females (MBzP), could be attributed to the phthalate association with hCG. CONCLUSIONS: First-trimester hCG levels, normalized by fetal sex, may reflect sexually dimorphic action of phthalates on placental function and on genital development.

Mode of delivery preferences in a diverse population of pregnant women.

OBJECTIVE: The objective of the study was to assess women's preferences for vaginal vs cesarean delivery in 4 contexts: prior cesarean delivery, twins, breech presentation, and absent indication for cesarean. STUDY DESIGN: This was a cross-sectional study of pregnant women at 24-40 weeks' gestation. After assessing stated preferences for vaginal or cesarean delivery, we used the standard gamble metric to measure the strength of these preferences and the time tradeoff metric to determine how women value the potential processes and outcomes associated with these 2 delivery approaches. RESULTS: Among the 240 participants, 90.8% had a stated preference for vaginal delivery. Across the 4 contexts, these women indicated that, on average, they would accept a 59-75% chance of an attempted vaginal birth ending in a cesarean delivery before choosing a planned cesarean delivery, indicating strong preferences for spontaneous, uncomplicated vaginal delivery. Variations in preferences for labor processes emerged. Although uncomplicated labor ending in vaginal birth was assigned mean utilities of 0.993 or higher (on a 0-1 scale, with higher scores indicating more preferred outcomes), the need for oxytocin, antibiotics, or operative vaginal delivery resulted in lower mean scores, comparable with those assigned to uncomplicated cesarean delivery. Substantially lower scores (ranging from 0.432 to 0.598) were obtained for scenarios ending in severe maternal or neonatal morbidity. CONCLUSION: Although most women expressed strong preferences for vaginal delivery, their preferences regarding interventions frequently used to achieve that goal varied. These data underscore the importance of educating patients about the process of labor and delivery to facilitate incorporation of informed patient preferences in shared decision making regarding delivery approach.

Perinatal neuroprotection.

Fetal or neonatal brain injury can result in lifelong neurologic disability. The most significant risk factor for perinatal brain injury is prematurity; however, in absolute numbers, full-term infants represent the majority of affected children. Research on strategies to prevent or mitigate the impact of perinatal brain injury ("perinatal neuroprotection") has established the mitigating roles of magnesium sulfate administration for preterm infants and therapeutic hypothermia for term infants with suspected perinatal brain injury. Banked umbilical cord blood, erythropoietin, and a number of other agents that may improve neuronal repair show promise for improving outcomes following perinatal brain injury in animal models. Other preventative strategies include delayed umbilical cord clamping in preterm infants and progesterone in women with prior preterm birth or short cervix and avoidance of infections. Despite these advances, we have not successfully decreased the rate of preterm birth, nor are we able to predict term infants at risk of hypoxic brain injury in order to intervene prior to the hypoxic event. Further, we lack the ability to modulate the sequelae of neuronal cell insults or the ability to repair brain injury after it has been sustained. As a consequence, despite exciting advances in the field of perinatal neuroprotection, perinatal brain injury still impacts thousands of newborns each year with significant long-term morbidity and mortality.

Oxytocin and catechol-O-methyltransferase receptor genotype predict the length of the first stage of labor.

OBJECTIVE: We aimed to identify genetic factors that influence the rate of the first stage of labor. STUDY DESIGN: We prospectively enrolled 233 laboring nulliparous parturients. Demographic, clinical, and genetic data were collected. We evaluated the influence of population and individual variability using a nonlinear mixed effects model. RESULTS: Parturients who were homozygous for "G" at oxytocin receptor gene rs53576 transitioned to active labor later and thus had slower labor. Catechol-O-methyltransferase rs4633 genotype TT was associated with slower latent phase labor. Labor induction with prostaglandin was associated with faster labor, and request for meperidine was associated with slower labor. Birthweight was related inversely to the rate of the active phase. CONCLUSION: There are demographic, clinical, and genetic factors that influence an individual's rate of labor progress. This information could be used in automated form to improve the prediction of the length of the first stage of labor.

Effect of a change in policy regarding the timing of prophylactic antibiotics on the rate of postcesarean delivery surgical-site infections.

OBJECTIVE: The purpose of this study was to examine the effect of a change in policy regarding the timing of antibiotic administration on the rates of postcesarean delivery surgical-site infections (SSI). STUDY DESIGN: This was a retrospective cohort study of 1316 term, singleton cesarean deliveries at 1 institution. A policy change was instituted wherein prophylactic antibiotics were given before skin incision rather than after cord clamp. The primary outcome that was examined was SSI; secondary outcomes were the rates of endometritis and cellulitis. Multivariable regression was performed to control for potential confounders. RESULTS: The overall rate of SSI fell from 6.4-2.5% (P = .002). When we controlled for potential confounders, there was a decline in overall SSI with an adjusted odds ratio (aOR) of 0.33 (95% CI, 0.14,0.76), a decrease in endometritis (aOR, 0.34; 95% CI, 0.13,0.92), and a trend towards a decrease in cellulitis (aOR, 0.22; 95% CI, 0.05,1.22). CONCLUSION: At our institution, a change in policy to administer prophylactic antibiotics before skin incision led to a significant decline in postcesarean delivery SSIs.

Time of delivery and neonatal morbidity and mortality.

OBJECTIVE: The objective of the study was to examine the association between time of delivery and neonatal outcomes in term deliveries. STUDY DESIGN: We conducted a retrospective cohort study of all term pregnancies delivered at an academic institution with 24-hour in-house obstetric and anesthesia coverage. Time of delivery was categorized as day (7 am to 6 pm), evening (6 pm to 12 midnight), and late night (12 midnight to 7 am). Outcomes included 5-minute Apgar less than 7, umbilical artery pH less than 7.0, base excess less than -12, admission to the neonatal intensive care unit (NICU), and neonatal death. We excluded patients delivered via cesarean delivery not in labor. We had greater than 80% power to detect a 25% difference in Apgar score, base excess, and admission to the NICU and 80% power to detect a 50% difference in umbilical artery pH less than 7.0. RESULTS: Among the 34,424 deliveries meeting inclusion criteria, 15,664 were during the day, 8495 were during the evening, and 10,265 were during the night. In univariate comparisons, there were no statistically significant differences in neonatal outcomes. For example, the rate of pH less than 7.0 was 0.7% during the day, 1.0% in the evening, and 0.6% at night (P = .12). Admissions to the NICU were 3.6% during the day, 3.7% in the evening, and 3.5% at night (P = .81). When we controlled for obstetric history, demographic factors, and labor characteristics, there were still no differences in rates of either neonatal morbidity or mortality by time of delivery. CONCLUSION: At our institution, we could not demonstrate any significant differences in neonatal morbidity or mortality by time of day among neonates delivered at term. These data can be used to counsel patients and families concerned about differences in time of delivery and potential impact on their infant's health. Future research should include time of delivery in relation to maternal and neonatal outcomes in various types of inpatient settings.

Placenta previa and the risk of preterm delivery.

OBJECTIVES: We aimed to quantify the risk of preterm delivery and maternal and neonatal morbidities associated with placenta previa. STUDY DESIGN: We conducted a retrospective cohort study of singleton births that occurred between 1976 and 2001, examining outcomes including preterm delivery and perinatal complications. Multivariate logistic regression was used to control for potential confounders. Kaplan-Meier survival curves were constructed to compare preterm delivery in pregnancies complicated by previa vs. no previa. RESULTS: Among the 38 540 women, 230 women had previas (0.6%). Compared to controls, pregnancies with previa were significantly associated with preterm delivery prior to 28 weeks (3.5% vs. 1.3%; p = 0.003), 32 weeks (11.7% vs. 2.5%; p < 0.001), and 34 weeks (16.1% vs. 3.0%; p < 0.001) of gestation. Patients with previa were more likely to be diagnosed with postpartum hemorrhage (59.7% vs. 17.3%; p < 0.001) and to receive a blood transfusion (11.8% vs. 1.1%; p < 0.001). Survival curves demonstrate the risk of preterm delivery at each week and showed an overall higher rate of preterm delivery for patients with a placenta previa. CONCLUSIONS: Placenta previa is associated with maternal and neonatal complications, including preterm delivery and postpartum hemorrhage. These specific outcomes can be used to counsel women with previa.

Forceps compared with vacuum: rates of neonatal and maternal morbidity.

OBJECTIVE: To compare perinatal outcomes between forceps- and vacuum-assisted deliveries. Our hypothesis was that the force vectors achieved in forceps delivery will lead to fewer shoulder dystocias, but greater perineal lacerations. METHODS: This was a retrospective cohort study of 4,120 term, cephalic, singleton, nonrotational operative vaginal deliveries at a single institution. Outcomes examined included rates of neonatal trauma, shoulder dystocia, and perineal lacerations. Potential confounders, including maternal age, birthweight, ethnicity, parity, station at delivery, episiotomy, attending physician, anesthesia, and length of labor, were controlled for using multivariate logistic regression. RESULTS: Among the 2,075 (50.4%) forceps- and 2,045 (49.6%) vacuum-assisted deliveries, the rate of shoulder dystocia was lower among women undergoing forceps delivery (1.5% compared with 3.5%, P < .001), as was the rate of cephalohematoma (4.5% compared with 14.8%, P < .001), whereas the rate of third- or fourth-degree perineal laceration was higher (36.9% compared with 26.8%, P < .001). These differences in perinatal complications persisted when controlling for the confounders listed above. The adjusted odds ratio for shoulder dystocia was 0.34 (95% confidence interval [CI] 0.20-0.57), for cephalohematoma was 0.25 (95% CI 0.19-0.33), and for third- or fourth-degree lacerations was 1.79 (95% CI 1.52-2.10) when comparing forceps to vacuum. CONCLUSION: Vacuum-assisted vaginal birth is more often associated with shoulder dystocia and cephalohematoma. Forceps delivery is more often associated with third- and fourth-degree perineal lacerations. These differences in complications rates should be considered among other factors when determining the optimal mode of delivery. LEVEL OF EVIDENCE: II-2.