The Implications of a "Flat" Oral Glucose Tolerance Test Curve in Pregnancy.

OBJECTIVE: This study aimed to determine whether pregnant women who have "flat" oral glucose tolerance test (OGTT) curves in pregnancy are at increased risk of maternal or neonatal adverse outcomes. STUDY DESIGN: We conducted a retrospective cohort study of the perinatal outcomes of pregnant women whose 100-g OGTT curve was "flat," defined by a fasting serum glucose level below 95 mg/dL and the remaining values below 100 mg/dL. We compared their perinatal outcomes to women whose OGTT curve was "normal." The primary outcomes compared were the prevalence of macrosomic and small for gestational age (SGA) neonates. Secondary outcomes included hypertensive disorders of pregnancy (HDP), prelabor anemia, thrombocytopenia, intrauterine fetal demise, placental abruption, indicated induction of labor, meconium-stained amniotic fluid, mode of delivery, postpartum hemorrhage, blood product transfusion, postpartum readmission, neonatal gender, gestational age at delivery, preterm birth, birth weight, low birth weight, umbilical artery pH < 7.1, Apgar score <7 at 5 minutes, neonatal intensive care unit admission, neonatal respiratory and infectious morbidity, and hypoglycemia. Composite adverse maternal and neonatal outcomes were also evaluated. RESULTS: There were 1,060 patients in the study group and 10,591 patients in the control group. Patients with a flat OGTT were younger (28.3 vs. 29.8, p < 0.001) and less likely to be over 35 years old (14.1 vs. 23.4%, p < 0.001). They had a reduced risk of delivering a macrosomic neonate (11.4 vs. 15.1%, OR = 0.7 [0.58-0.89], p = 0.001) and having an unplanned cesarean delivery (7.5 vs. 10.2%, OR = 0.8 [0.58-0.96], p = 0.002). There was no difference in the rate of composite adverse maternal (14.0 vs. 15.4%, OR = 0.9 [0.7-1.0], p = 0.1) or neonatal outcome (5.3 vs. 4.5%, OR = 1.2 [0.9-1.5], p = 0.15). Neonates had a slightly lower mean birth weight (3,474 vs. 3,505 g, p = 0.04) but the rate of SGA was similar in the two groups (2.5 vs. 1.8%, OR = 1.3 [0.9-2.0], p = 0.08). CONCLUSION: Pregnant women whose OGTT curve is flat have a lower risk of delivering macrosomic neonates and undergoing unplanned cesarean delivery and are not at increased risk of adverse maternal or neonatal outcomes. More research is required to evaluate the relationship between different OGTT curves and the fetal growth rate. KEY POINTS: · Patients with a "flat" OGTT have a reduced risk of macrosomia.. · Patients with a "flat" OGTT have a reduced risk of cesarean delivery.. · Patients with a "flat" OGTT are not at increased risk of growth restriction..

Intrapartum fever complicated with maternal bacteremia: prevalence, bacteriology, and risk factors.

PURPOSE: To assess the prevalence, microbial profile, and clinical risk factors of maternal bacteremia associated with intrapartum fever (IPF). METHODS: A retrospective cohort study, in a single tertiary university-affiliated medical center between 2012 and 2018. Demographic and labor characteristics of women, who delivered at term (37+0/7-41+6/7) and developed bacteremia following IPF were compared to a control group of women with IPF but without bacteremia. RESULTS: During the study period there were 86,590 deliveries in our center. Of them, 2074 women (2.4%) were diagnosed with IPF, of them, for 2052 women (98.93%) the blood maternal cultures were available. In 26 patients (1.25%) maternal bacteremia was diagnosed. A lower rate of epidural anesthesia (84.6% vs 95.9%, p = 0.02) and a higher rate of antibiotics prophylaxis treatment prior to the onset of fever (30.8%.vs 12.1%, p = 0.006) were observed in patients who developed maternal bacteremia in comparison to those who have not. Maternal hyperpyrexia developed after initiation of antibiotics or without epidural anesthesia remained significantly associated with maternal bacteremia after applying a multivariate analysis, (Odds Ratio 3.14 95% CI 1.27-7.14, p = 0.009; 4.76 95% CI 1.35-12.5, p = 0.006; respectively). CONCLUSION: Maternal fever developing after initiation of antibiotics or without epidural is associated with maternal bacteremia.

The Feasibility of a Trial of Labor after Two Cesarean Deliveries: Outcomes and Prognostic Factors for Success.

OBJECTIVE: This study aimed to determine whether a trial of labor after two cesarean deliveries (TOLAC2) increases the risk of adverse maternal and neonatal outcomes and identify prognostic factors for TOLAC2 success. STUDY DESIGN: A retrospective cohort study was conducted at a single medical center. The study group was comprised of women with a history of TOLAC2. Outcomes were compared with women undergoing trial of labor after one previous cesarean delivery (TOLAC1). The primary outcome was trial of labor after cesarean delivery (TOLAC) success. Secondary outcomes included mode of delivery, uterine rupture, and combined adverse outcome (CAO; uterine rupture, postpartum hemorrhage, 5-minute Apgar score < 7, pH < 7.1). Logistic regression was used for the multivariate analysis to identify prognostic factors for TOLAC2 success. RESULTS: A total of 381 women who underwent TOLAC2 were compared with 3,635 women who underwent TOLAC1. Women attempting TOLAC2 were less likely to achieve vaginal births after cesarean delivery (VBAC; 80.8 and 92.5%; odds ratio [OR]: 0.35; 95% confidence interval [CI]: 0.26-0.47; p < 0.001) and more likely to experience uterine rupture (0.8 vs. 0.2%; OR: 4.1; 95% CI: 1.1-15.9; p = 0.02) but not CAO (4.2 vs. 4.8%; OR: 0.88; 95% CI: 0.5-1.5; p = 0.3). TOLAC2 women with no previous vaginal deliveries had a lower chance of VBAC and a higher risk of uterine rupture compared with TOLAC1 women without a prior vaginal delivery (45.2 vs. 86.3%; OR: 0.13; 95% CI: 0.07-0.25; p < 0.001; 2.3 vs. 0%) and TOLAC2 women with a prior vaginal delivery (45.2 vs. 85.3%; OR: 0.14; 95% CI: 0.1-0.3; p < 0.0001; 2.4 vs. 0.6%; OR: 4.1; 95% CI: 0.4-46.3; p = 0.3). Multivariate analysis revealed that a history of vaginal delivery is an independent predictor of TOLAC2 success. CONCLUSION: Women attempting TOLAC2 are less likely to achieve VBAC and are at greater risk of uterine rupture compared with those attempting TOLAC1. Despite these risks, the overall success rates remain very high, and the absolute risk of adverse outcomes is still very low. Prior vaginal delivery seems to have a protective effect on TOLAC outcomes. These data should be used to counsel women and assist in decision-making when considering the mode of delivery in women with two previous cesarean sections. KEY POINTS: · TOLAC2 has a lower chance of success and higher rate of uterine rupture compared with TOLAC1.. · Previous vaginal delivery is an independent predictor of TOLAC2 success.. · Overall TOLAC2 outcomes are associated with high chances of success and low risk of uterine rupture..

High-Order Parity Improves the Perinatal Outcome of Twin Deliveries.

OBJECTIVE: Twin gestations are associated with an increased risk of obstetric and perinatal complications. We studied the association between parity and the rate of maternal and neonatal complications in twins deliveries. STUDY DESIGN: We performed a retrospective analysis of a cohort of twin gestations delivered between 2012 and 2018. Inclusion criteria consisted of twin gestation with two nonanomalous live fetuses at ≥24 weeks' gestation and no contraindications to vaginal delivery. Women were divided into three groups based on parity: primiparas, multiparas (parity of 1-4), and grand multiparas (parity ≥5). Demographic data were collected from electronic patient records and included maternal age, parity, gestational age at delivery, need for induction of labor, and neonatal birth weight. The primary outcome was mode of delivery. Secondary outcomes were maternal and fetal complications. RESULTS: The study population included 555 twin gestations. One hundred and three were primiparas, 312 were multiparas, and 140 were grand multiparas. Sixty-seven (65%) primiparas delivered the first twin vaginally, as did 294 (94%) multiparas and 133 (95%) grand multiparas (p <0.05). Thirteen (2.3%) women required delivery of the second twin by cesarean section. Among those who delivered both twins vaginally, there was no significant difference in the average time interval between the delivery of the first and the second twins between the groups. The need for transfusion of blood products was higher in the primiparous group compared with the other two groups (11.6 vs. 2.5 and 2.8%, p < 0.05). The rate of adverse maternal composite outcomes was higher among primiparous women compared with multiparous and grand multiparous (12.6, 3.2, and 2.8%, respectively, p < 0.05). The gestational age at delivery was earlier in the primiparous group compared with the other two groups, and the rate of preterm labor at <34 weeks' gestation was higher among the primiparas. The rate of second twin's 5-minute Apgar's score <7 and the composite adverse neonatal outcome among the primiparous group were significantly higher than the multiparous and grand multiparous groups. CONCLUSION: Our study demonstrates that there is an association between high-parity and good obstetric outcomes in twin pregnancies; high parity seems to serve as a protective, rather than a risk factor for adverse maternal and neonatal outcomes. KEY POINTS: · There is an association between high-parity and good obstetric outcome in twin pregnancies.. · High parity serves as a protective factor for adverse maternal outcomes in twin deliveries.. · High parity serves as a protective factor for adverse neonatal outcomes in twin deliveries..

Ex-Vivo MRI of the Normal Human Placenta: Structural-Functional Interplay and the Association With Birth Weight.

BACKGROUND: Advanced magnetic resonance imaging (MRI) methods are increasingly being used to assess the human placenta. Yet, the structure-function interplay in normal placentas and their associations with pregnancy risks are not fully understood. PURPOSE: To characterize the normal human placental structure (volume and umbilical cord centricity index (CI)) and function (perfusion) ex-vivo using MRI, to assess their association with birth weight (BW), and identify imaging-markers for placentas at risk for dysfunction. STUDY TYPE: Prospective. POPULATION: Twenty normal term ex-vivo placentas. FIELD STRENGTH/SEQUENCE: 3 T/ T1 and T2 weighted (T1 W, T2 W) turbo spin-echo, three-dimensional susceptibility-weighted image, and time-resolved angiography with interleaved stochastic trajectories (TWIST), during passage of a contrast agent using MRI compatible perfusion system that mimics placental flow. ASSESSMENT: Placental volume and CI were manually extracted from the T1 W images by a fetal-placental MRI scientist (D.L., 7 years of experience). Perfusion maps including bolus arrival-time and full-width at half maximum were calculated from the TWIST data. Mean values, entropy, and asymmetries were calculated from each perfusion map, relating to both the whole placenta and volumes of interest (VOIs) within the umbilical cord and its daughter blood vessels. STATISTICAL TESTS: Pearson correlations with correction for multiple comparisons using false discovery rate were performed between structural and functional parameters, and with BW, with P < 0.05 considered significant. RESULTS: All placentas were successfully perfused and scanned. Significant correlations were found between whole placenta and VOIs perfusion parameters (mean R = 0.76 ± 0.06, range = 0.67-0.89), which were also significantly correlated with CI (mean R = 0.72 ± 0.05, range = 0.65-0.79). BW was correlated with placental volume (R = 0.62), but not with CI (P = 0.40). BW was also correlated with local perfusion asymmetry (R = -0.71). DATA CONCLUSION: Results demonstrate a gradient of placental function, associated with CI and suggest several ex-vivo imaging-markers that might indicate an increased risk for placental dysfunction. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: Stage 1.

Maternal presentation and neonatal outcome in peripartum enterovirus infection.

AIM: Enterovirus is a common pathogen. Although mostly asymptomatic, this infection has the potential to be life-threatening in neonates. This article aims to describe the early neonatal outcomes in peripartum infection. METHODS: We performed a retrospective cohort study in a tertiary hospital between 1/2014 and 5/2019. The enterovirus infection was established by real-time polymerase chain reaction analysis. RESULTS: Out of 161 neonates tested for the enterovirus infection 13 (8%) were positive. Maternal fever was the most common sign (n = 8, 66.7%). The mean gestational age at delivery was 36 + 5 (range 30 + 5 to 40 + 6 weeks). The mean time interval from birth to neonatal manifestations of infection was 5.2 (0-9) days. The most common presenting sign in the neonates was fever (n = 8, 61.5%). All neonates required the neonatal intensive care unit. The neonatal mortality rate was 3/13 (23%). CONCLUSION: The neonatal morbidity and mortality from the enterovirus infection may have been associated with the severity of maternal presentation at the time of admission. Enterovirus real-time polymerase chain reaction analysis should be considered as part of the maternal evaluation in cases of maternal fever of unknown origin. Deferral of the induction of delivery for term pregnancies with confirmed enterovirus infections should be considered.

The Contribution of an Infectious Workup in Understanding Stillbirth.

OBJECTIVE: This study was aimed to assess the utility of diagnostic tests of maternal and fetal infection in the evaluation of stillbirth. STUDY DESIGN: A single-center retrospective study from January 2011 to December 2016 of all women presenting to the hospital with intrauterine fetal death at or after 20 weeks of gestation. Standard evaluation included review of medical records, clinical and laboratory inflammatory workup, maternal serologies, fetal autopsy, placental pathology, and fetal and placental cultures. A suspected infectious etiology was defined as meeting at least two diagnostic criteria, and only after exclusion of any other identifiable stillbirth cause. RESULTS: During the 7-year study period, 228 cases of stillbirth were diagnosed at our center. An infectious etiology was the suspected cause of stillbirth in 35 cases (15.3%). The mean gestational age of infection-related stillbirth was 28 1/7 (range: 22-37) weeks, while for a noninfectious etiology, it was 34 0/7 (range: 25-38) weeks (p = 0.005). Placental histological findings diagnostic of overt chorioamnionitis and funisitis were observed in 31 (88.5%) cases. In 16 (45.7%) cases the placental and fetal cultures were positive for the same pathogen. Serology of acute infection was positive in three (8.5%) of the cases. CONCLUSION: Maternal and fetal infectious workup is valuable in the investigation of stillbirth, particularly before 30 weeks of gestation and should be considered a part of standard evaluation.

Obstetrical outcomes of ART pregnancies in patients with male factor infertility.

PURPOSE: Pregnancies conceived by in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) are associated with an increased incidence of obstetrical and neonatal complications. With the growing rate of male factor infertility, which is unique by not involving the maternal milieu, we aimed to assess whether obstetrical outcomes differed between IVF/ICSI pregnancies due to male factor infertility and those not due to male factor infertility. METHODS: A retrospective cohort study of women receiving IVF/ICSI treatments at a single hospital over a five-year period was involved in the study. Inclusion criteria were women with a viable pregnancy that delivered at the same hospital. Pregnancies were divided into male factor only related and non-male factor-related infertility. The groups were compared for several maternal and neonatal complications. RESULTS: In total, 225 patients met the study criteria, with 94 and 131 pregnancies belonging to the male factor and non-male factor groups, respectively. Demographic and clinical characteristics were comparable, except for younger maternal age and higher incidence of twin pregnancies in the male factor group. A sub-analysis for singleton pregnancies revealed a less likelihood of cesarean delivery, preterm birth, and male gender offspring in the male factor group (p < 0.05). These differences were not observed in the sub-analysis for twin pregnancies. Other outcome measures were similar in both groups, both for singleton and twin pregnancies. CONCLUSION: Singleton IVF pregnancies due to male factor infertility are associated with a reduced incidence of some adverse outcomes, likely due to lack of underlying maternal medical conditions or laboratory conditions related to ICSI. Our findings require validation by further studies on larger samples.

Risk factors for overt postpartum urinary retention-the effect of the number of catheterizations during labor.

INTRODUCTION AND HYPOTHESIS: Our aim was to examine the effect of the number of catheterizations during labor on the development of overt postpartum urinary retention (PUR) in women who had a vaginal delivery with epidural anesthesia. METHODS: A single-center retrospective matched case-control study between 1 January 2015 and 31 December 2016. Women who developed overt PUR were compared with those who did not following a singleton vaginal delivery with epidural anesthesia. For each study two controls, matched for maternal age, gestational age at delivery, and parity, were selected. Each woman's controls were the immediate subsequent or previous delivery that met matching criteria. RESULTS: Two hundred parturients with overt PUR were matched with 400 parturients without overt PUR. In univariate analysis, women with PUR underwent significantly more catheterizations during labor, had an epidural for a longer period of time, and were more likely to have undergone a vacuum-assisted delivery and a mediolateral episiotomy (p < 0.01 for all). In multivariate analysis controlling for epidural duration, episiotomy, and vacuum-assisted delivery, the risk of PUR among women with at least two catheterizations was greater when fewer catheterizations were performed (OR = 0.78, 95% CI 0.61-0.99). When controlling for the number of catheterizations overall, episiotomy, and vacuum-assisted delivery, PUR risk significantly increased with a longer epidural duration (OR 1.23, 95% CI 1.17-1.29). Episiotomy and vacuum-assisted delivery had no significant effect on PUR. CONCLUSIONS: The risk of PUR decreases as the number of catheterizations increases. Although longer epidural duration independently increases the risk of PUR, episiotomy and vacuum-assisted delivery do not.

Assessing the effectiveness of empiric antimicrobial regimens in cases of septic/infected abortions.

INTRODUCTION: Infected abortion is a life-threatening condition that requires immediate surgical and medical interventions. We aimed to assess the common pathogens associated with infected abortion and to test the microbial coverage of various empiric antimicrobial regimens based on the bacteriological susceptibility results in women with infected abortions. METHODS: A retrospective study in a single university-affiliated tertiary hospital. Electronic records were searched for clinical course, microbial characteristics, and antibiotic susceptibility of all patients diagnosed with an infected abortion. The effectiveness of five antibiotic regimens was analyzed according to bacteriological susceptibility results. RESULTS: Overall, 84 patients were included in the study. The mean age of patients was 32.3(SD ±â€¯5.8) years, and the median gestational age was 15 (IQR 8-19) weeks. Risk factors for infection were identified in 23 patients (27.3%), and included lack of medical insurance (n = 12), recent amniocentesis/chorionic villus sampling or fetal reduction due to multifetal pregnancies (n = 10). The most common pathogens isolated were Enterobacteriaceae (35%), Streptococci (31%), Staphylococci (9%) and Enterococci (9%). The combination of intravenous ampicillin, gentamicin and metronidazole showed significant superiority over all the other tested regimens according to the susceptibility test results. Piperacillin-tazobactam as an empiric single-agent drug of choice and provided a superior microbial coverage, with a coverage rate of 93.3%. CONCLUSIONS: A combination of ampicillin, gentamicin, and metronidazole had a better spectrum of coverage as a first-line empiric choice for patients with infected abortion.