Early Second-Trimester Fetal Growth Restriction and Adverse Perinatal Outcomes.

OBJECTIVE: To estimate the risk of adverse perinatal outcomes among women with isolated fetal growth restriction from 17 to 22 weeks of gestation. METHODS: This was a retrospective cohort study of all singleton, nonanomalous pregnancies undergoing ultrasonography to assess fetal anatomy between 17 and 22 weeks of gestation at a single center from 2010 to 2014. After excluding patients with fetal structural malformations, chromosomal abnormalities, or identified infectious etiologies, we compared perinatal outcomes between pregnancies with and without fetal growth restriction, defined as estimated fetal weight less than the 10th percentile for gestational age. Our primary outcome was small for gestational age (SGA) at birth, defined as birth weight less than the 10th percentile. Secondary outcomes included preterm delivery at less than 37 and less than 28 weeks of gestation, preeclampsia, abruption, stillbirth, neonatal death, neonatal intensive care unit admission, intraventricular hemorrhage, need for respiratory support, and necrotizing enterocolitis. RESULTS: Of 12,783 eligible patients, 355 (2.8%) had early second-trimester fetal growth restriction. Risk factors for growth restriction were African American race and tobacco use. Early second-trimester growth restriction was associated with a more than fivefold increase in risk of SGA at birth (36.9% compared with 9.1%, adjusted odds ratio [OR] 5.5, 95% CI 4.3-7.0), stillbirth (2.5% compared with 0.4%, OR 6.2, 95% CI 2.7-12.8), and neonatal death (1.4% compared with 0.3%, OR 5.2, 95% CI 1.6-13.5). Rates of indicated preterm birth at less than 37 weeks of gestation (7.3% compared with 3.3%, OR 2.3, 95% CI 1.5-3.5) and less than 28 weeks of gestation (2.5% compared with 0.2%, OR 10.8, 95% CI 4.5-23.4), neonatal need for respiratory support (16.9% compared with 7.8%, adjusted OR 1.6, 95% CI 1.1-2.2), and necrotizing enterocolitis (1.4% compared with 0.2%, OR 7.7, 95% CI 2.3-20.9) were also significantly higher for those with growth restriction. Rates of preeclampsia, abruption, and other neonatal outcomes were not significantly different. CONCLUSION: Although fetal growth restriction in the early second trimester occurred in less than 3% of our cohort and most of those with isolated growth restriction did not have adverse outcomes, it is a strong risk factor for SGA, stillbirth, neonatal death, and indicated preterm birth.

Impact of evidence-based interventions on wound complications after cesarean delivery.

BACKGROUND: A number of evidence-based interventions have been proposed to reduce post-cesarean delivery wound complications. Examples of such interventions include appropriate timing of preoperative antibiotics, appropriate choice of skin antisepsis, closure of the subcutaneous layer if subcutaneous depth is ≥2 cm, and subcuticular skin closure with suture rather than staples. However, the collective impact of these measures is unclear. OBJECTIVE: We sought to estimate the impact of a group of evidence-based surgical measures (prophylactic antibiotics administered before skin incision, chlorhexidine-alcohol for skin antisepsis, closure of subcutaneous layer, and subcuticular skin closure with suture) on wound complications after cesarean delivery and to estimate residual risk factors for wound complications. STUDY DESIGN: We conducted a secondary analysis of data from a randomized controlled trial of chlorhexidine-alcohol vs iodine-alcohol for skin antisepsis at cesarean delivery from 2011-2015. The primary outcome for this analysis was a composite of wound complications that included surgical site infection, cellulitis, seroma, hematoma, and separation within 30 days. Risk of wound complications in women who received all 4 evidence-based measures (prophylactic antibiotics within 60 minutes of cesarean delivery and before skin incision, chlorhexidine-alcohol for skin antisepsis with 3 minutes of drying time before incision, closure of subcutaneous layer if ≥2 cm of depth, and subcuticular skin closure with suture) were compared with those women who did not. We performed logistic regression analysis limited to patients who received all the evidence-based measures to estimate residual risk factors for wound complications and surgical site infection. RESULTS: Of 1082 patients with follow-up data, 349 (32.3%) received all the evidence-based measures, and 733 (67.7%) did not. The risk of wound complications was significantly lower in patients who received all the evidence-based measures compared with those who did not (20.3% vs 28.1%; adjusted relative risk, 0.75; 95% confidence interval, 0.58-0.95). The impact appeared to be driven largely by a reduction in surgical site infections. Among patients who received all the evidence-based measures, unscheduled cesarean delivery was the only significant risk factor for wound complications (27.5% vs 16.1%; adjusted relative risk, 1.71; 95% confidence interval, 1.12-2.47) and surgical site infection (6.9% vs 1.6%; relative risk, 3.74; 95% confidence interval, 1.18-11.92). Other risk factors, which include obesity, smoking, diabetes mellitus, chorioamnionitis, surgical experience, and skin incision type, were not significant among patients who received all of the 4 evidence-based measures. CONCLUSION: Implementation of evidence-based measures significantly reduces wound complications, but the residual risk remains high, which suggests the need for additional interventions, especially in patients who undergo unscheduled cesarean deliveries, who are at risk for wound complications even after receiving current evidence-based measures.

Staples compared with subcuticular suture for skin closure after cesarean delivery: a systematic review and meta-analysis.

OBJECTIVE: To estimate whether staples or subcuticular suture closure is associated with a higher risk of wound complications when used for transverse skin incisions after cesarean delivery. DATA SOURCES: A systematic review and meta-analysis were performed through electronic database searches (MEDLINE, Cochrane, and Trial Registries). METHODS OF STUDY SELECTION: We searched electronic databases from 1966 to September 2010 for randomized controlled trials (RCTs) and prospective cohort studies comparing staples to subcuticular sutures after cesarean delivery. The primary outcome was occurrence of a wound complication (infection or separation). Secondary outcomes were components of the composite outcome, operating time, postoperative pain, cosmesis, and patient satisfaction. Heterogeneity was assessed using the χ test for heterogeneity, and I test. Pooled odds ratios (ORs) were calculated using a fixed-effects model. We assessed publication bias using funnel plots and Egger test. RESULTS: Six studies met inclusion criteria: five RCTs and one prospective cohort study. Staple closure (n=803) was associated with a twofold higher risk of wound infection or separation compared with subcuticular suture closure (n=684) (13.4% versus 6.6%, pooled OR 2.06, 95% confidence interval [CI] 1.43-2.98). The number needed to harm associated with staple closure was 16. The increased risk persisted when analysis was limited to the RCTs (OR 2.43, 95% CI 1.47-4.02). There was no evidence of significant statistical heterogeneity among studies (χ=0.74, P=.327, I=13.7%) or publication bias (Egger test, t=-0.86, P=.439). Staple closure was associated with shorter duration of surgery, whereas the two techniques appeared equivalent overall with regard to pain, cosmesis, and patient satisfaction. CONCLUSION: Staple closure is faster to perform but associated with a higher risk of wound complications.