Perinatal morbidity among women with a previous caesarean delivery (PRISMA trial): a cluster-randomised trial.

BACKGROUND: Women with a previous caesarean delivery face a difficult choice in their next pregnancy: planning another caesarean or attempting vaginal delivery, both of which are associated with potential maternal and perinatal complications. This trial aimed to assess whether a multifaceted intervention, which promoted person-centred decision making and best practices, would reduce the risk of major perinatal morbidity among women with one previous caesarean delivery. METHODS: We conducted an open, multicentre, cluster-randomised, controlled trial of a multifaceted 2-year intervention in 40 hospitals in Quebec among women with one previous caesarean delivery, in which hospitals were the units of randomisation and women the units of analysis. Randomisation was stratified according to level of care, using blocked randomisation. Hospitals were randomly assigned (1:1) to the intervention group (implementation of best practices and provision of tools that aimed to support decision making about mode of delivery, including an estimation of the probability of vaginal delivery and an ultrasound estimation of the risk of uterine rupture), or the control group (no intervention). The primary outcome was a composite risk of major perinatal morbidity. This trial was registered with ISRCTN, ISRCTN15346559. FINDINGS: 21 281 eligible women delivered during the study period, from April 1, 2016 to Dec 13, 2019 (10 514 in the intervention group and 10 767 in the control group). None were lost to follow-up. There was a significant reduction in the rate of major perinatal morbidity from the baseline period to the intervention period in the intervention group as compared with the control group (adjusted odds ratio [OR] for incremental change over time, 0·72 [95% CI 0·52-0·99]; p=0·042; adjusted risk difference -1·2% [95% CI -2·0 to -0·1]). Major maternal morbidity was significantly reduced in the intervention group as compared with the control group (adjusted OR 0·54 [95% CI 0·33-0·89]; p=0·016). Minor perinatal and maternal morbidity, caesarean delivery, and uterine rupture rates did not differ significantly between groups. INTERPRETATION: A multifaceted intervention supporting women in their choice of mode of delivery and promoting best practices resulted in a significant reduction in rates of major perinatal and maternal morbidity, without an increase in the rate of caesarean or uterine rupture. FUNDING: Canadian Institutes of Health Research (CIHR, MOP-142448).

Mid-trimester microbial invasion of the amniotic cavity and the risk of preterm birth.

OBJECTIVE: To evaluate the rate of mid-trimester microbial invasion of the amniotic cavity (MIAC) in asymptomatic women and its association with preterm birth. STUDY DESIGN: This is a prospective cohort study of asymptomatic women undergoing mid-trimester amniocentesis for genetic testing between 14 and 24 weeks of gestation. For each participant, a sample of amniotic fluid was incubated in an aerobic and anaerobic facultative culture media and another sample was tested for the presence of specific Mycoplasma species (Ureaplasma urealyticum, Ureaplasma parvum, and Mycoplasma hominis) using quantitative-PCR. Results were not revealed to the participants or their health care providers. All participants were followed until delivery. MIAC was defined by a positive culture or a positive PCR for Mycoplasma species. The primary outcome was a spontaneous preterm birth or preterm premature rupture of membranes before 35 weeks of gestation. RESULTS: We included 812 women at a median gestational age of 16 5/7 (interquartile: 15 6/7-17 4/7) weeks. Twenty-six (3.2%) had a spontaneous delivery before 35 weeks. We observed no case of positive PCR for Mycoplasma species and 4 (0.5%) cases of positive culture that were all considered to be skin contaminants. None of those four cases was associated with preterm birth. Nulliparity, low family income and history of preterm birth were associated with spontaneous delivery before 35 weeks. CONCLUSION: We found no case of mid-trimester MIAC using a combination of culture and Mycoplasma-specific PCR techniques in a large cohort of low-risk asymptomatic pregnant women. We estimate that mid-trimester MIAC is rare in low-risk population but more sensitive and broad-range microbiologic techniques, such as 16S DNA detection by PCR, could be further evaluated.

Bacteriology of amniotic fluid in women with suspected cervical insufficiency.

OBJECTIVE: To determine the prevalence of mid-trimester microbial invasion of the amniotic cavity (MIAC) in women with suspected cervical insufficiency. METHODS: A prospective observational cohort study was performed in women with suspected cervical insufficiency and visible fetal membranes who were undergoing amniocentesis to rule out MIAC between 16 and 26 weeks of gestation. Women with preterm premature rupture of membranes, regular uterine contractions, or who had a cervical cerclage were excluded. Gram staining of amniotic fluid, glucose and lactate dehydrogenase (LDH) levels in amniotic fluid, and aerobic and anaerobic amniotic fluid cultures were performed, along with polymerase chain reaction (PCR) for the detection of Ureaplasma and Mycoplasma species. RESULTS: Fifteen women with a mean gestational age of 22.6 +/- 2.3 weeks were included in the study. The diagnosis of MIAC was confirmed in 47% (7/15), of whom 20% (3/15) were infected with more than one bacterial strain and 33% (5/15) with Ureaplasma species. According to receiver-operator curve analyses, amniotic fluid levels of glucose were associated with MIAC (P = 0.02), but not amniotic fluid LDH (P = 0.25). CONCLUSION: MIAC is present in approximately one half of women with suspected cervical insufficiency and visible fetal membranes at speculum examination.

Intra-amniotic sludge, short cervix, and risk of preterm delivery.

OBJECTIVE: To evaluate the association between intra-amniotic sludge seen at cervical ultrasound and preterm delivery. METHOD: This retrospective study included women at high risk for preterm delivery who were referred for second trimester cervical length measurement by ultrasound between 18 and 32 weeks' gestation. Patients with multiple gestations, cerclage, or preterm labour were excluded. Ultrasound images were reviewed by two independent observers and divided into three groups: (1) no amniotic sludge, (2) light sludge, and (3) dense sludge in the amniotic fluid. The primary outcome measures were delivery within 14 days of examination and delivery before 34 weeks' gestation. Logistic regression analyses were performed to adjust for confounding factors. RESULTS: Eighty-nine patients met the inclusion criteria. Mean gestational age at presentation was 25.8 +/- 4.4 weeks, and mean cervical length was 33 +/- 12 mm. The prevalence of light and dense amniotic fluid sludge was 10.1% and 5.6%, respectively. Delivery within 14 days of examination occurred in four (5.3%) women with no sludge, in two (22.2%) women with light sludge, and in three (60.0%) women with dense sludge (P < 0.01). Delivery before 34 weeks occurred in five (6.7%), four (44.4%) and four (80.0%) women, respectively (P < 0.01). Logistic regression analyses demonstrated that light amniotic fluid sludge, dense sludge, and cervical length of less than 25 mm were all significant and independent predictors of delivery within 14 days of examination and delivery prior to 34 weeks. CONCLUSION: The presence of amniotic fluid sludge is associated with delivery within 14 days and delivery before 34 weeks' gestation.

Early versus late amniotomy for labour induction: a randomized controlled trial.

OBJECTIVE: To evaluate the impact of early vs. late amniotomy on delivery mode in women undergoing induction of labor. STUDY DESIGN: 143 women admitted for induction were randomized to early amniotomy (EA, concomitant with the beginning of oxytocin infusion; n = 71) or to late amniotomy (LA, four hours after the beginning of oxytocin; n = 72). Randomization was stratified by parity. The primary outcome was the rate of cesarean. Secondary outcomes were duration of labor and intrapartum fever. RESULTS: The cesarean rate was similar between groups (18% vs. 17% among nulliparous; and 3% vs. 0% among parous women, in EA and LA group, respectively). However, EA was associated with shorter oxytocin-to-delivery interval (12 vs. 15 h) and a non-significant decrease in intrapartum fever (3% vs. 25%) than LA in nulliparous women (p = 0.05). CONCLUSION: For women undergoing oxytocin induction, early amniotomy is associated with shorter labor in nulliparous women with no effect on the risk of cesarean section in both nulliparous and multiparous women.

Effect of birth weight on adverse obstetric outcomes in vaginal birth after cesarean delivery.

OBJECTIVE: To estimate the association between neonatal birth weight and adverse obstetric outcomes in women attempting vaginal birth after cesarean. METHODS: We reviewed the medical records of all women undergoing a trial of labor after a prior low transverse cesarean delivery in our institution between 1987 and 2004. Patients were categorized according to birth weight (less than 3,500 g [group 1, reference], 3,500-3,999 g [group 2], and 4,000 g or more [group 3]) and prior vaginal delivery. The rates of failed trial of labor, uterine rupture, shoulder dystocia, and third- and fourth-degree perineal laceration were compared among groups. Multivariable logistic regressions were performed to adjust for potential confounding factors. RESULTS: Of 2,586 women, 1,519 (59%), 798 (31%), and 269 (10%) were included in groups 1, 2, and 3, respectively. Birth weight was directly correlated to the rate of failed trial of labor (19%, 28%, and 38% for groups 1, 2, and 3, respectively; P<.01), uterine rupture (0.9%, 1.8%, and 2.6%; P<.05), shoulder dystocia (0.3%, 1.6%, and 7.8%; P<.01), and third- and fourth-degree perineal laceration (5%, 7%, and 12%; P<.01). After adjustment for confounding variables, birth weight of 4,000 g or more remained associated with uterine rupture (odds ratio [OR] 2.62, 95% confidence interval [CI] 1.001-6.85), failed trial of labor (OR 2.47, 95% CI 1.82-3.34), shoulder dystocia (OR 25.13, 95% CI 9.31-67.86), and third- and fourth-degree perineal laceration (OR 2.64, 95% CI 1.66-4.19). CONCLUSION: Birth weight and specifically macrosomia are linked with failed trial of labor, uterine rupture, shoulder dystocia, and third- and fourth-degree perineal laceration in women who underwent prior cesarean delivery. Estimated fetal weight should be included in the decision-making process for all women contemplating a trial of labor after cesarean delivery. LEVEL OF EVIDENCE: II.

SOGC Clinical Practice Guidelines: Obesity in pregnancy. No. 239, February 2010.

OBJECTIVE: To review the evidence and provide recommendations for the counselling and management of obese parturients. OUTCOMES: OUTCOMES evaluated include the impact of maternal obesity on the provision of antenatal and intrapartum care, maternal morbidity and mortality, and perinatal morbidity and mortality. EVIDENCE: Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to April 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The evidence obtained was reviewed and evaluated by the Maternal Fetal Medicine and Clinical Practice Obstetric Committees of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS: Implementation of the recommendations in this guideline should increase recognition of the issues clinicians need to be aware of when managing obese women in pregnancy, improve communication and consultation amongst the obstetrical care team, and encourage federal and provincial agencies to educate Canadians about the values of entering pregnancy with as healthy a weight as possible.

Prenatal diagnosis of cloverleaf skull: watch the hands!

Pfeiffer syndrome is an extremely rare autosomal-dominant condition whose prenatal diagnosis has only been reported 6 times, mainly on the basis of a fetal cloverleaf skull deformity. Three types have been described, each with a different prognosis. This case report stresses the need to thoroughly analyze the fetus and particularly the fetal hands in case of prenatal observation of a cloverleaf skull. The discovery of characteristic hand abnormalities allowed the early prenatal detection of type 2 Pfeiffer syndrome in our patient.

Trial of labor in patients with a previous cesarean section: does maternal age influence the outcome?

OBJECTIVE: This study was undertaken to evaluate the effect of maternal age on the rate of vaginal delivery and the rate of uterine rupture in patients undergoing a trial of labor (TOL) after a prior cesarean delivery. STUDY DESIGN: A cohort study of all women with a live singleton fetus undergoing a TOL after a previous low-transverse cesarean delivery was performed between 1988 and 2002 in a tertiary care center. Patients were divided into 3 groups according to maternal age: less than 30 years old, 30 to 34 years old, and 35 years or older. Women with no prior vaginal delivery and with at least 1 prior vaginal delivery were analyzed separately. The rate of vaginal delivery and the rate of symptomatic uterine rupture were calculated. Multivariate logistic regression analyses were performed to adjust for potential confounding variables. RESULTS: Of the 2493 patients who met the study criteria, there were 1750 women without a prior vaginal delivery (659, 721, and 370, respectively) and 743 women with a prior vaginal delivery (199, 327, and 217, respectively). The rate of uterine rupture was comparable between the groups (2.0%, 1.1%, 1.4%, P=.404 and 0%, 0.3%, 0.9%, P=.312). Successful vaginal delivery was inversely related to maternal age (71.9%, 70.7%, 65.1%, P=.063, and 91.5%, 91.1%, 82.9%, P=.005). After adjusting for confounding variables, maternal age equal to or greater than 35 years old was associated with a lower rate of successful vaginal delivery in patients without prior vaginal delivery (odds ratio [OR] 0.73, 95% CI: 0.56-0.94), and in patients with a prior vaginal delivery (OR: 0.47, 95% CI: 0.29-0.74). CONCLUSION: Patients who are 35 years or older are more prone to have a failed TOL after a prior cesarean delivery.