Effect of Using Silver Nylon Dressings on Postoperative Pain after Cesarean Delivery.

OBJECTIVE: Silver dressings have been associated with a decrease in postoperative pain in selected populations, but it is unknown if the benefit can be observed after cesarean deliveries. We sought to evaluate the impact of silver nylon dressings in reducing postoperative pain after cesarean delivery. STUDY DESIGN: A secondary analysis of data from a blinded randomized clinical trial of women undergoing cesarean delivery scheduled and unscheduled at a single site was conducted. Women were recruited for participation from a single site and randomized to a silver nylon dressing or an identical-appearing gauze wound dressing. Wounds were evaluated in the outpatient clinic at 1 and 6 weeks after delivery and patient responded to the modified patient scar assessment scale. The primary outcome of this analysis was inpatient opioid and nonopioid analgesic dispensed. The secondary outcome was patient-reported pain at the 1- and 6-week postpartum visits. Data were analyzed using chi-square test, Student's t-test, Fisher's exact test, Wilcoxon-Mann-Whitney's test, and logistic regression where appropriate. A p-value of < 0.05 was considered significant. RESULTS: Among the 649 participants, women allocated to the silver nylon dressing group, when compared with the gauze group, were similar in the amount of dispensed opioid and nonopioid analgesic medications (morphine equivalent milligrams of opioids dispensed [82.5 vs. 90 mg, p = 0.74], intravenous nonsteroidal anti-inflammatory drugs (NSAIDs) [120 vs. 120 mg, p = 0.55], and oral NSAIDs [4,800 vs. 5,600 mg in the gauze group, p = 0.65]). After adjusting for confounding variables, postoperative wound infection (adjusted odds ratio [aOR]: 11.70; 95% confidence interval [CI]: 4.51-30.31) at 1-week postoperative and again at 6-week postoperative (aOR: 5.59; 95% CI: 1.03-30.31) but not gauze dressing was associated with patient-reported postoperative pain. CONCLUSION: Among women undergoing cesarean delivery, silver nylon dressing was not associated with a reduction in postoperative pain. KEY POINTS: · Silver dressings showed no decrease in pain medications.. · Wound infection is associated with pain postoperatively.. · Silver dressings did not reduce postoperative pain..

Impact of Using Abdominal Circumference Independently in the Diagnosis of Fetal Growth Restriction.

OBJECTIVE: Society for Maternal-Fetal Medicine guidelines for diagnosing fetal growth restriction (FGR) have broadened the definition to include abdominal circumference (AC) <10th percentile for gestational age (GA) regardless of estimated fetal weight (EFW). We aimed to compare the ability of three definitions of FGR to predict small for gestational age (SGA) neonates and adverse outcomes. METHODS: We performed a secondary analysis of a prospective cohort of patients who underwent assessment of fetal growth between GA of 26 and 36 weeks. We compared three definitions of FGR: EFW <10th percentile; AC <10th percentile; either EFW or AC <10th percentile. The primary outcome was successful prediction of neonatal SGA. Secondary outcomes included a composite adverse neonatal outcome (CANO). We further compared these definitions of FGR using area under receiver operative curves (AUC) to measure their discriminatory abilities. RESULTS: About 1054 women met inclusion criteria. Ninety-one (8.6%) had EFW <10th percentile, 122 (11.6%) had AC <10th percentile, and 137 (12.9%) had either EFW or AC <10th percentile. SGA was seen in 139 (13.2%); CANO was seen in 139 (13.2%). Ability for detecting neonatal SGA was significantly better when the definition included both EFW or AC <10th percentile compared to either variable independently. The AUC were: 0.74, 0.73, 0.69; P = .0003. There was no statistical significance in ability for predicting CANO (AUC 0.51, 0.51, 0.50; P = .7447). CONCLUSIONS: Addition of AC as a criterion for diagnosing FGR improves our ability to predict neonatal SGA compared to using EFW alone. All three definitions were poorly predictive of neonates at risk for adverse outcomes.

Prediction of Large-for-Gestational-Age Neonates by Different Growth Standards.

OBJECTIVE: Compare the accuracy of the Hadlock, the NICHD, and the Fetal Medicine Foundation (FMF) charts to detect large-for-gestational-age (LGA) and adverse neonatal outcomes (as a secondary outcome). METHODS: This is a secondary analysis from a prospective study that included singleton non-anomalous gestations with growth ultrasound at 26-36 weeks. LGA was suspected with estimated fetal weight > 90th percentile by the NICHD, FMF, and Hadlock charts. LGA was diagnosed with birth weight > 90th percentile. We tested the performance of these charts to detect LGA and adverse neonatal outcomes (neonatal intensive care unit admission, Ph < 7.1, Apgar <7 at 5 minutes, seizures, and neonatal death) by calculating the area under the curve, sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: Of 1054 pregnancies, 123 neonates (12%) developed LGA. LGA was suspected in 58 (5.5%) by Hadlock, 229 (21.7%) by NICHD standard, and 231 (22%) by FMF chart. The NICHD standard (AUC: .79; 95% CI: .75-.83 vs. AUC .64; 95%CI: .6-.68; p = < .001) and FMF chart (AUC: .81 95% CI: .77-.85 vs. AUC .64; 95%CI: .6-.68; p = < .001) were more accurate than Hadlock. The FMF and NICHD had higher sensitivity (77.2 vs. 72.4 vs. 30.1%) but Hadlock had higher specificity for LGA (97.5 vs. 88.5 vs. 85.4%). All standards were poor predictors for adverse neonatal outcomes. CONCLUSIONS: The NICHD and the FMF standards may increase the detection rate of LGA in comparison to the Hadlock chart. However, this may increase obstetrical interventions.

Effect of using silver nylon dressings to prevent superficial surgical site infection after cesarean delivery: a randomized clinical trial.

BACKGROUND: Surgical site infections are associated with significant healthcare cost and burden. Silver-impregnated dressings have been associated with a decrease in surgical site infections in select populations, but it is unknown whether the benefit can be observed after cesarean deliveries. OBJECTIVE: We sought to evaluate the impact of silver nylon dressings in reducing superficial surgical site infections after cesarean delivery. MATERIALS AND METHODS: A blinded randomized clinical trial of women undergoing scheduled or unscheduled cesarean delivery at a single site was conducted. Women were recruited for participation from September 2013 to June 2016. Women with vertical skin incisions were excluded. Enrolled participants were randomized to silver nylon dressing or an identical-appearing gauze wound dressing. Wounds were evaluated in the outpatient office at 1 week and 6 weeks after delivery. The primary outcome was superficial surgical site infection as defined by Centers for Disease Control criteria at any time within the first 6 weeks after cesarean delivery. A sample size of 330 per group (n = 660) was planned to compare the 2 arms. Data were analyzed using the χ2, Fisher exact test, Student t test, Mann-Whitney U test, and logistic regression where appropriate, and a value of P < .05 was considered significant. RESULTS: Among the 657 participants, overall, the primary outcome was similar between the 2 groups (4.6% in the silver nylon group vs 4.2% in the gauze group, P = .96). Women allocated to silver nylon, when compared to those who were allocated to gauze, had similar rates of superficial surgical site infection within 1 week (1.2% vs 0.9%) and within 6 weeks ( 4.6% vs 4.2%) after delivery (P >.99). The 2 groups were similar in age (30.9 ± 5.6 vs 31.0 ± 5.5 years, P = .95), body mass index (36.2 ± 8.7 vs 35.3 ± 8.2 kg/m2, P = .19), pregestational diabetes (6.2% vs 3.4%, P = .14), gestational diabetes (7.9% vs 7.3%, P = .88), cesarean delivery after labor (31.9% vs 31.1%, P = .86), presence of chorioamnionitis (5.2% vs 2.1% P = .06), and operative time (56.4 ± 20.6 vs 55.9 ± 17 minutes, P = .69). After adjusting for clinical and sociodemographic confounding variables, current smoking (adjusted odds ratio, 4.9; 95% confidence interval, 1.8-13.4) body mass index ≥40 kg/m2 (adjusted odds ratio, 3.08; 95% confidence interval, 1.3-6.8), and surgery length (minutes) (adjusted odds ratio, 1.02; 95% confidence interval, 1.002-1.04), but not use of gauze dressing, were associated with superficial surgical site infections. CONCLUSION: Among women undergoing cesarean delivery, silver nylon dressing was not more effective than gauze in reducing the risk of superficial surgical site infections.

Customized fetal growth standard compared with the INTERGROWTH-21st century standard at predicting small-for-gestational-age neonates.

INTRODUCTION: The INTERGROWTH-21st project (IG-21) was recently performed aiming to provide a universal benchmark for comparing fetal growth across different ethnicities. Our aim was to compare the IG-21 with a customized standard for predicting pregnancies at risk for neonatal small-for-gestational age (SGA) and adverse outcomes. MATERIAL AND METHODS: This was a prospective cohort study including singleton pregnancies presenting for fetal growth assessment between 26 and 36 weeks of gestation. Fetal growth restriction was defined as estimated fetal weight <10th centile for gestational age using IG-21 and a customized standard. Neonatal SGA was defined as birthweight <10th centile for gestational age by the Alexander chart. Primary outcome was the prediction of neonatal SGA. Secondary outcomes included a composite of adverse neonatal outcomes. The discriminatory ability of each growth standard was compared using area under receiver operating characteristic curves (AUC). RESULTS: Of 1054 pregnancies meeting the inclusion criteria, the incidence of neonatal SGA was 139 (13.2%), and a composite adverse neonatal outcome occurred in 300 (28.4%). The sensitivity of the customized standard (38.8%) was higher than that of IG-21 (24.5%) for predicting neonatal SGA, with AUC (95% CI) of 0.67 (0.63-0.71) for customized vs 0.62 (0.58-0.65) for IG-21; P = .003. Both standards were comparable in predicting the composite adverse neonatal outcomes: AUC (95% CI) 0.52 (0.50-0.55) for customized vs 0.51 (0.50-0.53) for IG-21; P = 0.25. CONCLUSIONS: Both growth standards had modest performance in detecting neonatal SGA and were poor at predicting short-term adverse neonatal outcome.

Three-Dimensional Power Doppler Evaluation of Cerebral Vascular Blood Flow: A Novel Tool in the Assessment of Fetal Growth Restriction.

OBJECTIVES: To determine whether fetuses with fetal growth restriction (FGR) are more likely to have abnormal cerebral vascular flow patterns compared to fetuses who are appropriate for gestational age (AGA) when quantified by using 3-dimensional (3D) power Doppler ultrasound. METHODS: We conducted a prospective cohort study of singleton gestations presenting for growth ultrasound examination between 24 and 36 weeks' gestation. Patients with FGR (estimated fetal weight < 10th percentile) were enrolled and matched 1:1 for gestational age (±7 days) with AGA fetuses. A standardized 3D power Doppler image of the middle cerebral artery territory was obtained from each patient. The vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) were calculated by the Virtual Organ computer-aided analysis technique (GE Healthcare, Milwaukee, WI). These indices were compared between FGR and AGA fetuses and correlated with 2-dimensional Doppler parameters. Neonatal outcomes were also compared with respect to the 3D parameters. RESULTS: Of 306 patients, there were 151 cases of FGR. There was no difference in the VI (6.0 versus 5.7; P = .65) or VFI (2.0 versus 1.8; P = .31) between the groups; however, the FI was significantly higher in FGR fetuses compared to AGA controls (33.9 versus 32.3; P = .009). There was a weak, but significant, negative correlation between the FI and both the middle cerebral artery pulsatility index (r = -0.34; P < .001) and cerebroplacental ratio (r = -0.29; P < .001). Within the FGR group, there was no difference in any of the 3D vascular indices with regard to neonatal outcomes. CONCLUSIONS: Three-dimensional power Doppler measurement of cerebral blood flow, but not the vascularization pattern, is significantly altered in FGR. This measurement may play a future role in distinguishing pathologic FGR from constitutionally small growth.

Gestational Weight Gain: Association with Adverse Pregnancy Outcomes.

Background It is unclear how adherence to the Institute of Medicine's (IOM) guidelines for weight gain affects pregnancy outcomes. Objective We investigated how weight gain outside the IOM's recommendations affects the risks of adverse pregnancy outcomes. Study Design We performed a secondary analysis of a prospective cohort study including singleton, nonanomalous fetuses. The risks of small for gestational age (SGA), macrosomia, preeclampsia, cesarean delivery, gestational diabetes, or preterm birth were calculated for patients who gained weight below or above the IOM's recommendations based on body mass index category. A time-to-event analysis was performed to account for gestational age at delivery. A Cox proportional model was fit to estimate hazard ratios accounting for possible confounders. Results Women who gained weight below recommendations were 2.5 times more likely to deliver SGA and twice as likely to deliver preterm. Normal-weight patients who gained below recommendations were 2.5 times more likely to deliver SGA and twice as likely to deliver preterm. Obese patients who gained inadequate weight were 2.5 times more likely to deliver SGA. Conclusion Among normal-weight patients, adhering to IOM recommendations may prevent growth abnormalities and preterm delivery. Among obese patients, a minimum weight gain requirement may prevent SGA infants.

First-trimester 3-dimensional power Doppler placental vascularization indices from the whole placenta versus the placental bed to predict preeclampsia: does pregnancy-associated plasma protein a or uterine artery Doppler sonography help?

OBJECTIVES: The purpose of this study was to compare the use of vascular indices derived from the whole placenta to those from the placental bed only for predicting preeclampsia and to determine whether the addition of pregnancy-associated plasma protein A (PAPP-A) and mean uterine artery Doppler values improves prediction. METHODS: We conducted a secondary analysis of a prospective cohort of women with singletons between 11 and 14 weeks' gestation undergoing sonography for aneuploidy screening. Placental vascularization indices from the whole placenta versus the placental bed were combined with first-trimester maternal serum PAPP-A levels, mean uterine artery Doppler values, or the combination of both to predict the development of preeclampsia or early preeclampsia (delivery <34 weeks). The predictive ability of each vascular index was calculated by using areas under receiver operating characteristic curves. The sensitivity of the model for predicting preeclampsia and early preeclampsia at fixed false-positive rates of 10% and 20% was calculated. RESULTS: Of 570 women, 48 (8.4%) had preeclampsia, and 10 (1.7%) had early preeclampsia. The area under the curve and sensitivity values for the prediction of preeclampsia or early preeclampsia were not different when evaluating the whole placenta versus the placental bed. Additionally, there was no significant improvement when adding PAPP-A, uterine artery Doppler values, or both. The variables in the model were more sensitive for the prediction of early preeclampsia than preeclampsia. CONCLUSIONS: Although placental bed vascular indices are modestly predictive of preeclampsia, the addition of PAPP-A and uterine artery Doppler values to vascularization indices in the whole placenta or the placental bed did not significantly improve their predictive ability.

Evaluating the Optimal Definition of Abnormal First-Trimester Uterine Artery Doppler Parameters to Predict Adverse Pregnancy Outcomes.

OBJECTIVES: To investigate the optimal definition of abnormal first-trimester uterine artery Doppler parameters associated with adverse pregnancy outcomes. METHODS: A prospective cohort of women with singleton gestations between 11 and 14 weeks consented to uterine artery Doppler measurements. Doppler parameters were measured bilaterally, and mean pulsatility index (PI) and resistive index (RI) values were calculated. The presence of notching was also determined. Each parameter was evaluated for prediction of preeclampsia, early preeclampsia (<34 weeks), preterm birth (<37 weeks), early preterm birth (<34 weeks), and small for gestational age (SGA; birth weight <10th percentile). Descriptive statistics evaluated the association between abnormal Doppler indices and outcomes. A receiver operating characteristic (ROC) analysis was used to define the best cutoff points for mean PI and RI. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) were calculated for bilateral notching and mean PI and RI percentiles. RESULTS: Of 1192 patients with complete outcome data, preeclampsia was seen in 8.4%, early preeclampsia in 1.8%, preterm birth in 12.9%, early preterm birth in 5.6%, and SGA in 8.5%. A mean PI above the 75th percentile (>1.91) was the best index for predicting early preeclampsia (sensitivity, 45.0%; specificity, 75.5%; NPV, 98.7%; ROC area, 0.65). A mean PI above the 75th percentile was also the best index for predictive early preterm birth (sensitivity, 40.0%; specificity, 76.0%; NPV, 95.5%; ROC area, 0.65). None of the parameters were significant for predicting SGA. CONCLUSIONS: A mean uterine PI above the 75th percentile is the most discriminative abnormal uterine artery Doppler parameter for predicting both early preeclampsia and early preterm birth.

Combined sonographic testing index and prediction of adverse outcome in preterm fetal growth restriction.

OBJECTIVE: We sought to test the hypothesis that a combined sonographic scoring system (CSTI) that incorporates features of the biophysical profile (BPP) and multivessel Doppler evaluation improves prediction of adverse outcomes in preterm intrauterine growth restriction. METHODS: This was a prospective cohort study of growth-restricted fetuses with abnormal umbilical artery (UA) Doppler studies, defined as pulsatility index (PI) > 95 th percentile for gestational age or absent/reversed end diastolic flow. Fetuses were followed with weekly BPP and Doppler evaluation of the UA, middle cerebral artery (MCA), and ductus venosus (DV) until the time of delivery. The cerebroplacental Doppler ratio (CPR) was then calculated (MCA PI/UA PI). MCA PI < 5 th percentile, MCA peak systolic velocity (PSV) > 1.5 multiples of the median, DV PI > 95 th percentile with or without absent/reversed flow, and CPR < 1.08 were considered abnormal. Using logistic regression modeling, a weighted scoring index for the prediction of a composite fetal vulnerability index (FVI), which included 5-minute Apgar score < 3, cord pH < 7.2, seizures, necrotizing enterocolitis, grade 4 intraventricular hemorrhage, periventricular leukomalacia, and neonatal death, was developed. A receiver operating characteristic (ROC) curve was used to identify the best score associated with the FVI. RESULTS: Of 66 patients meeting inclusion criteria over a 5-year period, 17 (25.8%) had a positive FVI. Abnormal BPP (< 8), MCA PI, MCA PSV, DV PI, and CPR were observed in 6, 27.3, 13.6, 56.1, and 33.3% of patients, respectively. From the logistic regression model, a CSTI was developed including a score of 1 for abnormal BPP, 3 for MCA PSV, 1 for DV, 6 for CPR, and 3 for oligohydramnios. The ROC curve identified a score of ≥ 7 to be the best predictor of FVI with sensitivity of 35.1% and specificity of 91.8% and a positive likelihood ratio of 4.3 (area under ROC curve 0.73). These test characteristics were better than those for any of the individual component antenatal tests. CONCLUSION: Although this novel scoring system performs modestly in predicting adverse outcomes in FGR, it appears to perform better than any individual antenatal test currently available.

Efficiency of first-trimester uterine artery Doppler, a-disintegrin and metalloprotease 12, pregnancy-associated plasma protein a, and maternal characteristics in the prediction of preeclampsia.

OBJECTIVES: The purpose of this study was to estimate the efficiency of first-trimester uterine artery Doppler, A-disintegrin and metalloprotease 12 (ADAM12), pregnancy-associated plasma protein A (PAPP-A), and maternal characteristics in the prediction of preeclampsia. METHODS: We conducted a prospective cohort study of patients presenting for first-trimester aneuploidy screening between 11 and 14 weeks' gestation. Maternal serum ADAM12 and PAPP-A levels were measured by an immunoassay, and mean uterine artery Doppler pulsatility indices were calculated. Outcomes of interest included preeclampsia, early preeclampsia (defined as requiring delivery at <34 weeks' gestation), and gestational hypertension. Logistic regression analysis was used to model the prediction of preeclampsia using ADAM12 multiples of the median (MoM), PAPP-A MoM, and uterine artery Doppler pulsatility index MoM, either individually or in combination. The sensitivity, specificity, and area under the receiver operating characteristic curves were used to compare the screening efficiency of the models using nonparametric U statistics. RESULTS: Among 578 patients with complete outcome data, there were 54 cases of preeclampsia (9.3%) and 13 cases of early preeclampsia (2.2%). Median ADAM12 levels were significantly lower in patients who developed preeclampsia compared to those who did not (0.81 versus 1.01 MoM; P = .04). For a fixed false-positive rate of 10%, ADAM12, PAPP-A, and uterine artery Doppler parameters in combination with maternal characteristics identified 50%, 48%, and 52% of patients who developed preeclampsia, respectively. Combining these first-trimester parameters did not improve the predictive efficiency of the models. CONCLUSIONS: First-trimester ADAM12, PAPP-A, and uterine artery Doppler characteristics are not sufficiently predictive of preeclampsia. Combinations of these parameters do not further improve their screening efficiency.

First-trimester prediction of preterm birth using ADAM12, PAPP-A, uterine artery Doppler, and maternal characteristics.

OBJECTIVE: The objective of this study was to estimate the efficiency of first-trimester a disintegrin and metalloprotease 12 (ADAM12), pregnancy-associated plasma protein A (PAPP-A), uterine artery Doppler, and maternal characteristics in the prediction of preterm birth (PTB). METHODS: This was a prospective cohort study of patients presenting for first-trimester aneuploidy screening. Maternal serum ADAM12 and PAPP-A levels were measured by immunoassay, and mean uterine artery Doppler pulsatility indices were calculated. The primary outcome was PTB <34 weeks' gestation, and the secondary outcome was PTB <37 weeks' gestation. Logistic regression was used to model the prediction of PTB using ADAM12, PAPP-A, uterine artery Doppler, and maternal characteristics, individually and in combination. Sensitivity, specificity, and area under the receiver-operating characteristic curves were compared between models. RESULTS: Of 578 patients, 36 (6.2%) delivered <34 weeks, and 78 (13.5%) delivered <37 weeks. For a 20% fixed false positive rate, ADAM12, PAPP-A, and uterine artery Doppler identified 58%, 52%, and 62% of patients with PTB <34 weeks and 42%, 48%, and 50% of patients with PTB <37 weeks, respectively. Combining these first-trimester parameters did not improve the predictive efficiency of the models. CONCLUSION: First-trimester ADAM12, PAPP-A, and uterine artery Doppler are each modestly predictive of PTB; however, combinations of these parameters do not further improve their screening efficiency.

Comparing fetal biometric growth velocity versus estimated fetal weight for prediction of neonatal small for gestational age.

OBJECTIVE: Growth velocities derived from fetal biometrics have been proposed to improve prediction of small for gestational age (SGA) neonates. We sought to determine if ultrasound growth velocities for abdominal circumference (AC) and estimated fetal weight (EFW) improve the prediction of SGA infants when compared to using EFW alone. STUDY DESIGN: This is a secondary analysis from a prospective study of women referred for growth ultrasounds during the third trimester. Growth velocities for AC and EFW were derived from the difference in Z-scores between measurements at the anatomy survey (18-22 weeks gestation) and later growth ultrasound (26-36 weeks gestation). Change in AC and EFW growth velocities <10th percentile were compared with prenatally suspected SGA from Hadlock EFW <10th percentile for prediction of SGA neonates. The primary outcome was defined as the sensitivity and specificity of the growth velocities and Hadlock EFW in predicting SGA neonates. Logistic regression modeling was used to determine if the growth velocities improved prediction of neonatal SGA. Area under the ROC curves (AUC) were determined and compared. RESULTS: Of 612 singleton pregnancies meeting inclusion criteria, 68 (11.1%) resulted in SGA neonates. Hadlock EFW <10th percentile had higher sensitivity and specificity when compared to AC growth velocity and EFW growth velocity. Only AC growth velocity and Hadlock EFW had significant odds ratios for association with neonatal SGA. The AUC were 0.54, 0.53, and 0.61 using AC growth velocity, EFW growth velocity, and Hadlock EFW, respectively. The AUC did not significantly improve when the growth velocities were combined with Hadlock EFW (0.63). Adjustment of Z-scores for gestational age at anatomy scan or third trimester growth scan did not significantly change these results (AUC = 0.69). CONCLUSION: EFW determined by Hadlock formula has the highest predictive value in detecting SGA neonates when compared to both AC and EFW growth velocities.

The value of fetal growth biometry velocities to predict large for gestational age (LGA) infants.

OBJECTIVE: The use of growth velocities derived from fetal biometrics have been suggested to improve prediction of large for gestational age (LGA). Our objective was to determine if ultrasonographic growth velocities (GV) for abdominal circumference (AC) and estimated fetal weight (EFW) improve the prediction of LGA infants when compared to Hadlock EFW. METHODS: This was a secondary analysis of data from a prospective study of women referred for growth ultrasounds during the 3rd trimester. Growth velocities (GV) for AC (AC - GV) and EFW (EFW - GV) were derived from the difference in Z-scores between measurements at the time of anatomy survey (18-24 week) and third trimester ultrasound (26-36 weeks). Change in AC - GV and EFW - GV >90th %ile alone or in combination with Hadlock EFW >90th%ile were compared for prediction of a LGA neonate. The primary outcome was the sensitivity and specificity of the (1) Hadlock EFW >90%ile, (2) AC - GV, (3) EFW - GV, (4) Hadlock EFW + AC - GV, and (5) Hadlock EFW + EFW - GV for the prediction of neonatal LGA. Test characteristics and area under the ROC curve (AUC) were determined. The association between the ultrasound predicted growth and adverse neonatal outcome was assessed using logistic regression. RESULTS: Of 630 women meeting inclusion criteria, 85 (13.5%) had LGA neonates. Hadlock EFW showed a better NPV (98.0%) and sensitivity (71.1%) when compared to AC - GV (NPV 87.5%, sensitivity 17.7%) and EFW - GV (NPV 88.0%, sensitivity 22.6%). Combining Hadlock EFW and AC-GV or EFW - GV did little to improve the test characteristics for the prediction of LGA (AUC 0.65 and 0.64, respectively). All five measurements were unable to predict a composite of adverse neonatal outcome or need for maternal cesarean delivery. Adjustment of the growth velocities for gestational age at anatomy scan or 3rd trimester growth scan did not change these results. CONCLUSION: AC and EFW growth velocities do not appear to improve the prediction of LGA infants when compared to using the third trimester Hadlock EFW.

Comparing the cerebro-placental to umbilico-cerebral Doppler ratios for the prediction of adverse neonatal outcomes in pregnancies complicated by fetal growth restriction.

OBJECTIVE: The cerebroplacental ratio (CPR) has shown utility as a surrogate marker for fetal growth restriction and can be used to stratify the risk for adverse perinatal outcomes in affected pregnancies. However, recent studies suggest that its inverse, the umbilico-cerebral ratio (UCR), may be a better predictor of such outcomes. The aim of this study was to compare the prognostic accuracy of CPR to that of UCR Doppler in predicting short-term adverse perinatal outcomes in growth-restricted fetuses. METHODS: We conducted a secondary analysis using data from a prospective study on women referred for fetal growth ultrasounds between 26 and 36 weeks of gestation and with an EFW < 10th percentile by Hadlock standard. The CPR and UCR were converted into Z-scores adjusted for gestational age at ultrasound. Abnormal CPR was defined as Z-score below the 10th percentile for the gestational age and abnormal UCR as Z-score above the 90th percentile. We calculated sensitivity and specificity of the two Doppler parameters for predicting composite adverse perinatal outcome (APO) defined as the presence of any one of the following: umbilical cord arterial pH <7.10, Apgars at 5 min <7, NICU admission,grade III/IV intraventricular hemorrhage (IVH), neonatal seizure and death. Logistic regression analysis was performed, ROC curves plotted and the area under the ROC curve (AUC) were compared between CPR and UCR. RESULTS: Over the study period, there were 197 women meeting inclusion criteria, of which 27 (13.7%) had a composite adverse neonatal outcome. The sensitivity using CPR Z-score for predicting the composite APO was higher thanwas similar to using UCR Z-score (39.3% compared with 37%) for a similar specificity (94.7 versus 94.1), respectively. However, the positive predictive value (PPV) was higher for CPR (55% vs UCR 50%) and the negative predictive values (NPV) were similar. For a fixed false positive rate of 10%, the detection rates for adverse neonatal outcomes were 40% using either CPR or UCR. The AUC for CPR and UCR were 0.70 and 0.68, respectively. CONCLUSION: This study did not find any advantage in utilizing the UCR over the CPR.

First-trimester prediction of preeclampsia using metabolomic biomarkers: a discovery phase study.

OBJECTIVE: We tested the hypothesis that first-trimester metabolic biomarkers offered a unique profile in women with preeclampsia (PE) in the second half of pregnancy, compared with controls. METHOD: We conducted a nested case-control study within a prospective cohort of pregnant women followed from the first-trimester to delivery. Cases were those who developed PE at any gestational age, and these were compared with a control group without adverse pregnancy outcome, matched for gestational age within 3 days. We analyzed maternal blood obtained at 11-14 weeks' gestation for 40 acylcarnitine species (C2-C18 saturated, unsaturated, and hydroxylated) and 32 amino acids by liquid chromatography tandem mass spectrometry. Logistic regression modeling estimated the association of each metabolite with development of PE. RESULTS: We compared 41 cases with PE with 41 controls and found four metabolites (hydroxyhexanoylcarnitine, alanine, phenylalanine, and glutamate) that were significantly higher in the cases with PE. The area under the curve (AUC) using these metabolites individually to predict PE varied from 0.77 to 0.80, and when combined, the AUC improved to 0.82 [95% confidence interval (95% CI): 0.80-0.85] for all cases of PE and 0.85 (95% CI: 0.76-0.91) for early onset PE. CONCLUSION: Our findings suggest a potential role for first-trimester metabolomics in screening for PE.

The value of introducing cerebroplacental ratio (CPR) versus umbilical artery (UA) Doppler alone for the prediction of neonatal small for gestational age (SGA) and short-term adverse outcomes.

OBJECTIVE: To compare the role of umbilical artery (UA) Doppler versus CPR in the prediction of neonatal SGA and short-term adverse neonatal outcome in a high-risk population. STUDY DESIGN: We conducted a prospective study on women referred for fetal growth ultrasounds between 26 and 36 weeks of gestation and with an EFW <20th percentile by Hadlock standard. UA and middle cerebral artery (MCA) Doppler assessments were performed. Abnormal UA Doppler was defined as: pulsatility index (PI) above the 95th percentile and absent or reverse end-diastolic flow. The CPR, calculated as a ratio of the MCA PI by the UA PI, was defined as low if <1.08. The primary outcome was the sensitivity and specificity of the two Doppler assessments to predict neonatal SGA, defined as birthweight <10th percentile by using Alexander curves. The secondary outcomes included umbilical cord arterial pH <7.10, Apgars at 5 minutes <7, NICU admission, respiratory distress syndrome (RDS), hypoglycemia or a composite including any of these secondary outcomes. Chi-square was performed for statistical analysis. RESULTS: Of the 199 women meeting inclusion criteria, 94 (47.2%) had SGA and 68 (34.2%) had a composite adverse outcome. A total of seven pregnancies with FGR had a low CPR. Abnormal UA Doppler showed a better sensitivity for predicting SGA and adverse neonatal outcomes with comparable specificity to low CPR. The area under the ROC curve (AUC) using abnormal UA Doppler for predicting SGA was 0.54, 95% CI 0.50-0.58; and 0.51, 95% CI 0.48-0.53 for low CPR. The AUC for predicting a composite adverse neonatal outcome are: 0.60, 95% CI 0.51-0.68 for abnormal UA Doppler; and 0.54, 95% CI 0.47-0.84 for low CPR. CONCLUSION: The CPR did not improve our ability to predict neonatal SGA or other short-term adverse outcomes.

Third trimester uterine artery Doppler indices as predictors of preeclampsia and neonatal small for gestational age.

Objective: To test the hypothesis that third-trimester uterine artery Doppler (UAD) predicts adverse pregnancy and neonatal outcomes in a high-risk population.Study design: This is a nested case control study of women with singleton gestations referred for a fetal growth ultrasound between 24 and 36 weeks. Third-trimester UAD was performed if estimated fetal weight (Hadlock's chart) was <20th percentile as these patients were considered high risk for poor pregnancy outcomes. The primary outcomes assessed were neonatal small for gestational age (SGA) and hypertensive disorders. Secondary outcomes included pH <7.10, NICU admission, Apgar <7 at 5 minutes, respiratory distress syndrome, hypoglycemia, and a composite (presence of one or more of the secondary outcomes) neonatal adverse outcome. The sensitivity and specificity of the UAD indices for predicting these outcomes were compared.Results: Among 200 women included, neonatal SGA occurred in 91 (46%) neonates, preeclampsia in 21 (10.5%), early preeclampsia in 4 (2%) and a composite adverse outcome in 67 (34%) neonates. Abnormal UAD indices, specifically left uterine artery notching and pulsatile index (PI) >95th percentile, were significantly correlated with an increased relative risk (RR) of a number of outcomes. Left uterine artery notching was significantly associated with SGA, RR 1.76 (1.03-3.04), preeclampsia, RR 2.53 (1.47-4.37) and early preeclampsia, RR 2.88 (1.34-6.20). The PI >95th percentile was significantly associated with SGA, RR 1.83 (1.21-2.76), NICU admission, RR 1.79 (1.14-2.79), preeclampsia, RR 1.98 (1.29-3.03), and early preeclampsia, RR 3.13 (2.54-3.86). The mean UAD PI >95th percentile had the best sensitivity for SGA, but the area under the ROC curve (AUC) was modest (0.60, 95% CI = 0.53-0.67). Left uterine artery notching and PI >95th percentile had similar predictive utility for preeclampsia AUC 0.65, 95% CI = 0.53-0.76 (mean uterine artery PI >95th percentile) and AUC 0.66, 95% CI = 0.54-0.77 (left uterine artery notching).Conclusion: Abnormal third-trimester UAD indices are associated with adverse perinatal outcomes including neonatal SGA, preeclampsia, and early preeclampsia. Though statistically significantly correlated, the predictive value of UAD indices for adverse pregnancy and neonatal outcomes was modest.

Comparing INTERGROWTH-21st Century and Hadlock growth standards to predict small for gestational age and short-term neonatal outcomes.

Objective: To compare the INTERGROWTH-21st Century growth standard to the Hadlock standard in predicting small for gestational age (SGA) and adverse neonatal outcomes.Method: This is a prospective cohort study on women with singleton gestations referred for fetal growth ultrasound between 26.0 and 36.6 weeks gestational age (GA). The primary outcome is prediction of neonatal SGA. Neonatal SGA was defined as birthweight <10th percentile for GA by Alexander chart. The discriminatory ability of the growth standards was compared using area under receiver operating characteristic curves (AUC).Results: Among 1054 patients who met inclusion criteria, 139 (13.2%) had neonatal SGA. The mean interval between estimated fetal weight and birthweight was 6.7 ± 3.1 weeks. Composite adverse neonatal outcome was seen in 300 (28.4%) patients. The sensitivity for identifying SGA neonates was higher for Hadlock compared with INTERGROWTH-21st standard (41.7 vs. 24.5%); AUC (95% CI) were 0.69 (0.65-0.73) and 0.62 (0.58-0.65), respectively. Both standards were comparable in predicting the composite adverse neonatal outcomes; AUC (95% CI) were 0.52 (0.50-0.53) and 0.52 (0.50-0.54), respectively; p = .28.Conclusions: The Hadlock standard had a moderate but higher discriminatory ability for predicting neonatal SGA compared to the INTERGROWTH-21st project standard. However, the two standards were poor predictors of early adverse neonatal outcomes.Rationale: The Intergrowth-21st project was recently introduced with the goal of providing a universal benchmark for comparing growth across different ethnicity. We performed a prospective cohort study to compare the Intergrowth-21st standard with the commonly used Hadlock standard for predicting pregnancies at risk for neonatal SGA and adverse outcomes. Hadlock fetal growth standard is moderately superior at predicting neonatal SGA compared to the Intergrowth-21st standard. Both standards are poor at predicting adverse neonatal outcomes. These findings, however, need further validation.

Obesity as a Predictor of Delayed Lactogenesis II.

BACKGROUND: Lactogenesis II is the onset of copious milk production. A delay in this has been associated with an increased risk of formula supplementation and early cessation of breastfeeding. Prepregnancy obesity has also been associated with decreased breastfeeding rates and early cessation. Research aim: This study aimed to evaluate the effect of prepregnancy obesity on self-reported delayed lactogenesis II. METHODS: We conducted a prospective observational cohort study of 216 women with a singleton pregnancy and who planned to breastfeed. We compared the onset of lactogenesis II between women with a body mass index (BMI) < 30 kg/m2 and women with a BMI ≥ 30 kg/m2. Using multivariate logistic regression analyses, we assessed the relationship between maternal BMI and delay of lactogenesis II. RESULTS: The prevalence of delayed lactogenesis II among women with prepregnancy BMI < 30 kg/m2 and BMI ≥ 30 kg/m2 was 46.4% and 57.9%, respectively. Delayed lactogenesis II occurred more frequently among women who were obese at the time of delivery ( p < .05). After controlling for the covariates, age, prepregnancy BMI, and gestational weight gain were positively associated with delayed lactogenesis II. CONCLUSION: Prepregnancy obesity and excessive gestational weight gain are associated with an increased risk of delayed lactogenesis II. Women who are at risk for delay in lactogenesis II and early breastfeeding cessation will need targeted interventions and support for them to achieve their personal breastfeeding goals.