Impact on Neonatal Outcomes with Late Preterm and Early Term Delivery in Women with Diabetes.

OBJECTIVE: Late preterm and early term deliveries are common in pregnancies complicated by diabetes due to higher rates of obstetric complications including increased stillbirth risk. However, early delivery is associated with multiple neonatal adverse outcomes, which may be further increased by maternal diabetes. We examined whether there is an additive effect on adverse neonatal outcomes in the setting of maternal diabetes in the late preterm and early term periods. STUDY DESIGN: This was a retrospective cohort study of women with a singleton, nonanomalous pregnancy delivering at a single academic medical center in the late preterm (340/7-366/7 weeks) or early term (370/7-386/7 weeks) period between 2010 and 2019. Women were categorized by diabetes status: no diabetes, type 1 (T1DM), type 2 (T2DM), or gestational diabetes (GDM). Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for risk of both mild and severe composite neonatal outcome with delivery in the late preterm or early term period using pregnancies without diabetes as the referent. RESULTS: A total of 8,072 pregnancies were included with T1DM, T2DM, and GDM complicating 1.8, 5.6, and 9.9% of pregnancies, respectively. Expected demographic differences were seen among groups including higher rates of non-Hispanic Black race, chronic hypertension, and higher body mass index in women with T2DM. The probability of severe composite adverse neonatal outcome was significantly increased in women with T1DM in the late preterm (aOR: 4.4; CI: 2.4-8.1) and early term (aOR: 1.6; CI: 1.1-2.3) periods, largely driven by the need for mechanical ventilation. The mild composite outcome was increased among all women with diabetes with early term delivery but highest in women with T1DM. CONCLUSION: Pregnancies complicated by diabetes, particularly T1DM, have higher rates of neonatal adverse outcomes independent of gestational age at delivery, which is an important consideration when late preterm or early term delivery is planned. KEY POINTS: · Diabetes in pregnancy increases risk of early delivery.. · Adverse neonatal outcomes are higher with diabetes, especially T1DM.. · Adverse neonatal outcomes are independent of gestational age..

Evaluating Prenatal Diagnostic Imaging for Micrognathia: A Systematic Review and Meta-Analysis.

OBJECTIVE: Studies evaluating the ability to diagnose and accurately predict the severity of micrognathia prenatally have yielded inconsistent results. This review aimed to evaluate reliability of prenatal diagnostic imaging in the diagnosis and characterization of micrognathia. DESIGN: Systematic review and meta-analysis. SETTING: Studies with a prenatal diagnosis of micrognathia via ultrasound with a confirmatory postnatal examination were included. Prenatal severity was defined with and without mandibular measurements. Extent of airway obstruction at birth was defined by level of intervention required. Meta-analyses of proportions and relative risk were performed. PATIENTS: A total of 16 studies with 2753 neonates were included. MAIN OUTCOME MEASURES: Primary outcome was the efficacy of characterizing the degree of micrognathia on prenatal imaging as it relates to respiratory obstruction at birth. Secondary outcome was the accuracy of prenatal diagnosis with the utilization of mandibular measurements versus without. RESULTS: Performing meta-analysis of proportions, the proportion of missed prenatal diagnoses of micrognathia made without mandibular measurements was 11.62% (95%CI 2.58-25.94). Utilizing mandibular measurements, the proportion of cases missed were statistically lower (0.20% [95%CI 0.00-0.70]). Patients determined to have severe micrognathia by prenatal imaging did not have a statistically significant increase in risk for more severe respiratory obstruction at birth (RR 3.13 [95%CI 0.59-16.55], P = .180). CONCLUSION: The proportion micrognathia cases missed when prenatal diagnosis was made without mandibular measurements was over 1 in 10, with mandibular measures improving accuracy. This study highlights the need for a uniform objective criterion to improve prenatal diagnosis and planning for postnatal care.

Risk of Stillbirth in Pregnancies Complicated by Diabetes, Stratified by Fetal Growth.

OBJECTIVE: To compare stillbirth rates per week of expectant management stratified by birth weight in pregnancies complicated by gestational diabetes mellitus (GDM) or pregestational diabetes mellitus. METHODS: A national population-based retrospective cohort study of singleton, nonanomalous pregnancies complicated by pregestational diabetes or GDM was performed using national birth and death certificate data from 2014 to 2017. Stillbirth rates per 10,000 patients (stillbirth incidence at gestational age week/ongoing pregnancies-[0.5×live births at gestational age week]) were determined for each week of pregnancy from 34 to 39 completed weeks of gestation. Pregnancies were stratified by birth weight, categorized as having small-for-gestational-age (SGA), appropriate-for-gestational-age (AGA), or large-for-gestational-age (LGA) fetuses, assigned by sex-based Fenton criteria. Relative risk (RR) and 95% CI for stillbirth were calculated for each gestational age week compared with the GDM-related AGA group. RESULTS: We included 834,631 pregnancies complicated by either GDM (86.9%) or pregestational diabetes (13.1%) in the analysis, with a total of 3,033 stillbirths. Stillbirth rates increased with advancing gestational age for pregnancies complicated by both GDM and pregestational diabetes regardless of birth weight. Compared with pregnancies with AGA fetuses, those with both SGA and LGA fetuses were significantly associated with an increased risk of stillbirth at all gestational ages. Ongoing pregnancies at 37 weeks of gestation complicated by pregestational diabetes with LGA or SGA fetuses had respective stillbirth rates of 64.9 and 40.1 per 10,000 patients. Pregnancies complicated by pregestational diabetes had an RR of stillbirth of 21.8 (95% CI 17.4-27.2) for LGA fetuses and 13.5 (95% CI 8.5-21.2) for SGA fetuses compared with GDM-related AGA at 37 weeks of gestation. The greatest absolute risk of stillbirth was in pregnancies complicated by pregestational diabetes at 39 weeks of gestation with LGA fetuses (97/10,000). CONCLUSION: Pregnancies complicated by both GDM and pregestational diabetes affected by pathologic fetal growth have an increased risk of stillbirth with advancing gestational age. This risk is significantly higher with pregestational diabetes, especially pregestational diabetes with LGA fetuses.

Effect of Antibiotic Treatment of Amniotic Fluid Sludge.

BACKGROUND: Amniotic fluid sludge refers to the sonographic presence of echogenic, free-floating aggregates of debris located within the amniotic cavity near the internal cervical os of women with intact membranes. Clinically, it is independently associated with increased obstetric, infectious, and neonatal morbidity, including: short cervix, chorioamnionitis, and an increased risk of preterm birth. It is thought to be infectious in nature and has been described as an intrauterine bacterial biofilm. There is little evidence on the impact of treatment with antibiotics on outcome. OBJECTIVE: To determine whether outpatient antibiotics administered to women with amniotic fluid sludge would reduce preterm birth risk compared to no antibiotic treatment. MATERIALS AND METHODS: This was a retrospective cohort study of all patients diagnosed with amniotic fluid sludge by transvaginal sonography between 15 and 25 weeks' gestation in the outpatient ultrasound unit at a single academic center between 2010 and 2017. Patients were segregated according to whether they were treated with oral antibiotics at the time of diagnosis. Women with multiple gestation, fetal anomalies, preterm rupture of membranes prior to initial diagnosis of amniotic fluid sludge, and active preterm labor placenta previa and/or suspected accreta were excluded from analysis. Primary outcome of preterm birth at less than 37 weeks' gestation was compared by univariate and regression analysis to control for potential co-linear and/or confounding variables. Additional outcomes were compared by univariate analysis. RESULTS: A total of 181 patients were initially identified, and 97 patients met inclusion criteria. Of these patients, 51 were treated with oral antibiotics (46 azithromycin and 5 moxifloxacin), and 46 were not treated. The overall incidence of preterm birth at <37 weeks was 49.4 % (48 of 97) and preterm birth <28 weeks was 22.7% (22 of 97). There was no significant difference in preterm birth, either at <37 weeks (P = .47) or <28 weeks (P = .83) between the treated and untreated women. After adjusting for race, body mass index, tobacco use, cervical length, and preterm birth history, antibiotic treatment did not reduce the risk of preterm birth (adjusted odds ratio, 1.3; confidence interval, 0.77-1.9). No differences were seen in the incidence of preterm premature rupture of membranes (P = .94) or median latency from diagnosis to delivery (P = .47). Birthweight (P = .99), sepsis (P = .53), intraventricular hemorrhage (P = .95), and neonatal intensive care unit (NICU) admission (P = .08) were not affected by antibiotic treatment. Antibiotic treatment did not affect the incidence of either clinical or histologic chorioamnionitis (P = .92 and .14, respectively) or histologic stage 2-3 maternal or fetal inflammation (P = .94 and 0.58, respectively). Sonographic resolution of amniotic fluid sludge on first subsequent scan was seen in 34% of antibiotic-treated women and 43% of untreated women (P = .42). There was no difference in latency from diagnosis to delivery or mean gestational age at delivery according to whether sludge resolved or persisted at the first subsequent scan (P = .14 for each). CONCLUSION: Antibiotic treatment of amniotic fluid sludge is not associated with a reduction in premature birth. Likewise, antibiotic treatment of amniotic fluid sludge was not associated with improvement in other obstetric, neonatal, or pathologic variables. These findings suggest that the presumed infectious nature of sludge and subsequent adverse outcomes are not treated or improved by administration of azithromycin following midtrimester sonographic diagnosis.

Microcrystalline Cellulose and Crospovidone Identified in Placentas With Vaginal Misoprostol Use.

Misoprostol is a prostaglandin analog commonly used to induce termination of pregnancy. Clandestine home terminations complicate forensic fetal autopsy when a history of misoprostol use is withheld and the gross and histologic findings are sparse, as is often the case. One hundred thirty-two placentas with no vaginal misoprostol use, low-dose misoprostol use, and high-dose misoprostol use were reviewed for the presence, volume, and locations of microcrystalline cellulose and crospovidone, common tablet fillers in misoprostol tablets. Microcrystalline cellulose and/or crospovidone was identified in 0 (0%) of 88 cases with no vaginal administration or low-dose vaginal administration and 29 (66%) of 44 placentas with high-dose vaginal administration. When identified, microcrystalline cellulose and/or crospovidone is most commonly present on the maternal surfaces of the extraplacental membranes. The presence of microcrystalline cellulose and/or crospovidone was associated with smaller placental weight (Mann-Whitney U, P = 0.019). These fillers have a reasonable sensitivity for high-dose vaginal tablet use and are very specific. Although they are not diagnostic for misoprostol administration, they provide a finding that may prompt additional investigation into the nature of the vaginal tablet administered and the circumstances surrounding birth.

Impact of dosing schedule on uptake of neuroprotective magnesium sulfate.

Background: Preterm delivery <32-week gestation is associated with significant neurodevelopmental morbidity ranging from mild delay to profound disability. Several randomized trials have shown that magnesium sulfate (MgSO4) is an effective neuroprotectant, demonstrating reduced rates of cerebral palsy, death, and gross motor dysfunction for the neonate or infant. Dosing was not consistent among the major trials and the onus was placed on institutions by ACOG to develop and implement protocols with respect to MgSO4 as a neuroprotectant. A recent study demonstrated that MgSO4 exposure <12 h prior to delivery was associated with a decrease in CP compared to more remote exposure.Objective: To assess impact of dosing schedule on uptake of neuroprotective MgSO4 in patients delivering <32 weeks gestational age.Study design: A retrospective cohort study of all deliveries occurring <32 weeks' gestation at a single academic center between March-December 2014 and March-December 2015 was conducted. Institutional policy shifted in 2015 from MgSO4 bolus with continuous infusion based on the BEAM trial to a single bolus dose based on the PREMAG trial. Patients with preeclampsia, known fetal anomalies, and/or stillbirth were excluded from this analysis. Patients were identified through query of the Medical University of South Carolina Perinatal Information System (PINS) database with respect to whether or not they had received MgSO4 within 12 h of delivery. Chi-squared analysis was performed to compare the overall rate of MgSO4 exposure and MgSO4 exposure <12 h prior to delivery between groups. Fisher's exact test was used to evaluate maternal, obstetric, and neonatal variables among those receiving MgSO4 within 12 h of delivery in each cohort. Binary logistic regression analysis was performed to control for co-linear or potential confounding variables.Results: A total of 224 patients were identified, 115 delivered between March-December 2014 and 109 delivered between March-December 2015. With respect to MgSO4 exposure prior to delivery, 27 (23.5%) received MgSO4 in the 2014 cohort compared to 44 (40.4%) in the 2015 cohort (OR: 2.2, p < .01). Of those being exposed within 12 h of delivery, there were 16 (13.9%) maternal exposures in the 2014 cohort versus 28 (26.7%) in the 2015 cohort (OR: 2.15, p = .02). Of the 18 neonates delivered in 2014 there were four cases of grade III or IV intraventricular hemorrhage versus one case among the 36 neonates (2.7%) born in 2015 (0.04). This finding holds after controlling for race, preterm labor, gestational age, corticosteroid, birthweight, and indomethacin exposure.Conclusions: Dosing of neuroprotective MgSO4 according to PREMAG trial specifications was associated with a significantly greater percentage of patients having received neuroprotective magnesium at any point prior to delivery or within the 12 h prior to delivery when compared to dosing according to BEAM trial specifications.

Hyperthyroidism During Pregnancy: A Clinical Approach.

Hyperthyroidism is relatively uncommon during pregnancy. However, those caring for pregnant patients should be versed in the evaluation and management of hyperthyroidism, as there are potential maternal and fetal implications that are related to the disease and to treatment. The differential diagnosis of hyperthyroidism includes clinical and subclinical entities, as well as transient laboratory findings that are related to the pregnancy itself. The clinical management, including the indications for the use of thioamide or antithyroid medications, will be discussed in the context of pregnancy. Finally, considerations for the management of the postpartum and/or breastfeeding patient with hyperthyroidism will be reviewed.

Case Studies in Thyroid Dysfunction and Pregnancy.

This chapter represents a selection of 8 clinical scenarios that may commonly be encountered. They help summarize some of the literature and teaching points of the previous chapters. They are not meant to represent every possible presentation of thyroid disease, but rather to present common symptoms and findings that may aid a clinician in making a diagnosis or in selecting initial treatment.

Amniotic fluid embolism: historical perspective, pathophysiology and clinical management / Embolia de líquido amniótico: perspectiva histórica , fisiopatología y manejo clínico

Amniotic fluid embolism (hereafter, AFE) is a uniformly devastating event that is both unpredictable and unpreventable. Despite having been first described nearly 80 years ago, it remains a significant cause of maternal mortality worldwide. AFE is characterized by the triad of sudden hypoxia and hypotension, followed in most cases by coagulopathy. The diagnosis of AFE is clinical and prompt recognition and multi-disciplinary intervention essential. This paper seeks to review the history, pathophysiology, potential risk factors, strategies for identification and management, and outcomes of this unfortunate and storied obstetric emergency.

La embolia de líquido amniótico (ELA) es una ocurrencia devastadora, impredecible y no prevenible. A pesar de haber sido descrita por primera vez hace casi 80 años, todavía es causa significativa de mortalidad materna en el mundo. La ELA se caracteriza por la triada consistente en hipoxia súbita e hipotensión, seguida en la mayoría de casos por coagulopatía. El diagnóstico de la ELA es clínico, y es esencial su pronto reconocimiento y la intervención multidisciplinaria. Este artículo trata de revisar la historia, fisiopatología, factores de riesgo potenciales, estrategias para su identificación y manejo, así como los resultados de esta desafortunada y antigua emergencia obstétrica.

Rates of human papillomavirus vaccine uptake amongst girls five years after introduction of statewide mandate in Virginia.

BACKGROUND: The Commonwealth of Virginia enacted statewide school-entry human papillomavirus vaccine mandate in 2008 requiring all girls to receive the vaccine before starting the 6th grade. The mandate, one of very few in the country, has been in effect for 5 years. This study assesses the impact that it has had on the rates of human papillomavirus uptake. OBJECTIVE: The purpose of this study was to evaluate the uptake of the human papillomavirus vaccine among girls seeking well-child care 5 years after the introduction of a statewide mandate in Virginia in October 2008. STUDY DESIGN: This prospective cohort study used the Clinical Data Repository at the University of Virginia to identify girls 11-12 years old who was seen for well-child care from January to December 2014. Billing and diagnosis codes were used to establish human papillomavirus vaccine administration. Those girls who were identified through the Clinical Data Repository were then contacted by advance letter followed by a representative from the University of Virginia Center for Survey Research who invited the responsible parent or guardian to complete a 50-item telephone questionnaire. Questionnaire results were used to inform objective findings and to assess parental attitudes that were related to human papillomavirus vaccination. Findings were compared against those of Pierce et al (2013), who evaluated human papillomavirus vaccination levels in a similar cohort of patients in 2008, before mandate enactment, to assess relative change attributable to vaccine mandate. RESULTS: Nine hundred eight girls were identified through the Clinical Data Repository; 50.9% of the girls received at least 1 dose of human papillomavirus vaccine. White race and private insurance coverage were found to be associated negatively with human papillomavirus vaccine uptake (relative risk, 0.74 and 0.71; 95% confidence interval, 0.64-0.85 and 0.62-0.81, respectively). Black race and public insurance coverage were found to be associated positively with vaccine uptake (relative risk, 1.35 and 1.39; 95% confidence interval, 1.17-1.55 and 1.22-1.58, respectively). In comparison with the previous study, there has been no change in human papillomavirus vaccine uptake or distribution of uptake after the introduction of the statewide mandate for human papillomavirus vaccination. CONCLUSION: The statewide human papillomavirus vaccine mandate has had no impact on the overall rate of human papillomavirus vaccination, nor has it diminished the previously described racial or payer disparities in vaccine uptake in school-aged girls being seen for well-child care in the state of Virginia.