Outpatient cervical ripening and labor induction with low-dose vaginal misoprostol reduces the interval to delivery: a systematic review and network meta-analysis.

OBJECTIVE: Several systematic reviews and meta-analyses have summarized the evidence on the efficacy and safety of various outpatient cervical ripening methods. However, the method with the highest efficacy and safety profile has not been determined conclusively. We performed a systematic review and network meta-analysis of published randomized controlled trials to assess the efficacy and safety of cervical ripening methods currently employed in the outpatient setting. DATA SOURCES: With the assistance of an experienced medical librarian, we performed a systematic search of the literature using MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and ClinicalTrials.gov. We systematically searched electronic databases from inception to January 14, 2020. STUDY ELIGIBILITY CRITERIA: We considered randomized controlled trials comparing a variety of methods for outpatient cervical ripening. METHODS: We conducted a frequentist random effects network meta-analysis employing data from randomized controlled trials. We performed a direct, pairwise meta-analysis to compare the efficacy of various outpatient cervical ripening methods, including placebo. We employed ranking strategies to determine the most efficacious method using the surface under the cumulative ranking curve; a higher surface under the cumulative ranking curve value implied a more efficacious method. We assessed the following outcomes: time from intervention to delivery, cesarean delivery rates, changes in the Bishop score, need for additional ripening methods, incidence of Apgar scores <7 at 5 minutes, and uterine hyperstimulation. RESULTS: We included data from 42 randomized controlled trials including 6093 participants. When assessing the efficacy of all methods, 25 µg vaginal misoprostol was the most efficacious in reducing the time from intervention to delivery (surface under the cumulative ranking curve of 1.0) without increasing the odds of cesarean delivery, the need for additional ripening methods, the incidence of a low Apgar score, or uterine hyperstimulation. Acupressure (surface under the cumulative ranking curve of 0.3) and primrose oil (surface under the cumulative ranking curve of 0.2) were the least effective methods in reducing the time to delivery interval. Among effective methods, 50 mg oral mifepristone was associated with the lowest odds of cesarean delivery (surface under the cumulative ranking curve of 0.9). CONCLUSION: When balancing efficacy and safety, vaginal misoprostol 25 µg represents the best method for outpatient cervical ripening.

Water birth: a systematic review and meta-analysis of maternal and neonatal outcomes.

OBJECTIVE: This systematic review and meta-analysis aimed to conduct a thorough and contemporary assessment of maternal and neonatal outcomes associated with water birth in comparison with land-based birth. DATA SOURCES: We conducted a comprehensive search of PubMed, EMBASE, CINAHL, and gray literature sources, from inception to February 28, 2023. STUDY ELIGIBILITY CRITERIA: We included randomized and nonrandomized studies that assessed maternal and neonatal outcomes in patients who delivered either conventionally or while submerged in water. METHODS: Pooled unadjusted odds ratios with 95% confidence intervals were calculated using a random-effects model (restricted maximum likelihood method). We assessed the 95% prediction intervals to estimate the likely range of future study results. To evaluate the robustness of the results, we calculated fragility indices. Maternal infection was designated as the primary outcome, whereas postpartum hemorrhage, perineal lacerations, obstetrical anal sphincter injury, umbilical cord avulsion, low Apgar scores, neonatal aspiration requiring resuscitation, neonatal infection, neonatal mortality within 30 days of birth, and neonatal intensive care unit admission were considered secondary outcomes. RESULTS: Of the 20,642 articles identified, 52 were included in the meta-analyses. Based on data from observational studies, water birth was not associated with increased probability of maternal infection compared with land birth (10 articles, 113,395 pregnancies; odds ratio, 0.93; 95% confidence interval, 0.76-1.14). Patients undergoing water birth had decreased odds of postpartum hemorrhage (21 articles, 149,732 pregnancies; odds ratio, 0.80; 95% confidence interval, 0.68-0.94). Neonates delivered while submerged in water had increased odds of cord avulsion (10 articles, 91,504 pregnancies; odds ratio, 1.75; 95% confidence interval, 1.38-2.24) and decreased odds of low Apgar scores (21 articles, 165,917 pregnancies; odds ratio, 0.69; 95% confidence interval, 0.58-0.82), neonatal infection (15 articles, 53,635 pregnancies; odds ratio, 0.64; 95% confidence interval, 0.42-0.97), neonatal aspiration requiring resuscitation (19 articles, 181,001 pregnancies; odds ratio, 0.60; 95% confidence interval, 0.43-0.84), and neonatal intensive care unit admission (30 articles, 287,698 pregnancies; odds ratio, 0.56; 95% confidence interval, 0.45-0.70). CONCLUSION: When compared with land birth, water birth does not appear to increase the risk of most maternal and neonatal complications. Like any other delivery method, water birth has its unique considerations and potential risks, which health care providers and expectant parents should evaluate thoroughly. However, with proper precautions in place, water birth can be a reasonable choice for mothers and newborns, in facilities equipped to conduct water births safely.

Adverse maternal outcomes associated with major fetal malformations after singleton live birth.

BACKGROUND: Major fetal malformations complicate 2% to 5% of live births. It is unclear what effect fetal malformations have on severe maternal morbidity. OBJECTIVE: This study aimed to compare maternal outcomes between individuals with a fetus with major or minor fetal malformations and those with a fetus without major or minor fetal malformations. STUDY DESIGN: This was a secondary analysis of the Consortium on Safe Labor database. Our study was limited to the current analysis of pregnant individuals with a singleton live birth. Major fetal malformations based on the Centers for Disease Control and Prevention's criteria were defined. Fetal malformations that did not meet the criteria for major fetal malformations were categorized as minor fetal malformations. Our primary maternal outcome was severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Missing values were imputed by multiple imputation using the k-nearest neighbor imputation method. Poisson regression with robust error variance was used to obtain adjusted relative risks with 95% confidence intervals, controlling for confounders. RESULTS: Of 216,881 deliveries, there were 201,860 cases (93.1%) with no congenital malformation, 12,106 cases (5.6%) with minor fetal malformations, and 2845 cases (1.3%) with major fetal malformations. Compared with individuals with no fetal malformation, those with major fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.2%; adjusted relative risk, 1.51; 95% confidence interval, 1.07-2.12), postpartum hemorrhage (3.6% vs 6.9%; adjusted relative risk, 1.76; 95% confidence interval, 1.50-2.06), preeclampsia (5.1% vs 8.3%; adjusted relative risk, 1.48; 95% confidence interval, 1.31-1.67), and cesarean delivery (26.7% vs 42.3%; adjusted relative risk, 1.51; 95% confidence interval, 1.45-1.58). Compared with individuals with no fetal malformation, those with minor fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.4%; adjusted relative risk, 1.73; 95% confidence interval, 1.48-2.02), maternal death (0.01% vs 0.03%; adjusted relative risk, 4.50; 95% confidence interval, 1.18-17.19), postpartum hemorrhage (3.6% vs 6.1%; adjusted relative risk, 1.54; 95% confidence interval, 1.41-1.68), preeclampsia (5.1% vs 8.6%; adjusted relative risk, 1.50; 95% confidence interval, 1.41-1.60), superimposed preeclampsia (1.2% vs 2.4%; adjusted relative risk, 1.25; 95% confidence interval, 1.14-1.38), cesarean delivery (26.7% vs 39.6%; adjusted relative risk, 1.38; 95% confidence interval, 1.35-1.41), chorioamnionitis (3.0% vs 4.7%; adjusted relative risk, 1.41; 95% confidence interval, 1.29-1.53), and postpartum endometritis (0.6% vs 1.0%; adjusted relative risk, 1.58; 95% confidence interval, 1.31-1.90). CONCLUSION: Major and minor congenital fetal malformations are independent risk factors for severe maternal morbidity and other pregnancy complications.

The Effectiveness of Pap and Visual Inspection With Acetic Acid (VIAA) Tests in Cervical Dysplasia Screenings During the COVID-19 Pandemic.

Objective This study was aimed at analyzing the validity and reliability of the Papanicolaou (Pap) test and visual inspection with acetic acid (VIAA) tests for cervical dysplasia screenings during the COVID-19 pandemic. Material and methods This was a retrospective study of patients 21 years or older seen at the Luis Negreiros Primary Care Center in Lima, Peru between 2020 and 2021, who underwent cervical dysplasia screening (Pap or VIAA). Relevant information regarding patient age, date of service, and Pap and VIAA results were collected. Parallel form reliability was analyzed with chi-square tests, and phi, contingency and Cramer's V coefficients. The validity of these tests was analyzed through the calculation of the sensitivity, specificity, and positive and negative predictive values with confidence intervals. A p-value less than 0.05 indicated statistical significance. Results From 4,503 records, the sensitivity, specificity, and positive and negative predictive values for Pap were 0.87 (0.81-0.92), 1.0 (1.0-1.0), 1.0 (1.0-1.0) and 0.99 (0.98-0.99), respectively, and those for VIAA were 0.22 (0.14-0.31), 0.10 (0.10-0.10), 0.53 (0.38-0.69) and 0.10 (0.10-0.10), respectively. Test validity varied slightly according to patient age and the year of testing. The correlation, although significant, was inverse; chi-square = 39.18, p <0.001, phi = -0.60, contingency = 0.51 and Cramer's V = -0.59. Conclusion The validity and reliability of Pap testing and VIAA for cervical dysplasia screening significantly decreased during the COVID-19 pandemic. The correlation between these tests, although significant, was inverse. More larger-scale studies are needed to confirm these findings and understand the reasons underlying the decreased effectiveness of these tests.

Birthweight and Apgar at 5 minutes of life for the prediction of severe neonatal outcomes in preterm prelabor rupture of membranes.

OBJECTIVE: The aim of our study was to investigate the predictive accuracy of clinical variables available after delivery for severe neonatal outcomes (SNO) in pregnancies complicated by PPROM. MATERIALS AND METHODS: This was a secondary analysis of a prospective cohort of pregnancies complicated by PPROM. We included expectant mothers from 13-46 years of age who were between 23 and 36 6/7 weeks of gestation. We excluded multiple gestations, complex fetal anomalies, those with fetal demise and outborn infants. Our primary outcome was a composite of SNO (respiratory distress syndrome, necrotizing enterocolitis, Intra-ventricular hemorrhage, sepsis, and death). The variables assessed where gestational age at delivery, birthweight, Apgar score at 5 min of life, Apgar <7 at 5 min of life, small for gestational age, sex, umbilical artery pH, and mode of delivery. Logistic regression was performed to evaluate the predictive accuracy of each of these variables. Stepwise multivariable logistic regression was utilized to assess the effect of variables with univariate analysis p value <.10 and those baseline characteristics with a statistically significant association with our composite score. RESULTS: We included 108 infants. SNO was diagnosed in 44 (41%) neonates. The Apgar score at 5 min (AUC = 0.89; p= <.001), the birthweight (AUC = 0.88; p= <.001), gestational age at delivery (AUC = 0.87; p= <.001), and the Apgar score < 7 at 5 min (AUC = 0.73; p= <0.001) were statistical significant predictors of SNO. Sex (p=.15), mode of delivery (p=.15), umbilical artery Ph (p=.28), SGA (p=.85) were not statistically significant predictors of SNO. After stepwise multivariable logistic regression only the Apgar at 5 min and birth weight remained statistically significant predictors for SNO (AUC = 0.94). CONCLUSIONS: In pregnancies complicated by PPROM the birthweight and the Apgar at 5 min of life are accurate predictors of a composite score of SNO. We acknowledge the need for larger and more diverse studies to corroborate our findings. BRIEF RATIONALE: We assessed the predictive accuracy of clinical variables available after delivery for severe neonatal outcomes in pregnancies complicated by PPROM. We found that the birthweight and the Apgar score at 5 min were accurate predictors of such outcomes in this population. Our results may aid providers in the counseling of premature infants born after PPROM.

Risk of preterm birth and neonatal outcomes after cerclage placement in triplet pregnancies.

BACKGROUND: The number of triplet pregnancies in the United States has increased significantly. Perinatal morbidity and mortality are higher in these pregnancies mainly due to higher preterm birth rates. Interventions to decrease the risk of preterm delivery in this population are needed. Evidence regarding cerclage placement in triplets is limited. We performed a population-based, retrospective cohort study to study the risk of preterm birth and neonatal outcomes after cerclage placement in triplet pregnancies. METHODS: All U.S. triplet deliveries from 2006 to 2013 with risk factors for cervical insufficiency were selected, excluding cases with indicated preterm delivery. Cases were categorized according to cerclage placement status. The risk of preterm birth and adverse neonatal outcomes were calculated using propensity score analysis, generalized linear, and logistic regression models. RESULTS: From ∼33 million deliveries, 43,000 were triplets, and 7308 fulfilled eligibility criteria. There was no difference in the gestational age at delivery between the cerclage and noncerclage groups, aOR (95% CI) = 1.0(0.9-1.0). The difference between the risk of preterm delivery at <34 weeks and <32 weeks was not statistically significant. The risk of the composite outcome of neonatal complications was higher in the cerclage compared to the noncerclage group, aOR (95% CI) = 1.5 (1.1-2.2). CONCLUSIONS: Cerclage placement in triplet pregnancies does not appear to decrease preterm birth rates and seems to increase the risk of neonatal complications.

Detection of small for gestational age in preterm prelabor rupture of membranes by Hadlock versus the Fetal Medicine Foundation growth charts.

OBJECTIVE: The primary outcome was to compare the diagnostic accuracy of neonatal small for gestational age (SGA) by the Hadlock and Fetal Medicine Foundation (FMF) charts in our cohort, followed by the ability to predict composite severe neonatal outcomes (SNO) in pregnancies with preterm prelabor rupture of membranes (PPROM). METHODS: This study was a secondary analysis of a prospective cohort of pregnancies with PPROM from 2015 to 2018, from 23 to 36 completed weeks of gestation. Sensitivity, specificity, and positive and negative predictive values for the primary and secondary outcomes of the Hadlock and FMF fetal charts were calculated. The discriminatory ability of each chart was compared using the area under the receiver's operating curves of clinical characteristics. RESULTS: Of the 106 women who met the inclusion criteria, 48 (45%) were screened positive using the FMF fetal growth chart and 22 (21%) were screened positive using the Hadlock chart. SGA was diagnosed in 12 infants (11%). Both fetal growth charts had comparable diagnostic accuracies and were statistically significant predictors of SGA (Hadlock: area under the receiver operating characteristic curves [AUC], 0.76, risk ratio [RR], 7.6, 95% confidence interval [CI], 2.5-23; and FMF: AUC, 0.76 RR, 13.3 95%CI 1.8-99.3). Both growth standards were poor predictors of SNO. CONCLUSION: The Hadlock and FMF fetal growth charts have a similar accuracy to predict SGA in pregnancies complicated by PPROM. The FMF fetal growth chart may result in a 2-fold increase in positive screens, potentially increasing fetal surveillance.

Uterine artery pulsatility index for the prediction of obstetrical complications in preterm prelabor rupture of membranes.

INTRODUCTION: Abnormal uterine artery Doppler studies have been associated with an increased risk of preeclampsia, fetal growth restriction (FGR), placental abruption, and fetal demise. These obstetrical complications can affect pregnancies with preterm prelabor rupture of membranes (PPROM). Therefore, our objective was to assess the prediction accuracy of the uterine artery pulsatility index (UtAPI) to detect these complications in pregnancies with PPROM. MATERIALS AND METHODS: This was a prospective study of pregnancies complicated by PPROM from October 2015 to May 2018. We included mothers aged 13-46 years old with singleton pregnancies from 23 to 36 + 6 weeks with PPROM. Those without UtAPI measurements and complex fetal anomalies were excluded. Our primary outcome was a composite of obstetrical complications, defined as having one or more of the following: gestational hypertension or preeclampsia, placenta abruption, FGR, or fetal demise. The UtAPI was obtained at the time of enrollment. Logistic regression models with receiver operating curves were used to determine the predictive value of the UtAPI for obstetrical complications. A p value of <.05 was considered significant. RESULTS: A total of 103 patients met inclusion criteria, of those 37 (36%) developed an obstetrical complication (FGR = 22 (21.5%); preeclampsia or gestational hypertension = 9 (9%); placental abruption = 8 (8%); fetal demise = 1 (1%)). Six mothers had more than one complication. The UtAPI was not a statistically significant predictor of a composite of obstetrical complications (AUC = 0.61; p = .07) or for any of the individual complications studied. CONCLUSIONS: The UtAPI appears to have limited clinical value for the prediction of obstetrical complications previously associated with abnormal uterine artery Doppler indices in pregnancies with PPROM. Larger and more diverse studies are needed to corroborate our findings. BRIEF RATIONALE: An accurate prediction for adverse outcomes in patients with PPROM may help identify those that may benefit from increased surveillance protocols.

Risk factors for cervical ectopic pregnancy.

OBJECTIVE: To evaluate risk factors for cervical ectopic pregnancies. METHODS: Retrospective, quasi-experimental case-control study of cervical ectopic pregnancy (CEP) cases from 2000-2013. Two groups were selected as controls, patients with tubal ectopic (TEP) and intrauterine pregnancies (IUP) without a history of TEP, matched by year of pregnancy and randomly sampled in a 1:3 case-control ratio per each study group. RESULTS: 21 cases were identified and 126 controls included, 63 TEP and IUP each. A binary logistic regression model was used to analyze whether statistically significant preceding factors from a bivariate analysis could predict CEP. Compared to patients with IUP, CEP patients had a higher history of elective abortions, D&C and cervical excisional procedures, with a high effect size (>0.7). Compared to patients with TEP, CEP patients had a higher history of D&C and cervical excisional procedures, with a high effect size (>.7). The risk of CEP was significantly higher with a prior history of D&C compared to an IUP (aOR 1.4; 95% CI, 1.1-9.1; p=0.04) and a TEP (aOR 6.1; 95% CI, 1.8-21.2; p=0.04). CONCLUSION: D&C is a strong risk factor for CEP when compared to pregnancies in other locations. These findings confirm previous associations described in case series.

Outcomes in subsequent pregnancies after wedge resection for interstitial ectopic pregnancy: a retrospective cohort study.

OBJECTIVE: The objective of this study is to evaluate pregnancy outcomes in patients with a history of wedge resection for interstitial ectopic pregnancy (WRIEP). METHODS: Retrospective cohort study of pregnancies with a history of WRIEP from 2000 to 2013 at two inner city hospitals in Detroit, MI. Pregnant-matched controls (1:3) were selected and included patients with history of surgically treated tubal ectopic pregnancy and delivered patients without history of ectopic pregnancy. Pregnancy outcomes, including a composite, were compared among the groups. RESULTS: Eighty-three cases of interstitial pregnancy were identified. Sixty-three (75.9%) underwent WRIEP from which 19 (30.2%) had a subsequent pregnancy and 11 (57.9%) carried it ≥20 weeks. No difference in subsequent pregnancy outcomes including the composite was found among patients with prior WRIEP and patients with history of surgically treated tubal ectopic pregnancy except for a longer interpregnancy interval. Compared with delivered patients without a history of ectopic pregnancy, no difference in late obstetric outcomes was found including the composite, gestational age at delivery in weeks (38.2 versus 38.1, p = .955), preterm delivery rate (30% versus 21%, p = .674), and proportion of term vaginal (40% versus 52%, p = .721) or cesarean deliveries (60% versus 30%, p = .137). The most common indication for cesarean among patients with a history of WRIEP was a history of such (5/6, 83.3%) and there were no cases of abnormal placentation. CONCLUSION: Findings suggest that a history of WRIEP is not associated with increased risk of adverse pregnancy outcomes.

Risk of Expectant Management and Optimal Timing of Delivery in Low-Risk Term Pregnancies: A Population-Based Study.

OBJECTIVE: The benefits of the 39-week rule have been questioned and concerns of increased stillbirth after adoption of this rule have been raised. Whether expectant management risks outweigh the benefits of awaiting 39 weeks has not been studied. We analyze the risks of expectant management at term and the optimal timing for delivery. STUDY DESIGN: All U.S. nonanomalous singleton term deliveries in 2013 were selected, excluding diabetes/hypertension, and low birth weight. Maternal/neonatal complications and stillbirth/infant death were compared among expectant management versus deliveries at each term gestational age. Logistic regression was used to calculate adjust odds ratios of complications according to delivery plan at each gestational age. RESULTS: From approximately 3 million deliveries, maternal complications during expectant management were lower at early term, and became higher at 39 weeks, relative risk [RR] (95% confidence interval [CI]) = 1.18 (1.16-1.19). Neonatal complications during expectant management were lower during early term, and became higher at ≥39 weeks, RR (95% CI) = 1.09 (1.08-1.09). The risk of perinatal mortality in the expectant management group was lower during early term, and became higher at ≥39 weeks, 18.93 (17.83-20.10) versus 17.37 (16.61-18.16), p = 0.010. CONCLUSION: Complications during expectant management occurring while awaiting full term do not outweigh the benefits of better outcomes from reaching 39 weeks. However, extending beyond 39 weeks may put these pregnancies at an increased risk.

Racial/ethnic disparities in magnesium sulfate neuroprotection: a subgroup analysis of a multicenter randomized controlled trial.

OBJECTIVE: Despite known racial disparities in obstetrics, as well as differences in magnesium pharmacodynamics according to race, the effect of race/ethnicity in magnesium sulfate (MgSO4) use during pregnancy has not been studied. Whether some mothers are at increased risk of side effects, or infants at decreased neuroprotective effects is unknown. We analyze the effect of race/ethnicity in maternal/infant outcomes after MgSO4 neuroprotection. STUDY DESIGN: Subgroup analysis of a multicenter clinical trial (BEAM trial) where pregnant women at risk of preterm birth were randomized to either MgSO4 or placebo. For this study, nonanomalous singleton pregnancies were studied. The effect of race in maternal/neonatal outcomes after MgSO4 was analyzed with Breslow-Day and multifactorial ANOVA. Logistic regression was used to calculate odds ratios (OR) of complications according to race. RESULTS: 922 MgSO4 and 972 placebo cases were included (45.0% African-American, 36.2% Caucasian, 17.8% Hispanics, and 1.0% Asians). Interaction analysis showed a significant effect of race/ethnicity (p = .043). Hispanics presented the highest frequency (88.3%, p < .001), as well as the highest odds of MgSO4 side effects [OR(95%CI) = 6.6 (1.3-33.8)]. CONCLUSION: Hispanics present increased risk of magnesium toxicity compared to other racial/ethnic groups. Whether specific racial/ethnic groups require closer surveillance for early signs of magnesium toxicity needs to be further explored.

Maternal side effects & fetal neuroprotection according to body mass index after magnesium sulfate in a multicenter randomized controlled trial.

OBJECTIVE: Evidence supports the need of dose-adjustment of several drugs according to body mass index (BMI) to prevent toxicity in the underweight, and ensure efficacy in obese women. However, for MgSO4 neuroprotection, the effect of BMI on maternal toxicity and fetal neuroprotection is understudied. We analyze the effect of BMI on maternal/infant outcomes after MgSO4. METHODS: Secondary analysis of a clinical trial that studied MgSO4 neuroprotection. Maternal side effects, magnesium cord levels, and offspring cerebral palsy/death were analyzed along BMI strata using ANOVA and chi-square test. Logistic regression was used to calculate adjusted odds ratios according to the treatment and BMI, using nonobese that received placebo as reference. Interaction analyses were performed to validate differential efficacy of BMI. RESULTS: From 2241 women, more side effects and higher magnesium cord levels were seen in underweight women (p = 0.05). MgSO4 neuroprotection was effective in the non-obese (p = 0.02), but not in obese women (p = 1.00). In multivariate analyses, MgSO4 significantly reduced cerebral palsy only in nonobese women. Interaction analyses showed the moderator effect of BMI (p = 0.169). Increasing MgSO4 dose in obese mothers may ensure neuroprotective efficacy without representing increased maternal risks. Considering costs of studying this association, current analysis may form the basis for reasonable practice.

A brief history of fetal echocardiography and its impact on the management of congenital heart disease.

Congenital heart disease (CHD), the most common congenital malformation, is associated with adverse outcome. Development of fetal echocardiography has made prenatal diagnosis of CHD a reality, and in the process revolutionized its management. This historical review briefly narrates this development over the decades focusing on the emergence of the primary modalities of fetal echocardiography comprised of the time-motion mode, two-dimensional B-mode, spectral Doppler, color Doppler, and three- and four-dimensional cardiac imaging. Collaboration between clinicians and engineers has been central to these advances. Also discussed are the accuracy and impact of fetal echocardiography on the management of CHD, and especially its role in the prenatal diagnosis of critical CHD in individualizing the management and improving the outcome. Despite these advances, most cases of CHD are not identified prenatally, emphasizing the continuing need for further technological and educational innovation and improvement.

Contemporary epidemiology and novel predictors of uterine rupture: a nationwide population-based study.

PURPOSE: In spite of several policies aiming to decrease cesarean rates and related complications such as uterine rupture, data show that uterine rupture and associated morbidity are increasing along the years. Whether previously unidentified risk factors are currently playing an important role on these trends is unknown. We analyze current risks of uterine rupture and main preceding factors from more recent years compared to former data. METHODS: All uterine rupture cases in the US from 2011-2012 were selected, with matched non-uterine rupture cases selected as controls. Variables considered for analysis included demographics, maternal morbidity, and obstetric complications. Likelihood forward selection was used to identify main risk factors of uterine rupture. Medians of main factors identified were used to simulate groups at risk and calculate odds ratios of uterine rupture. RESULTS: From ~8 million births, 1925 presented uterine rupture. In patients with no prior cesarean delivery, multiple gestation, chronic hypertension and chorioamnionitis presented the highest odds of uterine rupture, with the combination of these factors increasing the odds of rupture 59 times (~1%). In women with prior cesarean delivery, induction/augmentation and chorioamnionitis were the most significant predictors, with the combination increasing the odds 33 times (~3%). CONCLUSIONS: Despite policies implemented and changes in clinical practice, uterine rupture remains an important issue. Previously unidentified risk factors are playing now an important role, information that should be considered during patient counseling and clinical practice. Combinations of some of these factors may increase the risk of uterine rupture significantly enough to modify clinical care.

Is mean platelet volume a better biomarker in pre-eclampsia?

AIM: Platelet activation and destruction is a well recognized feature of pre-eclampsia, but the current literature is contradictory regarding the role of mean platelet volume (MPV) in the diagnosis of this condition. We investigated whether MPV, compared with other routine laboratory markers such as platelet count, is a more significant biomarker of pre-eclampsia, giving special attention to the intrapartum period. METHODS: Biochemical and hematological markers along pregnancy including MPV were compared retrospectively between pre-eclampsia and matched controls. Laboratory marker data were compared using independent t-test. A logistic regression model was used to compare the strength of the associations of MPV and other routine markers such as platelet count with pre-eclampsia. Receiver operating characteristic curves were plotted. RESULTS: There were a total of 150 cases of pre-eclampsia and 297 controls. In the pre-eclampsia group, there were 60 cases of mild pre-eclampsia (40.0%); 84, severe (56.0%); and six of eclampsia (4.0%). MPV was significantly higher in the pre-eclampsia than in the control group (11.3 ± 1.0 vs 10.1 ± 0.8 fL, P = 0.002). On multivariate analysis, MPV was the only statistically significant biomarker of pre-eclampsia (OR, 4.5; 95%CI: 1.5-13.7), and severe pre-eclampsia (OR, 6.2; 95%CI: 1.6-24.6); performing superiorly to platelet count. CONCLUSIONS: Mean platelet volume is a more significant biomarker of pre-eclampsia. It is more significantly associated with this condition than other routinely measured laboratory markers such as platelet count. MPV is routinely obtained on complete blood cell count and its utilization in the assessment of pre-eclampsia in a clinical setting should continue to be evaluated.

Contemporary analysis of maternal and neonatal morbidity after uterine rupture: A nationwide population-based study.

AIM: Uterine rupture is a rare but feared perinatal event. Despite abundant research and changes to guidelines implemented to reduce this complication, evaluation of whether uterine rupture still engenders significant maternal/neonatal morbidity has not been conducted. We analyzed recent cases of maternal/neonatal morbidity after uterine rupture. METHODS: Deliveries complicated by uterine rupture from 2011 to 2012 in the United States were selected. Comparison cases without uterine rupture were used as controls. Measures of maternal/neonatal complications were compared with χ2 test, and relative risks were calculated. Logistic regression was used to identify the most significant complications. P < 0.05 indicated statistical significance. RESULTS: From 7 922 016 births, 1925 cases of uterine rupture and 3765 controls were identified. Regression models retained four maternal outcomes; blood transfusion was the most common (~15%) and unplanned hysterectomy had the highest odds (~97-fold). For newborns, the model retained three measures of morbidity; neonatal intensive care unit admission was the most common (~35%) and seizures had the highest odds (~20-fold). CONCLUSIONS: Despite efforts to reduce complications, mothers remain at significant risk of unplanned hysterectomy and intensive care unit admission. Neonates are at sizeable risk for neonatal intensive care unit admission and seizures, recognized markers of long-term neurobehavioral abnormality. Uterine rupture remains a major risk for mothers and babies.

Morbid obesity and outcome of ectopic pregnancy following capped single-dose regimen methotrexate.

PURPOSE: Evaluate whether morbid obesity influenced resolution, number of doses or ultimately surgical management of tubal ectopic pregnancy (TEP) when treated with single-dose regimen methotrexate (SDR-MTX) capped at 100 mg. METHODS: Retrospective cohort study of patients with a diagnosis of TEP who underwent MTX treatment from 2000 to 2013. Patients were excluded if initial ß-hCG <1000 mIU/mL, did not have ß-hCG follow-up or were not treated with SDR-MTX. Per protocol, dose was administered at 50 mg/m2 with a capped maximum of 100 mg. Patients were divided based on their BMI (<40 and ≥40 kg/m2). Demographic variables, ß-hCG before treatment, maximum diameter of ectopic size, embryonic heart tones, decrease of ß-hCG, need for additional MTX doses and surgery despite treatment were recorded and compared among the groups. RESULTS: 151 women were included in the study, 89.4% (135/151) non-morbidly obese and 10.6% (16/151) morbidly obese. No differences in age distribution, ethnicity, pre-treatment presence of embryonic heart tones, maximum diameter of ectopic size ≥35 mm and ß-hCG ≥5000 mIU/ml were found. Following treatment, the proportion of patients with at least an 80% decrease in their ß-hCG levels or need for surgery were similar, however, morbidly obese patients were significantly more likely [11/134 vs. 5/16, OR 5.1 (1.5-17.3, p = 0.015)] to require an additional MTX dose. CONCLUSION: Among patients with TEP, morbidly obese patients were five times more likely to require an additional dose compared to non-morbidly obese when SDR-MTX capped at 100 mg was used for medical management.