Risk of Postpartum Hemorrhage in Hypertensive Disorders of Pregnancy: Stratified by Severity.

OBJECTIVE: We aimed to determine the composite maternal hemorrhagic outcome (CMHO) among individuals with and without hypertensive disorders of pregnancy (HDP), stratified by disease severity. Additionally, we investigated the composite neonatal adverse outcome (CNAO) among individuals with HDP who had postpartum hemorrhage (PPH) versus did not have PPH. STUDY DESIGN: Our retrospective cohort study included all singletons who delivered at a Level IV center over two consecutive years. The primary outcome was the rate of CMHO, defined as blood loss ≥1,000 mL, use of uterotonics, mechanical tamponade, surgical techniques for atony, transfusion, venous thromboembolism, intensive care unit admission, hysterectomy, or maternal death. A subgroup analysis was performed to investigate the primary outcome stratified by (1) chronic hypertension, (2) gestational hypertension and preeclampsia without severe features, and (3) preeclampsia with severe features. A multivariable regression analysis was performed to investigate the association of HDP with and without PPH on a CNAO which included APGAR <7 at 5 minutes, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, seizures, neonatal sepsis, meconium aspiration syndrome, ventilation >6 hours, hypoxic-ischemic encephalopathy, or neonatal death. RESULTS: Of 8,357 singletons, 2,827 (34%) had HDP. Preterm delivery <37 weeks, induction of labor, prolonged oxytocin use, and magnesium sulfate usage were more common in those with versus without HDP (p < 0.001). CMHO was higher among individuals with HDP than those without HDP (26 vs. 19%; adjusted relative risk [aRR] 1.11, 95% CI 1.01-1.22). In the subgroup analysis, only individuals with preeclampsia with severe features were associated with higher CMHO (n = 802; aRR 1.52, 95% CI 1.32-1.75). There was a higher likelihood of CNAO in individuals with both HDP and PPH compared to those with HDP without PPH (aRR 1.49, 95% CI 1.06-2.09). CONCLUSION: CMHO was higher among those with HDP. After stratification, only those with preeclampsia with severe features had an increased risk of CMHO. Among individuals with HDP, those who also had a PPH had worse neonatal outcomes than those without hemorrhage. KEY POINTS: · Individuals with HDP had an 11% higher likelihood of CMHO.. · After stratification, increased CMHO was limited to those with preeclampsia with severe features.. · There was a higher likelihood of CNAO in those with both HDP and PPH compared to HDP without PPH..

Association of adverse outcomes with three-tiered risk assessment tool for obstetrical hemorrhage.

BACKGROUND: Guidelines promote stratification for the risk for postpartum hemorrhage among parturients, although the evidence for the associated differential morbidity among the groups remains inconsistent among published reports. OBJECTIVE: Using the California Maternal Quality Care Collaborative schema modified by the American College of Obstetrics and Gynecology, we compared the composite maternal hemorrhagic outcome and the composite neonatal adverse outcome among singletons who were categorized after delivery by the researchers as low-, medium-, or high-risk for postpartum hemorrhage. We hypothesized that the composite outcomes would be significantly different among the individuals in the different 3-tiered categories. STUDY DESIGN: This was a retrospective cohort study of all singleton parturients with a gestational age of at least 14 weeks who delivered at a single site within 1 year. The composite maternal hemorrhagic outcome included any of the following: estimated blood loss ≥1000 mL, use of uterotonics (excluding prophylactic oxytocin) or Bakri balloon, surgical management of postpartum hemorrhage, blood transfusion, hysterectomy, thromboembolism, admission to the intensive care unit, or maternal death. The composite neonatal adverse outcome included Apgar score <7 at 5 minutes, birth injury, bronchopulmonary dysplasia, intraventricular hemorrhage, neonatal seizure, sepsis, ventilation > 6 hrs., brachial plexus palsy, hypoxic-ischemic encephalopathy, or neonatal death. Multivariable Poisson regression models with robust error variance were used to estimate the adjusted relative risks with 95% confidence intervals. RESULTS: Of the 4544 deliveries in the study period, 4404 (96.7%) met the inclusion criteria, and among them, 1745 (39.6%) were categorized as low, 1376 (31.2%) as medium, and 1283 (29.1%) as high risk. Overall, 941 (21.4%) participants experienced the composite maternal hemorrhagic outcome with 285 (16.4%) of those being in the low-risk group, 319 (23.2%) in the medium-risk group, and 337 (26.3%) in the high-risk group. Among all parturients, 95.7% in the low-, 89.4% in the medium-, and 85.3% in the high-risk group neither had an estimated blood loss or a quantified blood loss ≥1000 mL nor were transfused. After multivariable adjustment and when compared with the low-risk group, there was a significantly higher risk for the composite maternal hemorrhagic outcome in the medium-risk group (adjusted relative risk, 1.23; 95% confidence interval, 1.05-1.43) and in the high-risk group (adjusted relative risk, 1.51; 95% confidence interval, 1.31-1.75). Overall, 366 newborns (8.4%) developed the composite neonatal adverse outcome with 76 (4.2%) in of those being in the low-risk group, 153 (11.3%) in the medium-risk group, and 140 (11.1%) in the high-risk group. After multivariable adjustment and when compared with the low-risk group, there were no significant differences in the composite neonatal adverse outcome in the medium- (adjusted relative risk, 1.27; 95% confidence interval, 0.97-1.68) or the high-risk group (adjusted relative risk, 1.29; 95% confidence interval, 0.98-1.68). CONCLUSION: Although 8 of 10 parturients categorized as high risk neither had blood loss ≥1000 mL nor underwent transfusion, the risk stratification provides information regarding the composite maternal hemorrhagic outcome.

Definitive vs palliative pelvic radiation for patients with newly diagnosed stage IVB cervical cancer treated with bevacizumab - An exploratory study.

Objective: Platinum-based chemotherapy and bevacizumab is the standard treatment for stage IVB cervical cancer. When metastases resolve, the benefit of radiating the primary tumor is unclear. We investigate the effect of pelvic radiation on PFS following chemotherapy and bevacizumab in stage IVB cervical cancer. Methods: This is a retrospective series of 29 patients with stage IVB cervical cancer treated with platinum-based chemotherapy and bevacizumab. 3 subgroups were evaluated: definitive pelvic radiation, palliative radiation, and no radiation. The primary outcome was the mean PFS. Progression was determined radiographically. Kaplan-Meier method and the log-rank test for equality analyzed OS and PFS. Results: The median OS was 38.4 months. 11 patients (38%) received definitive radiation, 9 (31%) received palliative and 9 (31%) received no radiation. 7/8 in the palliative group, 7/10 who received no radiation and all in the definitive group experienced progression. The median PFS was 7.5 months and not statistically different (p = 0.62). The median OS was not attained in the definitive group, was 23 months [19.6, -] for the palliative group and 19 months [24.9-45.4] for the no radiation group (p = 0.13). OS was higher in patients receiving definitive radiation vs all others (median OS survival not reached vs 6.6 months, p = 0.04). No difference in PFS between those receiving definitive radiation vs others (12 months vs 5.1 months p = 0.32). Conclusion: Definitive radiation is associated with improved survival among in stage IVB cervical cancer treated with chemotherapy and bevacizumab. This association could be due to treatment, patient, or disease factors associated with improved oncologic outcomes. In absence of higher-level data, shared decision-making with consideration for comorbidities and performance status should be employed.

Cesarean delivery at term for non-reassuring fetal heart rate tracing: risk factors and predictability.

OBJECTIVE: To delineate risk factors for adverse outcomes among those who underwent cesarean delivery (CD) for non-reassuring fetal heart rate tracing (NRFHT) and ascertain whether neonatal or maternal morbidity can be predicted accurately. METHODS: The Consortium on Safe Labor Database was utilized for this secondary analysis. Inclusion criteria were non-anomalous, singleton gestations between 37.0 and 41.6 weeks who underwent CD for NRFHT. Composite adverse neonatal outcomes (CANO) included Apgar <5 at 5 min, seizures, mechanical ventilation, sepsis, intraventricular hemorrhage, necrotizing enterocolitis or neonatal death. Composite adverse maternal outcomes (CAMO) included endometritis, blood transfusion, wound complication, admission to intensive care unit, thromboembolism, hysterectomy or death. Bivariable analysis and multivariable Poisson regression were used to identify risk factors independently associated with adverse outcomes. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for adverse outcomes. RESULTS: Of 228,438 births in the database, 7310 individuals (3.7%) met inclusion criteria. Among this cohort, CANO occurred 3.8% of the time. CANO was less common among people over 35 years (9.8% versus 18.4% p < .01) but was more common among those with at least high-school education (15.3% versus 11.2%; p < .01), varying by ethnicity (p < .01). CAMO occurred in 3.4% and was less common among those undergoing induction of labor (37.3% versus 49.4%; p < .01) and more common among those with clinical chorioamnionitis (8.4% versus 4.3%; p < .01). The area under the curve (AUC) for ROC curve to identify CANO was 0.63 implying a limited ability to predict neonatal adverse outcomes. The AUC for identifying women with maternal adverse outcomes was 0.69 also indicating a moderate prediction ability. CONCLUSIONS: Among singletons between 37 and 41 weeks who labored, the rate of CD for NRFHT was about 3.7% and among them CANO occurred in 3.8%. While risk factors for adverse neonatal outcomes following CD for NRFHT are identifiable, they do not suffice to predict them.

Prevalence and Risk Factors for New-Onset Hypertension in Labor.

OBJECTIVE: Little is known about prevalence, risk factors, rate of treatment, or adverse outcomes associated with intrapartum hypertension. Thus, our objective was to describe these findings. STUDY DESIGN: This was a retrospective study of laboring term gestations with no history of hypertensive disorders. Intrapartum blood pressures were reviewed, and women were subdivided based on blood pressures: normal (<140 mm Hg systolic and <90 mm Hg diastolic), mild hypertension (140-159 or 90-109), and severe hypertension (≥ 160 or ≥ 110). Groups were compared using chi-square test and analysis of variance. RESULTS: A total of 724 women were studied during 4 months: 248 (34%) had mild and 69 (10%) had severe hypertension. Severe hypertensives were more likely to be nulliparous, obese, or have received an epidural or oxytocin. There were no cases of eclampsia, stroke, or pulmonary edema in severe hypertensives (95% confidence interval, 0-5). Despite severely elevated pressures, only 4/69 (6%) patients received intravenous antihypertensive therapy, and 3 (4%) required medications at discharge. CONCLUSION: One in 3 women exhibits mild hypertension and 1 in 10 develop severe hypertension in labor. Only 6% of patients received treatment for severe blood pressures. This study highlights lack of treatment of hypertension in labor and further investigation into causes and outcomes of intrapartum elevations of blood pressures.

Liberal versus Indicated Maternal Oxygen Supplementation in Labor: A Before-and-After Trial.

BACKGROUND: Although supplemental oxygen (SO2) is routinely administered to laboring gravidas, benefits and harms are not well studied. OBJECTIVE: This article compares strategies of liberal versus indicated SO2 therapy during labor on cesarean delivery (CD) rate and neonatal outcomes. STUDY DESIGN: A controlled, before-and-after trial of laboring women with term, singleton pregnancies. During an initial 8-week period, maternal SO2 was administered at the discretion of the provider followed by an 8-week period where SO2 was to be given only for protocol indications. RESULTS: Our study included 844 women. There was no difference in number of women receiving SO2 (53% liberal vs. 50% indicated; p = 0.33). For those receiving SO2, there was no difference in SO2 duration (median, 89 minutes [interquartile range, 42-172] vs. 87 minutes [36-152]; p = 0.42). There were no differences in overall CD rate (20% vs. 17%; p = 0.70), CD for nonreassuring fetal status, or use of intrauterine resuscitative measures. There were more 5-minute APGAR < 7 in the indicated group, but no difference in umbilical artery pH < 7.1 or neonatal intensive care unit (NICU) admission. CONCLUSION: Approximately half of women receive SO2 intrapartum regardless of a strategy of liberal or indicated oxygen use. There were no clinically significant differences in outcomes between strategies.