Cervicovaginal microbiome in twin vs singleton gestations.

BACKGROUND: The vaginal microbiome diversity profile varies by race and ethnicity and changes considerably from the nonpregnant state to the pregnant state, specifically with a shift to Lactobacillus predominance in singleton gestations. There is a paucity of data that evaluate the cervicovaginal microbiome in women with twin gestations as a distinct population from those with singleton gestations. OBJECTIVE: We sought to characterize the cervicovaginal microbiome diversity profiles among twin gestations in the second trimester of pregnancy. STUDY DESIGN: In this prospective cross-sectional cohort study, women with twin gestations were matched to singleton controls without a history of a short cervix or preterm birth by gestational age ±2 weeks and race. Cervicovaginal lavage samples were collected from 14 to 24 weeks of gestation during prenatal visits followed by a cervical length measurement. Cervicovaginal microbiota were analyzed with 16S RNA gene sequencing and classified into community state types based on Lactobacillus species predominance. Microbiome alpha and beta diversities were compared between twin and singleton gestations. RESULTS: A total of 19 twin gestations and 19 singleton gestations underwent second-trimester cervicovaginal microbiome analysis. The groups were similar in gestational age at sample collection, maternal age, parity, body mass index, preterm birth history, and comorbidity. The cohort was predominantly of Black race (79%). Of twin gestations, 79% were dichorionic and diamniotic and 21% monochorionic and diamniotic. Of note, 3 twin gestations and 1 singleton gestation were complicated by a short cervix (P=.6). The vaginal microbiome of twin gestations had decreased alpha and beta diversities compared with singleton gestations. Twin gestations had lower taxon abundance and decreased variability in taxon abundance than singleton gestations. Overall, there was decreased diversity of community state type groups among twin gestations compared with singleton gestations. Community state types I and III were more prevalent among twin gestations, whereas community state types II and IV were similar among these 2 groups. Community state type IV, which is defined by a lack of Lactobacillus species and the presence of diverse strict anaerobes, was the predominant type among microbiota profiles of twin gestations (55%) and singleton gestations (64%). Community state type V was more prevalent in singleton gestations. When stratified by race, we found similar alpha diversity in Black and non-Black patients with twin gestations. CONCLUSION: In our predominantly Black population of pregnant women, the second-trimester vaginal microbiome in twin gestations showed decreased alpha and beta diversities compared with singleton controls. Our findings increased the understanding of the content of microbial communities in the second trimester of pregnancy in twin gestations and suggested a potential mechanism for preterm birth in twin gestations.

Fetal overgrowth in pregnancies complicated by diabetes: validation of a predictive index in an external cohort.

PURPOSE: To assess validity of a fetal overgrowth index in an external cohort of women with diabetes in pregnancy METHODS: We performed a retrospective analysis of data derived from women with singleton gestations complicated by diabetes who delivered January 2015-June 2018. The following index variables were used to calculate risk of fetal overgrowth as defined by a customized birthweight ≥ 90th centile: age, history of fetal overgrowth in a prior pregnancy, gestational weight gain, fetal abdominal circumference measurement and fasting glucose between 24 and 30 weeks. RESULTS: In our validation cohort, 21% of 477 pregnancies were complicated by fetal overgrowth. The predictive index had a bias-corrected bootstrapped area under receiver operating characteristic curve of 0.90 (95% CI 0.86-0.93). 55% of the cohort had a low-risk index (≤ 3) which had a negative predictive value of 97% (95% CI 94-98%), while 18% had a high-risk index (≥ 8) that had a positive predictive value of 74% (95% CI 66-81%). CONCLUSION: The fetal overgrowth index incorporates five factors that are widely available in daily clinical practice prior to the period of maximum fetal growth velocity in the third trimester. Despite substantial differences between our cohort and the one studied for model development, we found the performance of the index was strong. This finding lends support for the general use of this tool that may aid counseling and allow for targeted allocation of healthcare resources among women with pregnancies complicated by diabetes.

Tension compared to no tension on a Foley transcervical catheter for cervical ripening: a randomized controlled trial.

BACKGROUND: Cervical ripening of an unfavorable cervix can be achieved by placement of a transcervical catheter. Advantages of this method include both lower cost and lower risk of tachysystole than other methods. Despite widespread use with varying degrees of applied tension, an unanswered question is whether there is an advantage to placing the transcervical catheter to tension compared with placement without tension. OBJECTIVE: The purpose of this study was to determine whether tension placed on a transcervical balloon catheter that is inserted for cervical ripening results in a faster time to delivery. STUDY DESIGN: This was a prospective, randomized controlled trial; 140 women who underwent cervical ripening (Bishop score, ≤6) were assigned randomly to a balloon catheter with applied tension vs no tension. Tension was created when the catheter was taped to the patient's thigh and tension was reapplied in 30-minute increments. There were 67 patients in the tension group and 73 patients in the no tension group. Low-dose oxytocin (maximum, 6 mU/min) was administered after catheter placement. The primary outcome was time from catheter insertion to delivery. A secondary outcome was time from insertion to catheter expulsion. The Kolmogorov-Smirnov test was used to determine whether the data were distributed normally. Survival curves that used lifetables were constructed from time of catheter insertion to delivery and from time of catheter insertion to catheter expulsion and were compared with the use of the Wilcoxon (Gehan) Breslow statistic. A probability value of <.05 was set to denote statistical significance. RESULTS: Baseline characteristics were similar between groups. The median time from catheter insertion to delivery was not significantly different between the tension group and the no tension group (16.2 vs 16.9 hours; P=.814). The median time from catheter insertion to expulsion, however, was significantly less in the tension group vs the no tension group (2.6 vs 4.6 hours; P<.001), respectively. Vaginal delivery within 24 hours was not significantly different between the tension and no tension groups (41/52 [79%] vs 37/52 [71%]; P=.365) nor were there significant differences in cesarean delivery rates between the tension and no tension groups (17/67 [25%] vs 27/73 [37%]; P=.139). CONCLUSION: Application of tension did not result in faster delivery times but did result in faster times to catheter expulsion.

Standard External Doppler Fetal Heart Tracings versus External Fetal Electrocardiogram in Very Preterm Gestation: A Pilot Study.

Introduction Very preterm babies can be difficult to monitor using standard external Doppler fetal heart tracings (eFHR). External fetal electrocardiogram (fECG) is a potential alternative. Methods This was a prospective observational pilot study of hospitalized patients at 24 to 28 weeks' gestation. A total of 30 women were traced for up to 2 hours using eFHR followed by up to 2 hours using fECG. The percentage of time the fetal heart rate was traced during the 2-hour window for each modality was calculated. Differences of ≥ 60, ≥ 80, and ≥ 90% total time traced were compared between modalities using McNemar's test. Differences were also assessed for each method between nonobese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2) women using chi-square and Fisher's exact tests. Results Superior performance was found with eFHR at ≥ 60% (93.3 vs. 46.7%, p < 0.001), ≥ 80% (80.0 vs. 30.0%, p < 0.001), and ≥ 90% (60.0 vs. 23.3%, p < 0.01) total time traced. There was a statistically significant finding favoring nonobese women at ≥ 80% total time traced using fECG (7.1 vs. 50.0%, p = 0.017). Conclusion With current technology fECG performance in very preterm gestation was worse than conventional eFHR, although fECG may have a role in nonobese patients.

Orthopedic Injury in Pregnancy.

There are many reasons why a woman's pregnancy can put her at risk for orthopedic pain and injury. Given the high percentage of pregnant patients experiencing some degree of musculoskeletal pain, it is surprising that this is not an area of wider study. This chapter takes an evidence based approach to help the reader understand the implications of the numerous anatomic and physiologic changes associated with the gravid state, and how they act to promote both discomfort and injury. One-third of pregnant women in America are obese, further increasing risk. Exercise in most pregnancies is recommended and regarded as safe and thus obstetric care providers need to understand risk, diagnostic techniques and treatments.

The Effect of Clinical Chorioamnionitis on Cesarean Delivery in the United States.

OBJECTIVE: To examine the association of clinical chorioamnionitis on cesarean delivery in a national sample of hospital discharges. DATA SOURCE: Hospital discharge data from the 1998-2010 Nationwide Inpatient Sample. STUDY DESIGN: We performed a cross-sectional study and general linear modeling was used to determine the association of clinical chorioamnionitis on risk of cesarean delivery. PRINCIPAL FINDINGS: A total of 10,843,682 deliveries and 51,799,431 nationally weighted deliveries were identified. Clinical chorioamnionitis was present in 2.9 percent of cesarean and 1.3 percent of vaginal deliveries (p < .001). In multivariate analysis, clinical chorioamnionitis was associated with a 1.39-fold increased risk of cesarean delivery. Compared with women without clinical chorioamnionitis at an urban/teaching hospital, women with clinical chorioamnionitis at an urban/teaching, urban/nonteaching, and rural hospital were 1.4-1.5 times more likely to have cesarean delivery. Compared with women without clinical chorioamnionitis in the Midwest, the relative risk for cesarean in women with clinical chorioamnionitis was 1.54 for women in the South, 1.47 in the Northeast, 1.39 in the Midwest, and 1.34 in the West. CONCLUSIONS: Women with clinical chorioamnionitis were more likely to have cesarean delivery than those without clinical chorioamnionitis, and the risk of cesarean delivery varied significantly by hospital location, teaching status, and U.S. region.

A barrier retractor to reduce surgical site infections and wound disruptions in obese patients undergoing cesarean delivery: a randomized controlled trial.

BACKGROUND: Surgical site infections (SSIs) are an important cause of morbidity following cesarean delivery, particularly in obese patients. Methods to reduce SSIs after cesarean delivery would have an important impact in obese obstetric patients. OBJECTIVE: The purpose of this study was to determine whether the Alexis O cesarean delivery retractor, a barrier self-retaining retractor, reduces SSIs and wound disruptions in obese patients undergoing cesarean delivery. STUDY DESIGN: This was a randomized controlled trial of obese women (body mass index ≥ 30 kg/m(2)) undergoing nonemergent cesarean delivery. Patients were randomized to the treatment group (using the Alexis O cesarean delivery retractor) or to the control group (using conventional handheld retractors). The primary outcome was SSI or wound disruption during the 30 day postoperative period. Secondary outcomes included operative time, estimated blood loss, change in hemoglobin, antiemetic use, length of postoperative hospital stay, hospital readmission, and other postoperative complications. RESULTS: A total of 301 patients were enrolled in the study. One hundred forty-four patients were randomized to the treatment group and 157 to the control group. Baseline characteristics and indications for cesarean delivery were similar between the 2 groups. Median body mass index was 40.1 kg/m(2). There were no significant differences between the treatment and the control group in the primary outcome of SSI or wound disruption rates at the 30 day assessment (20.6% vs 17.6%, P = .62), during the postoperative inpatient hospitalization or at the 1-2 week postoperative visit. There were also no differences in the primary outcome when adjusting for obesity class or thickness of the subcuticular layer. Patients in the treatment group had lower rates of uterine exteriorization (54.3% vs 87.3%, P < .001), but there were no differences in all other outcomes. CONCLUSION: Use of the Alexis retractor in cesarean delivery deliveries did not decrease SSI or wound disruption rates in an obese population. Its use as a retractor should be left to the discretion of the surgeon and clinical circumstances.

A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy.

OBJECTIVE: Women commonly experience low back pain during pregnancy. We examined whether a multimodal approach of musculoskeletal and obstetric management (MOM) was superior to standard obstetric care to reduce pain, impairment, and disability in the antepartum period. STUDY DESIGN: A prospective, randomized trial of 169 women was conducted. Baseline evaluation occurred at 24-28 weeks' gestation, with follow-up at 33 weeks' gestation. Primary outcomes were the Numerical Rating Scale (NRS) for pain and the Quebec Disability Questionnaire (QDQ). Both groups received routine obstetric care. Chiropractic specialists provided manual therapy, stabilization exercises, and patient education to MOM participants. RESULTS: The MOM group demonstrated significant mean reductions in Numerical Rating Scale scores (5.8 ± 2.2 vs 2.9 ± 2.5; P < .001) and Quebec Disability Questionnaire scores (4.9 ± 2.2 vs 3.9 ± 2.4; P < .001) from baseline to follow-up evaluation. The group that received standard obstetric care demonstrated no significant improvements. CONCLUSION: A multimodal approach to low back and pelvic pain in mid pregnancy benefits patients more than standard obstetric care.

Childhood lead poisoning prevention through prenatal housing inspection and remediation in St. Louis, MO.

OBJECTIVE: We assessed the screening and remediation of home lead hazards prenatally in a high-risk population, hypothesizing that average blood-lead level and the number of poisonings would drop by 25%. STUDY DESIGN: One hundred fifty-two women underwent prenatal home inspections by certified lead inspectors. The hazards that were identified were remediated. The blood-lead levels of children of participating women were compared with matched control subjects. RESULTS: Blood-lead levels were obtained from 60 children and compared with matched control subjects. The average blood-lead level of children in the treatment group was 2.70 µg/dL vs 3.73 µg/dL in control subjects (P = .019). The percentage of children with levels >10 µg/dL in the treatment group was 0% vs 4.2% in control subjects (P = .128). CONCLUSION: Screening and remediation of houses of pregnant women is effective to reduce the average blood-lead level and number of children that exceed the federal level of concern for lead poisoning in a high-risk population.

Clinical and laboratory trends in fetal lung maturity testing.

BACKGROUND: The surfactant/albumin ratio is a popular fetal lung maturity (FLM) test that will be unavailable in the near future. We conducted surveys of obstetricians and clinical laboratorians to assess FLM testing trends from the perspectives of both disciplines and to identify how both communities might adapt to the loss of the surfactant/albumin ratio. METHODS: 2067 physicians were surveyed about their familiarity with and clinical utility of various FLM tests. 6137 laboratorians were surveyed about their FLM test menu and volumes. RESULTS: Twenty-five percent of physicians indicated a decrease in FLM test ordering and the frequency of FLM testing has decreased significantly (p=0.011) since 1998. The surfactant/albumin ratio is the most frequently offered FLM test and was the test of choice for 62% of physicians. Without the surfactant/albumin ratio, 68% of physicians would order the lecithin/sphingomyelin ratio and 44% would order the lamellar body count (LBC) which were offered by 18 and 13% of laboratories, respectively. 16% of laboratories were planning to offer the LBC within 24 months. CONCLUSIONS: FLM testing is decreasing. The loss of the surfactant/albumin ratio will increase the demand for the lecithin/sphingomyelin ratio and the LBC, yet few laboratories offer either test and most are not planning to offer the LBC.

Comparison of costs of surgical site infection and endometritis after cesarean delivery using claims and medical record data.

We used administrative and clinical data from a case-control study to calculate the costs of surgical site infection and endometritis after cesarean delivery. Attributable costs determined by multivariate generalized least-squares regression models with the 2 data sets were similar, suggesting that administrative data can be used to calculate infection costs.

Attributable costs of surgical site infection and endometritis after low transverse cesarean delivery.

BACKGROUND: Accurate data on costs attributable to hospital-acquired infections are needed to determine their economic impact and the cost-benefit of potential preventive strategies. OBJECTIVE: To determine the attributable costs of surgical site infection (SSI) and endometritis (EMM) after cesarean section by means of 2 different methods. DESIGN: Retrospective cohort. SETTING: Barnes-Jewish Hospital, a 1,250-bed academic tertiary care hospital. PATIENTS: There were 1,605 women who underwent low transverse cesarean section from July 1999 through June 2001. METHODS: Attributable costs of SSI and EMM were determined by generalized least squares (GLS) and propensity score matched-pairs by means of administrative claims data to define underlying comorbidities and procedures. For the matched-pairs analyses, uninfected control patients were matched to patients with SSI or with EMM on the basis of their propensity to develop infection, and the median difference in costs was calculated. RESULTS: The attributable total hospital cost of SSI calculated by GLS was $3,529 and by propensity score matched-pairs was $2,852. The attributable total hospital cost of EMM calculated by GLS was $3,956 and by propensity score matched-pairs was $3,842. The majority of excess costs were associated with room and board and pharmacy costs. CONCLUSIONS: The costs of SSI and EMM were lower than SSI costs reported after more extensive operations. The attributable costs of EMM calculated by the 2 methods were very similar, whereas the costs of SSI calculated by propensity score matched-pairs were lower than the costs calculated by GLS. The difference in costs determined by the 2 methods needs to be considered by investigators who are performing cost analyses of hospital-acquired infections.

Risk factors for endometritis after low transverse cesarean delivery.

OBJECTIVE: To determine independent risk factors for endometritis after low transverse cesarean delivery. STUDY DESIGN: We performed a retrospective case-control study during the period from July 1999 through June 2001 in a large tertiary care academic hospital. Endometritis was defined as fever beginning more than 24 hours or continuing for at least 24 hours after delivery plus fundal tenderness in the absence of other causes for fever. Independent risk factors for endometritis were determined by means of multivariable logistic regression. A fractional polynomial method was used to examine risk of endometritis associated with the continuous variable, duration of rupture of membranes. RESULTS: Endometritis was identified in 124 (7.7%) of 1,605 women within 30 days after low transverse cesarean delivery. Independent risk factors for endometritis included age (odds ratio [OR] for each additional year, 0.93 [corrected] [95% confidence interval {CI}, 0.90-0.97]) and anemia or perioperative blood transfusion (OR, 2.18 [CI, 1.30-3.68]). Risk of endometritis was marginally associated with a proxy for low socioeconomic status, lack of private health insurance (OR, 1.72 [CI, 0.99-3.00]); with amniotomy (OR, 1.69 [CI, 0.97-2.95]); and with longer duration of rupture of membranes. CONCLUSION: Risk of endometritis was independently associated with younger age and anemia and was marginally associated with lack of private health insurance and amniotomy. The odds of endometritis increased approximately 1.7-fold within 1 hour after rupture of membranes, but increased duration of rupture was only marginally associated with increased risk. Knowledge of these risk factors can guide selective use of prophylactic antibiotics during labor and heighten awareness of the risk in subgroups at highest risk of infection.

Risk factors for surgical site infection after low transverse cesarean section.

BACKGROUND: Independent risk factors for surgical site infection (SSI) after cesarean section have not been well documented, despite the large number of cesarean sections performed and the relatively common occurrence of SSI. OBJECTIVE: To determine independent risk factors for SSI after low transverse cesarean section. DESIGN: Retrospective case-control study. SETTING: Barnes-Jewish Hospital, a 1,250-bed tertiary care hospital. PATIENTS: A total of 1,605 women who underwent low transverse cesarean section during the period from July 1999 to June 2001. METHODS: Using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for SSI or wound complication and/or data on antibiotic use during the surgical hospitalization or at readmission to the hospital or emergency department, we identified potential cases of SSI in a cohort of patients who underwent a low transverse cesarean section. Cases of SSI were verified by chart review using the definitions from the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance System. Control patients without SSI or endomyometritis were randomly selected from the population of patients who underwent cesarean section. Independent risk factors for SSI were determined by logistic regression. RESULTS: SSIs were identified in 81 (5.0%) of 1,605 women who underwent low transverse cesarean section. Independent risk factors for SSI included development of subcutaneous hematoma after the procedure (adjusted odds ratio [aOR], 11.6 [95% confidence interval [CI], 4.1-33.2]), operation performed by the university teaching service (aOR, 2.7 [95% CI, 1.4-5.2]), and a higher body mass index at admission (aOR, 1.1 [95% CI, 1.0-1.1]). Cephalosporin therapy before or after the operation was associated with a significantly lower risk of SSI (aOR, 0.2 [95% CI, 0.1-0.5]). Use of staples for skin closure was associated with a marginally increased risk of SSI. CONCLUSIONS: These independent risk factors should be incorporated into approaches for the prevention and surveillance of SSI after surgery.

A short interpregnancy interval is a risk factor for preterm birth and its recurrence.

OBJECTIVE: We tested the hypothesis that short interpregnancy intervals (IPIs) increase the risk for preterm birth (PTB), recurrence of PTB, and delivery at early extremes of gestational age. STUDY DESIGN: Using the Missouri Department of Health's birth certificate database, we performed a population-based cohort study of 156,330 women who had 2 births from 1989-1997. The association between IPI and subsequent pregnancy outcome was assessed. RESULTS: The shortest IPIs (<6 months) increased the risk of extreme PTB (adjusted odds ratio, 1.41; 95% CI, 1.13-1.76). IPIs of <6 months and 6-12 months increased the overall risk of PTB (adjusted odds ratios, 1.48 [95% CI, 1.37-1.61] and 1.14 [95% CI, 1.06-1.23], respectively) and PTB recurrence (adjusted odds ratios, 1.44 [95% CI, 1.19-1.75] and 1.24 [95% CI, 1.02-1.50], respectively). CONCLUSION: The risk of PTB and its recurrence increases with short IPIs, even after adjustment for coexisting risk factors. This highlights the importance of counseling women with either an initial term or preterm birth to wait at least 12 months between delivery and subsequent conception.

A prospective randomized safety trial of celecoxib for treatment of preterm labor.

OBJECTIVE: We compared the safety of celecoxib, a selective cyclo-oxygenase-2 inhibitor, with the safety of the nonselective cyclo-oxygenase inhibitor indomethacin, when it was administered for treatment of preterm labor. STUDY DESIGN: In a randomized, double-blind, placebo-controlled trial, 24 pregnant women in preterm labor at 24 to 34 weeks of gestation received either indomethacin or celecoxib for 48 hours. Clinical assessment, fetal sonography, and Doppler blood flow studies of the fetal ductus arteriosus were performed daily. RESULTS: Mean maximum ductal flow velocity was significantly elevated over baseline (82.9 +/- 4.6 cm/s vs 111.14 +/- 14.3 cm/s; P =.02) after 24 hours of indomethacin, but not celecoxib. Both medications were associated with a transient decrease in amniotic fluid volume, with a greater effect by indomethacin. The medications were equally effective in the maintenance of tocolysis. There were no significant maternal or neonatal adverse events. CONCLUSION: In this initial evaluation, the safety of short-term celecoxib in women with preterm labor was superior to that of indomethacin.