Maternal and Fetal Outcomes After Therapy for Hodgkin or Non-Hodgkin Lymphoma Diagnosed During Pregnancy.

IMPORTANCE: The management of lymphoma diagnosed during pregnancy is controversial and has been guided largely by findings from case reports and small series. OBJECTIVE: To determine maternal and fetal outcomes of women diagnosed with Hodgkin lymphoma (HL) or non-Hodgkin lymphoma (NHL) during pregnancy. DESIGN, SETTING, AND PARTICIPANTS: This retrospective analysis studied a cohort of 39 pregnant women diagnosed with HL and NHL (31 HL and 8 NHL) at a single specialized cancer institution between January 1991 and December 2014. MAIN OUTCOMES AND MEASURES: We examined data on disease and treatment characteristics, as well as maternal and fetal complications and outcomes. The Kaplan-Meier method was used to compare progression free survival (PFS) and overall survival (OS) according to receipt of antenatal therapy and other clinical factors. Univariate and multivariate analyses were performed by using Cox proportional hazard regression models to identify potential associations between clinical and treatment factors and survival. RESULTS: The median (range) age of the 39 women in the patient cohort was 28 (19-38) years; 32 women (82%) had stage I or II disease at diagnosis, and 13 had bulky disease. Three women electively terminated the pregnancy to allow immediate systemic therapy; of the remaining 36 women, 24 received antenatal therapy (doxorubicin based combination chemotherapy in 20 of 24 patients), and 12 deferred therapy until after delivery. Four women experienced miscarriage, all of whom had received antenatal systemic therapy and 2 during the first trimester. Delivery occurred at a median (range) of 37 (32-42) weeks and was no different based on receipt of antenatal (median [range], 37 [33-42] weeks) vs postnatal (median [range], 37 [32-42] weeks) therapy (P = .21). No gross fetal malformations or anomalies were detected. At a median (range) follow-up time of 67.9 (8.8-277.5) months since the diagnosis of lymphoma, 5-year rates of PFS and OS were 74.7% and 82.4%, respectively; these rates did not differ according to timing of therapy. On univariate analysis, bulky disease (>10 cm), extranodal nonbone marrow involvement, and poor performance status (Eastern Cooperative Oncology Group score, ≥2) predicted increased risk of disease progression. On multivariate analysis, extranodal nonbone marrow disease and performance status remained significant for both PFS and OS. CONCLUSIONS AND RELEVANCE: Systemic therapy given for lymphoma after the first trimester of pregnancy is likely safe and results in acceptable maternal and fetal outcomes.

Outcomes of children exposed in utero to chemotherapy for breast cancer.

INTRODUCTION: The incidence of breast cancer diagnosed during pregnancy is expected to increase as more women delay childbearing in the United States. Treatment of cancer in pregnant women requires prudent judgment to balance the benefit to the cancer patient and the risks to the fetus. Prospective data on the outcomes of children exposed to chemotherapy in utero are limited for the breast cancer population. METHODS: Between 1992 and 2010, 81 pregnant patients with breast cancer were treated in a single-arm, institutional review board-approved study with 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC) in the adjuvant or neoadjuvant setting. Labor and delivery records were reviewed for each patient and neonate. In addition, the parents or guardians were surveyed regarding the health outcomes of the children exposed to chemotherapy in utero. RESULTS: In total, 78% of the women (or next of kin) answered a follow-up survey. At a median age of 7 years, most of the children exposed to chemotherapy in utero were growing normally without any significant exposure-related toxicity or health problems. Three children were born with congenital abnormalities: one each with Down syndrome, ureteral reflux or clubfoot. The rate of congenital abnormalities in the cohort was similar to the national average of 3%. CONCLUSIONS: During the second and third trimesters, pregnant women with breast cancer can be treated with FAC safely without concerns for serious complications or short-term health concerns for their offspring who are exposed to chemotherapy in utero. Continued long-term follow-up of the children in this cohort is required. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00510367. Other Study ID numbers: ID01-193, NCI-2012-01578. Registration date: 31 July 2007.

Nonclinical parameters affecting primary cesarean rates in the United States.

OBJECTIVE: Cesarean is the single most common operation in United States and has reached epidemic proportions in recent decades. Our objective was to study the effect of nonclinical parameters on primary cesarean rates in a large contemporary population. STUDY DESIGN: We designed a retrospective multicenter study using data obtained from electronic medical records from 19 U.S. hospitals between 2005 and 2007 (Consortium on Safe Labor Database), which included 145,764 term, singleton, nonanomalous, vertex, live births that included labor. The impact of nonclinical parameters (patient and provider characteristics, time of delivery, institutional policies, and insurance type) was investigated using modified Poisson regression methodology and classification and regression tree analysis. RESULTS: There were 125,517 vaginal and 20,247 cesarean deliveries. Using the multivariable model, the nonclinical parameters with statistical significance for primary cesarean were delivery during evening hours, a male provider, public insurance, and nonwhite race (p < 0.001). CONCLUSIONS: Cesarean rates are associated with several nonclinical factors. Further investigation into these factors might help to develop strategies to reduce their influence and hence the rates of cesarean.

Accuracy of an accelerated, culture-based assay for detection of group B streptococcus.

OBJECTIVE: To determine the validity of a novel Group B Streptococcus (GBS) diagnostic assay for the detection of GBS in antepartum patients. STUDY DESIGN: Women were screened for GBS colonization at 35 to 37 weeks of gestation. Three vaginal-rectal swabs were collected per patient; two were processed by traditional culture (commercial laboratory versus in-house culture), and the third was processed by an immunoblot-based test, in which a sample is placed over an antibody-coated nitrocellulose membrane, and after a six-hour culture, bound GBS is detected with a secondary antibody. RESULTS: 356 patients were evaluated. Commercial processing revealed a GBS prevalence rate of 85/356 (23.6%). In-house culture provided a prevalence rate of 105/356 (29.5%). When the accelerated GBS test result was compared to the in-house GBS culture, it demonstrated a sensitivity of 97.1% and a specificity of 88.4%. Interobserver reliability for the novel GBS test was 88.2%. CONCLUSIONS: The accelerated GBS test provides a high level of validity for the detection of GBS colonization in antepartum patients within 6.5 hours and demonstrates a substantial agreement between observers.

Oxytocin regimen for labor augmentation, labor progression, and perinatal outcomes.

OBJECTIVE: To examine the effects and safety of high-dose (compared with low-dose) oxytocin regimen for labor augmentation on perinatal outcomes. METHODS: Data from the Consortium on Safe Labor were used. A total of 15,054 women from six hospitals were eligible for the analysis. Women were grouped based on their oxytocin starting dose and incremental dosing of 1, 2, and 4 milliunits/min. Duration of labor and a number of maternal and neonatal outcomes were compared among these three groups stratified by parity. Multivariable logistic regression and generalized linear mixed model were used to adjust for potential confounders. RESULTS: Oxytocin regimen did not affect the rate of cesarean delivery or other perinatal outcomes. Compared with 1 milliunit/min, the regimens starting with 2 milliunits/min and 4 milliunits/min reduced the duration of first stage by 0.8 hours (95% confidence interval 0.5-1.1) and 1.3 hours (1.0-1.7), respectively, in nulliparous women. No effect was observed on the second stage of labor. Similar patterns were observed in multiparous women. High-dose regimen was associated with a reduced risk of meconium stain, chorioamnionitis, and newborn fever in multiparous women. CONCLUSION: High-dose oxytocin regimen (starting dose at 4 milliunits/min and increment of 4 millliunits/min) is associated with a shorter duration of first-stage of labor for all parities without increasing the cesarean delivery rate or adversely affecting perinatal outcomes. LEVEL OF EVIDENCE: II.

Laparoscopy in the morbidly obese pregnant patient using a modified foley lap-lift technique: case report.

Obesity in women of reproductive age is increasing. Gynecologic laparoscopy in the morbidly obese pregnant patient presents challenges, and is not often attempted. Herein is reported a successful case using a modified Foley lap-lift technique, which improved visualization and facilitated mechanical ventilation.

Labor induction: a review of current methods.

This article reviews the essential criteria for inductions of labor, weighing both the advantages and disadvantages of labor induction, and the various mechanical and pharmacologic agents available for cervical ripening. At the end of this article, one should be able to counsel women about the potential risks and benefit of labor induction and understand the neonatal consequences of elective induction of labor before 39 weeks of gestation. This article also discusses the different mechanical and pharmacologic agents available for cervical ripening.

Laparoscopic management of fallopian tube torsion at 35 weeks of gestation: case report.

Isolated fallopian tube torsion requiring surgical intervention in pregnancy is rare. Herein is reported a case of fallopian tube torsion that was managed laparoscopically at 35 weeks of gestation.

A comparison of obstetric maneuvers for the acute management of shoulder dystocia.

OBJECTIVE: To assess the efficacy of obstetric maneuvers for resolving shoulder dystocia and the effect that these maneuvers have on neonatal injury when shoulder dystocia occurs. METHODS: Using an electronic database encompassing 206,969 deliveries, we identified all women with a vertex fetus beyond 34 0/7 weeks of gestation who incurred a shoulder dystocia during the process of delivery. Women whose fetuses had a congenital anomaly and women with an antepartum stillbirth were excluded. Medical records of all cases were reviewed by trained abstractors. Cases involving neonatal injury (defined as brachial plexus injury, clavicular or humerus fracture, or hypoxic-ischemic encephalopathy or intrapartum neonatal death attributed to the shoulder dystocia) were compared with those without injury. RESULTS: Among 132,098 women who delivered a term cephalic liveborn fetus vaginally, 2,018 incurred a shoulder dystocia (1.5%), and 101 (5.2%) of these incurred a neonatal injury. Delivery of the posterior shoulder was associated with the highest rate of delivery when compared with other maneuvers (84.4% compared with 24.3-72.0% for other maneuvers; P<.005 to P<.001) and similar rates of neonatal injury (8.4% compared with 6.1-14.0%; P=.23 to P=.7). The total number of maneuvers performed significantly correlated with the rate of neonatal injury (P<.001). CONCLUSION: Delivery of the posterior shoulder should be considered following the McRoberts maneuver and suprapubic pressure in the management of shoulder dystocia. The need for additional maneuvers was associated with higher rates of neonatal injury.

Contemporary patterns of spontaneous labor with normal neonatal outcomes.

OBJECTIVE: To use contemporary labor data to examine the labor patterns in a large, modern obstetric population in the United States. METHODS: Data were from the Consortium on Safe Labor, a multicenter retrospective study that abstracted detailed labor and delivery information from electronic medical records in 19 hospitals across the United States. A total of 62,415 parturients were selected who had a singleton term gestation, spontaneous onset of labor, vertex presentation, vaginal delivery, and a normal perinatal outcome. A repeated-measures analysis was used to construct average labor curves by parity. An interval-censored regression was used to estimate duration of labor, stratified by cervical dilation at admission and centimeter by centimeter. RESULTS: Labor may take more than 6 hours to progress from 4 to 5 cm and more than 3 hours to progress from 5 to 6 cm of dilation. Nulliparous and multiparous women appeared to progress at a similar pace before 6 cm. However, after 6 cm, labor accelerated much faster in multiparous than in nulliparous women. The 95 percentiles of the second stage of labor in nulliparous women with and without epidural analgesia were 3.6 and 2.8 hours, respectively. A partogram for nulliparous women is proposed. CONCLUSION: In a large, contemporary population, the rate of cervical dilation accelerated after 6 cm, and progress from 4 cm to 6 cm was far slower than previously described. Allowing labor to continue for a longer period before 6 cm of cervical dilation may reduce the rate of intrapartum and subsequent repeat cesarean deliveries in the United States.

Contemporary cesarean delivery practice in the United States.

OBJECTIVE: To describe contemporary cesarean delivery practice in the United States. STUDY DESIGN: Consortium on Safe Labor collected detailed labor and delivery information from 228,668 electronic medical records from 19 hospitals across the United States, 2002-2008. RESULTS: The overall cesarean delivery rate was 30.5%. The 31.2% of nulliparous women were delivered by cesarean section. Prelabor repeat cesarean delivery due to a previous uterine scar contributed 30.9% of all cesarean sections. The 28.8% of women with a uterine scar had a trial of labor and the success rate was 57.1%. The 43.8% women attempting vaginal delivery had induction. Half of cesarean for dystocia in induced labor were performed before 6 cm of cervical dilation. CONCLUSION: To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor.

Wound complications from surgery in pregnancy-associated breast cancer (PABC).

BACKGROUND: there are concerns that physiologic changes of the peripartum breast may result in complications in breast conservation therapy. We present the complications of breast conservation surgeries and mastectomies performed for pregnancy-associated breast cancer (PABC). MATERIALS AND METHODS: from April 1989 through April 2008, sixty-seven breast cancer patients underwent surgical management for PABC, defined as surgery during pregnancy or within one year postpartum. Records of women who had surgery were examined for post-operative wound complications of milk fistula, cellulitis, abscess, or hematoma. RESULTS: Forty-seven patients underwent mastectomy. Twenty were treated with conservative breast surgery. There were six complications, all treated in the outpatient setting. There were no documented milk fistulae. CONCLUSIONS: in our series, we had few postoperative complications and no milk fistulae for those patients undergoing surgery for PABC. When compared to those who had mastectomy for PABC, women who underwent breast conserving therapy did not appear to have increased frequency of surgical complications.

Mode of delivery in women with antepartum fetal death and prior cesarean delivery.

We describe obstetric outcomes in a group of patients with prior cesarean delivery (CD) presenting with an intrauterine fetal demise (IUFD). A secondary analysis of an observational study of women with prior CD was performed. All antepartum singleton pregnancies with a prior CD and IUFD ≥20 weeks' gestation or 500 g were evaluated. Two hundred nine patients met inclusion criteria for analysis. The mean gestational age ± standard deviation at delivery was 31.3 ± 6.5 weeks. The trial of labor rate was 75.6% (158/209), and the vaginal birth after cesarean (VBAC) success rate was 86.7%. Labor induction or augmentation occurred in 83.3% of attempted VBAC. Uterine rupture occurred in five women (2.4%), and in 3.4% of those being induced but none of these required hysterectomy. Women with a history of previous CD and an IUFD often undergo trial of labor with a high VBAC success rate. Uterine rupture complicates 2.4% of such cases.

Maternal and neonatal outcomes by labor onset type and gestational age.

OBJECTIVE: We sought to determine maternal and neonatal outcomes by labor onset type and gestational age. STUDY DESIGN: We used electronic medical records data from 10 US institutions in the Consortium on Safe Labor on 115,528 deliveries from 2002 through 2008. Deliveries were divided by labor onset type (spontaneous, elective induction, indicated induction, unlabored cesarean). Neonatal and maternal outcomes were calculated by labor onset type and gestational age. RESULTS: Neonatal intensive care unit admissions and sepsis improved with each week of gestational age until 39 weeks (P < .001). After adjusting for complications, elective induction of labor was associated with a lower risk of ventilator use (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.28-0.53), sepsis (OR, 0.36; 95% CI, 0.26-0.49), and neonatal intensive care unit admissions (OR, 0.52; 95% CI, 0.48-0.57) compared to spontaneous labor. The relative risk of hysterectomy at term was 3.21 (95% CI, 1.08-9.54) with elective induction, 1.16 (95% CI, 0.24-5.58) with indicated induction, and 6.57 (95% CI, 1.78-24.30) with cesarean without labor compared to spontaneous labor. CONCLUSION: Some neonatal outcomes improved until 39 weeks. Babies born with elective induction are associated with better neonatal outcomes compared to spontaneous labor. Elective induction may be associated with an increased hysterectomy risk.

Cost-effectiveness of universal prophylaxis in pregnancy with prior group B streptococci colonization.

OBJECTIVE: To estimate the costs and outcomes of rescreening for group B streptococci (GBS) compared to universal treatment of term women with history of GBS colonization in a previous pregnancy. STUDY DESIGN: A decision analysis model was used to compare costs and outcomes. Total cost included the costs of screening, intrapartum antibiotic prophylaxis (IAP), treatment for maternal anaphylaxis and death, evaluation of well infants whose mothers received IAP, and total costs for treatment of term neonatal early onset GBS sepsis. RESULTS: When compared to screening and treating, universal treatment results in more women treated per GBS case prevented (155 versus 67) and prevents more cases of early onset GBS (1732 versus 1700) and neonatal deaths (52 versus 51) at a lower cost per case prevented ($8,805 versus $12,710). CONCLUSION: Universal treatment of term pregnancies with a history of previous GBS colonization is more cost-effective than the strategy of screening and treating based on positive culture results.

Recurrence of group B streptococci colonization in subsequent pregnancy.

OBJECTIVE: To estimate the prevalence of group B streptococci (GBS) colonization in a subsequent pregnancy in women with and without GBS colonization in an index pregnancy. METHODS: A retrospective cohort study of women who had two consecutive deliveries with the availability of GBS culture result at 35 to 37 weeks of gestation or the diagnosis of GBS colonization by urine culture for both pregnancies was undertaken. Women in the index pregnancy with GBS genitourinary tract colonization were compared by culture date with the next woman that screened negative for GBS colonization. To detect a doubling of GBS colonization from 20% to 40% would require 91 women in each arm at P<.05 with a power of 80%. Risk factors for GBS colonization were ascertained. Univariable and conditional logistic regression analyses were performed. P<.05 was considered statistically significant. RESULTS: A total of 102 women positive for GBS genitourinary colonization were compared with controls. The rate of recurrence for GBS colonization (53%) was significantly higher when judged against women GBS negative in their index pregnancy (15%) (adjusted odds ratio 11.7, 95% confidence interval 3.5-38.9, P<.01). Women who were GBS positive in the index pregnancy were more often of African-American race and less likely to be nulliparous or smoke tobacco. CONCLUSION: Women with GBS colonization are at increased risk of GBS colonization in a subsequent pregnancy. Prior GBS colonization should be considered in the algorithm to treat unknown GBS status during term labor.

Utilization of obstetrical ultrasound in a referral population.

OBJECTIVE: To determine the number of ultrasounds performed prior to presentation to a maternal-fetal medicine (MFM) sub-specialist and the patient's perceived reason for referral. STUDY DESIGN: Women presenting for their first targeted ultrasound at an MFM unit in an urban center between November 2003 and April 2004 reported the number, location, and gestational age (GA) of prior ultrasounds and whether their insurance company had been billed for these studies. They also reported their current GA, insurance type, and perceived reason for referral. Pearson correlation and Kruskal-Wallis were used where appropriate; p < 0.05 was considered significant. RESULTS: Six hundred fifty-five women were invited to participate; 207 declined, leaving 448 available for the final analysis. The median number of prior ultrasounds was two (range 0-11). Twelve percent reported no prior ultrasound, 30% reported having had one, 28% reported having had two, and 29% reported having had three or more. Women presented at a mean GA of 21.3 +/- 5.4 weeks. They reported having had their first ultrasound at 9.9 +/- 2 weeks and their most recent prior ultrasound at 16.9 +/- 6.7 weeks. GA at presentation did not correlate with the number of prior ultrasounds (r = 0.17). Of 396 women with at least one prior ultrasound, 336 had at least one performed in their doctor's office and 74 had at least one performed in an ultrasound clinic; 183 stated that their insurance had been billed and 168 did not know if their insurance had been billed. The majority, 60%, had private insurance, 37% had Medicaid, and 2% had no insurance. Women with private insurance had a higher number of prior ultrasounds than women with Medicaid (2.3 +/- 1.4 vs. 1.5 +/- 1.3, p < 0.001). In response to the perceived reason for referral, 280 women stated their reason for referral to the MFM unit was for a routine ultrasound or to determine gender, 158 women reported that they were referred because their doctor was concerned about 'something', and 10 were unsure of their indication. CONCLUSION: Most women have at least one ultrasound prior to presenting to an MFM unit for a targeted scan. Many, especially those with private insurance, have had several prior ultrasounds. Patient education is needed about reasons for referral to an MFM unit for ultrasound and the possible increased financial burden of multiple ultrasounds.

Diagnosis of short cervix in a community hospital prior to placement of a therapeutic cerclage.

The purpose of this study was to describe how obstetricians in the community define a short cervix prior to cerclage placement. A secondary analysis of cerclages placed for the diagnosis of short cervix, defined by either digital or ultrasound examination, were identified from a cohort of 1076 cerclages placed at a community hospital from January 1, 2000, through December 31, 2004. Two hundred twenty-six cerclages were placed for the diagnosis of short cervix. Fifty-eight women (25.7%) were nulliparous. The mean estimated gestational age at placement was 15.4 +/- 3.8 weeks. More than half of the cerclages (n = 125; 55.3%) were placed prior to 15 weeks estimated gestational age. Of those cases with documented cervical length by ultrasound (n = 171), 36 of these patients (21.1%) had a cervical length of > or = 25 mm. The most common indications for cerclage placement were short cervix only (40.3%), previous cone biopsy/loop electrocautery excision procedure (28.8%), and multiple gestation (9.7%). In a community hospital, cerclages for short cervix are often performed in nulliparous women without antecedent risk factors at a gestational age when cervical length is not a reliable tool for predicting adverse pregnancy outcome.