Comparative analysis of cesarean delivery rates over a 10-year period in a single Institution using 10-class classification.

OBJECTIVE: To evaluate the variables associated with changes in cesarean delivery (CD) rates in a University Hospital with standardized and unchanged protocols of care. METHODS: Retrospective analysis of consecutive deliveries between two triennia 10 years apart. The Robson classification of CD was used, and the analysis focused on factors affecting Robson's classes 1 and 2 combined (term singleton cephalic nulliparae) and class 5 (previous CD). RESULTS: A total of 8237 deliveries occurred in the 1st period, and 8420 in the 2nd. CD increased from 12.5 to 18% (p < 0.001). Robson's classes 1 and 2 combined contributed more than other classes to CD rates (32 vs 36%; p < 0.001). At multivariate analysis, BMI (Odds ratio [OR]: 1.08; 95% CI: 1.06-1.1) and maternal age (OR: 1.06; 95% CI: 1.05-1.08) were independently related to CD. In Robson class 5, the rate of CD increased from 34 to 46%, p < 0.001, mostly due to an increase in elective CD (39 vs 67.5%; p < 0.001). At multivariate analysis, BMI (OR: 1.06 95% CI: 1.02-1.1) and more than one previous CD (OR: 18.7; 95% CI: 9.6-36.4) were independently related to CD. CONCLUSIONS: BMI and maternal age are independent factors associated to the increasing rate of CD in nulliparae with spontaneous or induced labor at term. In women with previous CD, BMI and more than one previous CD are factors associated with the increasing rate of CD.

Two- or three-dimensional ultrasonography: which is the best predictor of pulmonary hypoplasia?

OBJECTIVE: The aim of our study is to compare the three-dimensional (3D) ultrasound fetal lung volume measurements with two-dimensional (2D) ultrasound biometric parameters in predicting pulmonary hypoplasia (PH). METHODS: From June 2006 to November 2008, we identified 35 fetuses at high risk for developing PH, including premature preterm rupture of membranes (17), fetal skeletal malformations (7), hydrothorax (7), and bilateral renal dysplasia (4). 3D lung volumes adjusted for gestational age (GA) or estimated fetal weight (EFW), thoracic circumference adjusted for GA or femur length, thoracic/abdominal circumference ratio, and thoracic/heart area ratio were measured. RESULTS: Three infants were excluded because no clinical or histological information regarding lung hypoplasia was available. Of the 32 remaining infants, 13 (41%) were diagnosed with PH at postmortem examination or by clinical and radiological examination. 3D lung volume measurements had a better diagnostic accuracy for predicting PH either when adjusted for GA [sensitivity, 12/13 (92%); specificity, 16/19 (84%); positive predictive value 12/15 (80%); negative predictive value, 16/17(94%)] or EFW [sensitivity, 11/13 (85%); specificity, 18/19 (94%); positive predictive value 11/12(92%); negative predictive value, 18/20(90%)] compared to the 2D biometric measurement. CONCLUSION: 3D lung volume measurements seem to be useful in the prenatal prediction of PH.

Antenatal variables associated with severe adverse neurodevelopmental outcome among neonates born at less than 32 weeks.

OBJECTIVE: To determine the association between antenatal factors and severe adverse neurodevelopmental outcome (ANDO) in preterm infants. STUDY DESIGN: Neurodevelopmental follow-up was performed in a cohort of babies born at <32.0 weeks' gestation with birth weight <1500 grams between 1999 and 2006. Logistic regression analysis was used to relate obstetric, perinatal and neonatal ultrasonographic predictors to severe ANDO, defined as cerebral palsy or neurodevelopmental impairment, including sensory damage and adjusted development quotient <70. RESULTS: 88.6% (195/220) of surviving babies underwent follow up for a median of 24 months (range 12-96); 45 of them (23%) had ANDO, which was severe in 28 (14.3%). Abnormal ultrasonographic findings (intraventricular hemorrhage grades 3 or 4, periventricular leukomalacia, or ventriculomegaly) were observed in 18 cases (9.2%) and they were significantly associated with severe ANDO (OR 11.8 95% CI 4.0-34.0). Only gestational age at delivery (OR 0.80 95% CI 0.66-0.97), but not intrauterine infection, was independently related to severe ANDO. Infants with severe ANDO born before 28 weeks presented lower umbilical artery pH (7.24±0.1 vs 7.31±0.06, p=0.005) and a significantly higher rate of cesarean delivery (85.7% vs 50%, OR 6 95%CI 1.3-26.3, p=0.03) compared with infants without severe ANDO. CONCLUSION: Gestational age at delivery and low umbilical artery pH at less than 28 weeks, but not intrauterine infection, are independent risk factors for severe ANDO in babies with birth weight <1500g.

Gestational age at glucocorticoids administration after premature rupture of membranes and cerebral white matter damage.

OBJECTIVE: We investigated whether gestational age at glucocorticoids administration in very preterm premature rupture of membranes (PROM) affects the occurrence of neonatal cerebral white matter damage (WMD). METHODS: In a cohort of singleton neonates born at 24.0-33.6 weeks after PROM who underwent at least one full course of glucocorticoids (n = 130), we compared the gestational age at first and last course of glucocorticoids between those who developed WMD (n = 8) and those who did not (n = 122) after adjusting for gestational age at PROM using logistic regression with P < 0.05 considered significant. RESULTS: Gestational age at first course of glucocorticoids (P = 0.2), at last course of glucocorticoids (P = 0.2) and at delivery (P = 0.2), were not significantly different between those who developed WMD and those who did not. Although latency between PROM and first course of glucocorticoids was protective against WMD (P = 0.02), the significance was lost after controlling for gestational age at PROM, which was significantly lower in cases that developed WMD (P < 0.01). CONCLUSIONS: In very preterm PROM, the beneficial effect of glucocorticoids on occurrence of WMD is not related to gestational age at steroid administration.

Which factors affect the occurrence of severe cerebral lesions in preterm neonates who are born with intrauterine infection?

OBJECTIVE: The purpose of this study was to evaluate which factors affect the occurrence of neonatal ultrasonographic evidence of severe cerebral lesions in the presence of intrauterine infection. STUDY DESIGN: From a cohort of 567 singleton neonates who were born between 24.0 and 31.6 weeks of gestation, we identified the 180 infants with histologic and/or clinical evidence of intrauterine infection. We excluded stillbirths and congenital anomalies. Obstetric and neonatal variables were related to evidence of severe neonatal ultrasonographic cerebral lesions with the use of logistic regression analysis. RESULTS: Severe cerebral lesions were identified in 10% of infants (18/180). After we controlled for variables that were clinically relevant, logistic regression analysis demonstrated that ultrasound evidence of severe neonatal cerebral lesions was associated independently with antenatal administration of corticosteroids (adjusted odds ratio, 0.3; 95% CI, 0.11-0.88; P = .03) and occurrence of placental abruption (adjusted odds ratio, 5.4; 95% CI, 1.4-20.7; P = .02). CONCLUSION: Antenatal administration of corticosteroids in the presence of intrauterine infection has a protective effect on the risk of ultrasonographic evidence of severe neonatal cerebral lesions.

Pregnancy and women with spinal cord injuries.

OBJECTIVE: To investigate the impact of pregnancy and childbearing on women with spinal cord injuries and their attitude toward pregnancy. Design and setting. State-wide questionnaire survey from two databases, Florida, USA. METHODS: Women with spinal cord injuries between 18 and 40 years were invited to participate. MAIN OUTCOME MEASURES: Knowledge about pregnancy after spinal cord injury and complications of pregnancy. Population. Hundred and fourteen women with spinal cord injuries. RESULTS: Twenty-three women (20%) received information about pregnancy during rehabilitation, but only 12 (10%) found it adequate. Rates of response of 'adequate information' were similar between women who became pregnant after injury and those who did not (9.0% vs. 8.6%, p=1.0). Younger age at injury was the only predictor of pregnancy after spinal cord injuries. Preterm delivery occurred in 33% of women; 22% were unable to feel preterm labor. Thrombosis (8%), urinary complications (59%), dysreflexia (27%), and worsened spasticity (22%) were the most common complications in pregnancy and post-partum depression (35%) was the most common complication in the puerperium. CONCLUSIONS: Inadequate information about pregnancy is common among young women with spinal cord injury. Heightened surveillance for certain complications is warranted in women with spinal cord injuries.

Predictors of umbilical artery acidosis in preterm delivery.

OBJECTIVE: The purpose of this study was to investigate the significance of preterm acidosis and its risk factors. STUDY DESIGN: From a cohort of 786 consecutive singleton neonates who were born after spontaneous or iatrogenic preterm delivery at 24.0-33.6 weeks of gestation from January 1993 to December 2005 with an evaluation of umbilical artery pH at delivery, we extracted demographic, obstetric, neonatal, and placental histologic variables and related them to umbilical artery evidence of fetal acidemia, which was defined as pH <7.10. Excluded were stillbirths and neonates with major congenital anomalies. Fetal distress was defined as nonreassuring fetal hearth rate tracing or biophysical profile or appearance of thick meconium at delivery. Statistical analysis included 1-way analysis of variance and logistic regression with a probability value of <.05 considered significant. RESULTS: Neonates with umbilical cord evidence of acidosis (n = 34) were born more frequently after abruption (P < .001), fetal distress (P < .001), and by cesarean delivery (P < .04) and were born less frequently after a complete course of corticosteroids (P = .03) and labor (P = .05) than nonacidotic babies (n = 752). Acute inflammatory lesions at placental histologic evaluation were less frequent (P = .049), and placental vascular lesions were more common in acidotic than in nonacidotic preterm neonates (P = .039). Logistic regression analysis demonstrated that cord acidosis was associated independently with the occurrence of abruptio placentae (odds ratio, 7.3; 95% CI, 2.9, 18.8), fetal distress (odds ratio, 12.0; 95% CI, 4.9, 18.3), and vascular placental lesions (odds ratio, 2.8; 95% CI, 1.2, 6.8) CONCLUSION: In preterm infants, umbilical artery acidosis is significantly more common in the presence of placental abruption, fetal distress, and histologic evidence of placental vascular disease.

Fetal intra-abdominal calcifications from meconium peritonitis: sonographic predictors of postnatal surgery.

OBJECTIVE: To study the relationship between prenatal ultrasound features and postnatal course of meconium peritonitis. STUDY DESIGN: We reviewed our cohort of cases of meconium peritonitis (MP) (n = 13/37, 225 pregnancies or 0.3/1000) as well as those published in the English literature with prenatal ultrasonographic findings and postnatal follow-up (n = 56). The total number of cases (n = 69) was divided into 4 grades of progressive severity based on the number of pertinent sonographic findings: grade 0, isolated intra-abdominal calcifications (n = 18); grade 1, intra-abdominal calcifications and ascites (n = 17) or pseudocyst (n = 2) or bowel dilatation (n = 6); grade 2, two associated findings (n = 20); and grade 3, all sonographic features (n = 6). Presence of polyhydramnios was also recorded. Prenatal predictors of need for neonatal surgery and risk of neonatal death were identified using Chi-square and Fisher exact test, with P < 0.05 considered significant. RESULTS: Neonatal surgical intervention was required in 0% (0/18) of newborns with grade 0 MP; in 52% (13/25) of those with grade 1; in 80% (16/20) with grade 2; and in 100% (6/6) with grade 3 MP (P < 0.001, Chi-square for trend). Moreover, neonatal surgery was more frequent in the presence than absence of polyhydramnios [69% (18/26) vs 37% (16/43); P = 0.007]. Neonatal mortality was 6% (4/69; 3 after surgery and 1 for premature delivery) and it was confined to the subgroup with polyhydramnios (4/26, 15%). CONCLUSIONS: Prenatal sonographic features are related to postnatal outcome. Persistently isolated intra-abdominal calcifications have an excellent outcome. Delivery in a tertiary care center is recommended when calcifications are associated with other sonographic findings.

Alagille syndrome: prenatal sonographic findings.

We report a case of Alagille syndrome in which sonographic examination revealed the presence of angulation of the fetal spine due to vertebral fusion as well as tetralogy of Fallot. Histologic examination after pregnancy termination revealed the presence of agenesis of the gallbladder with a paucity of intrahepatic bile ducts, leading to the diagnosis of Alagille syndrome. In the presence of cardiac and axial skeletal anomalies, attention should be paid to the fetal gallbladder, whose absence would signal a diagnosis of Alagille syndrome.

Large uterine leiomyomata and risk of cesarean delivery.

OBJECTIVE: To study the causes of the observed association between presence of leiomyomata in pregnancy and increase in risk of cesarean delivery. METHODS: We accessed the obstetric database of women who underwent second-trimester ultrasound screening between January 1996 and December 2004 and who delivered at more than 22 weeks of gestation. Ultrasonographic characteristics of the leiomyomata, including number, maximum diameter, change in size during pregnancy, and location were recorded. Pregnancy outcome was compared between the cohort with large uterine leiomyomata (5 cm or more) (n=251) and those without leiomyomata (n=24,546) using chi(2), Fisher exact test, Student t test, and linear and logistic regression analysis, with an odds ratio (OR) with 95% confidence interval (CI) not inclusive of the unity considered significant. RESULTS: Women with large leiomyomata had higher rates of cesarean delivery before onset of labor (OR 3.1, 95% CI 2.2-4.2) but not during labor (OR 1.0, 95% CI 0.6-1.6). The association between leiomyomata and cesarean delivery before labor remained significant after controlling for maternal age, nulliparity, fetal malpresentation, and placenta previa (OR 2.1, 95% CI 1.4-3.1). The only ultrasonographic leiomyoma characteristic independently associated with cesarean delivery before labor after controlling for confounders was maximum diameter of the largest leiomyoma (OR 1.3, 95% CI 1.1-1.4, P=.001). CONCLUSION: Uterine leiomyomata 5 cm or larger are independently associated with cesarean delivery performed before labor, and the risk increases with the size of the leiomyoma. LEVEL OF EVIDENCE: II.

Predictors of perinatal survival in a cohort of pregnancies with severe oligohydramnios due to premature rupture of membranes at <26 weeks managed with serial amnioinfusions.

OBJECTIVE: To evaluate whether successful amnioinfusion is an independent predictor of perinatal survival in a cohort of cases with extreme and persistent oligohydramnios due to preterm premature rupture of membranes (pPROM) who reached viability and were managed with serial amnioinfusions. STUDY DESIGN: We included all consecutive singleton pregnancies with pPROM at <26 weeks and oligohydramnios lasting >4 days between 1/1991 and 12/2001 and who consented to undergo amnioinfusion (n=77). Women received serial transabdominal amnioinfusions in an attempt to maintain a pocket of fluid >2 cm. The procedure was deemed successful if the median deepest pocket of fluid during the latency period was >2 cm. Excluded were miscarriages (n=10), fetal deaths before viability (24 weeks) (n=15), and cases that did not develop oligohydramnios (n=17). Prenatal predictors of outcome were compared between cases who survived the perinatal period and those who did not using Wilcoxon rank-sum test, Fisher's exact test and stepwise logistic regression analysis, with a two-tailed P<0.05 considered significant. RESULTS: Of the 35 patients fulfilling the study criteria, 20 (57%) survived the perinatal period. Perinatal survivors had similar gestational age at pPROM (P=0.68) and at first amnioinfusion (P=0.53) as those who died in the perinatal period, but longer latency (P=0.013). Consequently, median gestational age at delivery [29.2 (25.4-35.3) weeks versus 26.1 (24.0-34.0) weeks, P<0.001] and median birth weight [1220 (650-2240) g versus 863 (520-2200) g, P=0.001] were significantly greater among survivors than among those who died. Significant predictors of survival at univariate analysis were entered into a stepwise logistic regression analysis in the chronological order in which they normally occur. The analysis demonstrated that successful amnioinfusion (OR=6.9, 95% CI 1.2-40.4) and administration of steroids (OR=14.6, 95% CI 1.5-144.1) were independent and significant predictors of perinatal survival. CONCLUSION: In a cohort of women with pPROM at <26 weeks and severe oligohydramnios managed with serial amnioinfusions, successful procedures and prenatal administration of corticosteroids are the only independent predictors of perinatal survival.