Prevalence and descriptive analysis of congenital heart disease in parturients: obstetric, neonatal, and anesthetic outcomes.

STUDY OBJECTIVE: The study objectives are to (1) assess prevalence of congenital heart disease (CHD), (2) describe outcomes of pregnancies in women with CHD, (3) compare outcomes in women with and without CHD, and (4) characterize neonatal outcomes in pregnancies complicated by CHD. DESIGN: This was a retrospective cohort study of women who delivered at the University of Colorado Hospital. Diagnosis of CHD was identified based on history of cardiac disease, pulmonary disease, or subacute bacterial endocarditis prophylaxis during labor and confirmed with echocardiogram when available. Comprehensive retrospective review of anesthetic, obstetric, and neonatal outcomes was performed. SETTING: University of Colorado Hospital. PATIENTS: 18,226 women. INTERVENTIONS: Medical record review. MEASUREMENTS: Valvular abnormalities, New York Heart Failure Association classification scores, types of CHD, maternal age, race, gravidity, parity, maternal prepregnancy body mass index, cigarette use, type of delivery, type of analgesia used, early initiation of neuraxial analgesia, arrhythmias, need for peripartum diuretics, prolonged maternal hospital stay, preterm birth, small for gestational age, neonatal CHD, neonatal or maternal intensive care unit (ICU) admissions, and maternal or neonatal death. MAIN RESULTS: We identified 117 pregnancies in 110 women with CHD. Parturients with CHD were more likely to have operative vaginal delivery (P < .0001), neonatal ICU admissions (P = .003), and had prolonged hospital stays. Occurrence of CHD in neonates was 6%. Moderate-to-severe valvular disease was associated with increased rates of operative vaginal delivery, early initiation of neuraxial labor analgesia, cardiac complications (including arrhythmia and use of diuretics), prolonged hospital stay, and maternal ICU admission. However, most deliveries and births were uncomplicated; and there were one case each of maternal mortality and fetal death after birth. CONCLUSION: Operative abdominal deliveries and neonatal ICU admissions are more common in women with CHD, but these pregnancies are generally well tolerated with low mortality rates.

Fetal weight estimation in diabetic pregnancies using the gestation-adjusted projection method: comparison of two timing strategies for third-trimester sonography.

OBJECTIVES: The gestation-adjusted projection method extrapolates birth weight using third-trimester sonography. This technique is shown to be more accurate for sonographic examinations from 34 weeks to 36 weeks 6 days than 37 weeks to 38 weeks 6 days. Our objective was to determine whether even earlier sonographic examinations (31 weeks-33 weeks 6 days) further improves birth weight prediction in patients with diabetes. METHODS: We conducted a retrospective cohort analysis of 388 pregnant women with pregestational or gestational diabetes who delivered at 37 weeks or later and had a sonographic examination performed between 31 weeks and 36 weeks 6 days. Sonographic examinations were categorized as "early" if performed at 31 weeks to 33 weeks 6 days or "late" if performed at 34 weeks to 36 weeks 6 days. We estimated birth weight using the gestation-adjusted projection method, compared errors in prediction of birth weight using the t test and Mann-Whitney U test, and performed a 2-sample test of proportions to compare prediction of macrosomia (birth weight >4000 g). RESULTS: The early and late groups had similar mean gestational ages at birth (38 weeks 4 days versus 38 weeks 5 days; P = .13) and rates of macrosomia (10.7% versus 12.4%; P = .63). The early group had a greater mean absolute error (336 versus 297 g; P = .03) and percent error (9.9% versus 7.9%; P = .01) in birth weight prediction but a lower mean birth weight (3303 versus 3426 g; P = .02). Sensitivity for prediction of macrosomia was 19% in the early group versus 45% in the late group (P = .07), whereas specificity was similar (98% versus 96%; P = .27). CONCLUSIONS: Using the gestation-adjusted projection method in our patients with diabetes, we found that sonographic examinations performed at 34 weeks to 36 weeks 6 days better predicted birth weight than those performed at 31 weeks to 33 weeks 6 days.

Association of extremes of prepregnancy BMI with the clinical presentations of preterm birth.

OBJECTIVE: The purpose of this study was to examine associations between the prepregnancy maternal body mass index (BMI) across the 3 clinical presentations of preterm birth (PTB). STUDY DESIGN: We conducted a retrospective cohort study of the records of 11,726 women. The World Health Organization International Classification was used to categorize BMI. The primary outcome of the study was PTB (<37 weeks' gestation) presenting as spontaneous preterm labor, preterm premature rupture of the membranes, or a medical indication. We used univariable and multivariable logistic regression analysis to analyze the data (P < .05). RESULTS: We found (1) a significant increase in the overall incidence of PTB at the extremes of BMI, (2) a higher risk for PTB from spontaneous preterm labor at the lower extremes (low plus moderate thinness) of BMI (adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4-4.2; P = .003), (3) a higher risk for preterm premature rupture of the membranes at the upper extremes (obese class II plus III) of BMI (aOR, 1.6; 95% CI, 1.1-2.3; P = .02), and (4) a higher risk for a medically indicated PTB at the lower (aOR, 2.8; 95% CI, 1.4-5.6; P = .004) and upper (aOR, 1.5; 95% CI, 1.1-2.2; P = .02) extreme of BMI. CONCLUSION: Women at the extremes of prepregnancy BMI are at risk for PTB.

Intrapartum management of premature rupture of membranes: effect on cesarean delivery rate.

OBJECTIVE: To estimate whether it is possible to define clinically a subgroup of women who have so high a cesarean delivery rate as to avoid spontaneous onset of labor or induced labor. METHODS: We conducted a retrospective cohort study (October 2005 to January 2010) on a data set of women who had premature rupture of membranes (PROM) at greater than 24 weeks of gestation, a singleton pregnancy, and a viable fetus without congenital anomalies. Patients were treated in a common way regarding indications for delivery. The primary outcome was cesarean delivery. RESULTS: We identified 1,026 women (comprising 7.9% of all deliveries) who had PROM and met the inclusion criteria. There were 404 with preterm deliveries. One hundred thirty-seven (13.4%) had a contraindication to either labor or vaginal delivery. For women with induction (n=355), vaginal delivery occurred in 82%, whereas for those with spontaneous labor (n=534), vaginal delivery occurred in 87% (P=.03). No clinically defined subgroup had an observed cesarean delivery rate greater than 27%, and in most subgroups, it was lower, even when we built in multiple risk factors, including gestational age less than 34 weeks, chorioamnionitis, abruption, and nulliparity. CONCLUSION: In the absence of a contraindication to labor or to vaginal delivery, the likelihood of vaginal delivery after PROM, with either spontaneous or induced labor, is high, even when we included multiple risk factors for cesarean delivery. LEVEL OF EVIDENCE: II.