Pregnancy outcomes in women with bariatric surgery as compared with morbidly obese women.

OBJECTIVE: Pregnancies among morbidly obese women are associated with serious adverse maternal and neonatal outcomes. Our study objective is to evaluate the effect of bariatric surgery on obstetrical outcomes. METHODS: We carried out a retrospective cohort study using the healthcare cost and utilization project - Nationwide Inpatient Sample from 2003 to 2011 comparing outcome of births among women who had undergone bariatric surgery with births among women with morbid obesity. Logistic regression was used to estimate the adjusted effect of bariatric surgery on maternal and newborn outcomes. RESULTS: There were 8 475 831 births during the study period (221 580 (2.6%) in morbidly obese women and 9587 (0.1%) in women with bariatric surgery). Women with bariatric surgery were more likely to be Caucasian and ≥35 years old as compared with morbidly obese women. As compared with women with morbid obesity, women with bariatric surgery had lower rates of hypertensive disorders, premature rupture of membrane, chorioamnionitis, cesarean delivery, instrumental delivery, postpartum hemorrhage, and postpartum infection. Induction of labor, postpartum blood transfusions, venous thromboembolisms, and intrauterine fetal growth restriction were more common in the bariatric surgery group. There were no differences observed in preterm births, fetal deaths, or reported congenital anomalies. CONCLUSION: In general, women who undergo bariatric surgery have improved pregnancy outcomes as compared with morbidly obese women. However, the bariatric surgery group was more likely to have venous thromboembolisms, to require a blood transfusion, to have their labor induced and to experience fetal growth restriction.

Incidence, indications, and predictors of adverse outcomes of postpartum hysterectomies: 20-year experience in a tertiary care centre.

OBJECTIVE: Postpartum hysterectomy is an uncommon yet serious obstetric procedure associated with maternal morbidity and mortality. The objectives of our study were to assess the incidence of and indications for PH and to identify predictors of massive hemorrhage and coagulopathy. METHODS: We conducted a retrospective cohort study on all cases of PH performed at the Jewish General Hospital, McGill University, between 1992 and 2011. Data were collected from individual patient charts and logistics regression models were used to evaluate predictors of adverse events. RESULTS: Over a 20-year study period, there were 76 938 live births and 67 postpartum hysterectomies for an overall incidence of 0.87/1000. Although overall PH rates increased over time predominantly because of increasing rates of planned PH for placental abnormalities, there was a decrease in unplanned emergency postpartum hysterectomies. The main indications for PH were abnormal placentation (64.2%) and postpartum hemorrhage (26.9%). In adjusted analysis, the risk of requiring massive blood transfusion was increased when PH was performed after vaginal delivery or Caesarean section (OR 102.1; 95% CI 4.22 to 2468) and in association with postpartum hemorrhage (OR 9.1; 95% CI 1.3 to 64.3). The risk of massive hemorrhage was lower if occlusive balloons were placed antenatally in the uterine arteries (OR 0.13; 95% CI 0.03 to 0.68) and if PH was performed by a dedicated experienced surgeon (OR 0.23; 95% CI 0.06 to 0.86). CONCLUSION: Although overall rates of PH are increasing, antenatal recognition of placental pathologies have resulted in fewer postpartum hysterectomies being done as emergencies. The use of occlusive balloons in the uterine arteries and having the procedure performed by a dedicated surgeon skilled in performing postpartum hysterectomy can reduce overall serious morbidity.

Objectif : L'hystérectomie postpartum (HP) est une intervention obstétricale peu courante, mais grave, qui est associée à de la morbidité et à la mortalité chez la mère. Les objectifs de notre étude étaient d'évaluer l'incidence de l'HP et ses indications, et d'identifier les facteurs prédictifs de l'hémorragie massive et de la coagulopathie. Méthodes : Nous avons mené une étude de cohorte rétrospective qui portait sur tous les cas d'HP menés à l'Hôpital général juif de l'Université McGill entre 1992 et 2011. Les données ont été tirées des dossiers des patientes ciblées et nous avons utilisé des modèles de régression logistique pour évaluer les facteurs prédictifs d'événements indésirables. Résultats : Au cours de la période d'étude de 20 ans, nous avons constaté 76 938 naissances vivantes et 67 cas d'hystérectomie postpartum, l'incidence globale de cette dernière étant donc de 0,87/1 000. Bien que les taux globaux d'HP aient connu une hausse avec le temps (principalement en raison de la hausse des taux d'HP planifiée en raison de la présence d'anomalies placentaires), nous avons constaté une baisse du nombre de cas d'hystérectomie postpartum d'urgence (non planifiées). Les principales indications de l'HP ont été la présence d'une placentation anormale (64,2 %) et celle d'une hémorragie postpartum (26,9 %). Dans le cadre d'une analyse corrigée, nous avons constaté que le risque de nécessiter une transfusion massive de sang connaissait une hausse lorsqu'une HP était menée à la suite d'un accouchement vaginal ou d'une césarienne (RC, 102,1; IC à 95 %, 4,22 - 2 468), ainsi qu'en association avec la présence d'une hémorragie postpartum (RC, 9,1; IC à 95 %, 1,3 - 64,3). Le risque d'hémorragie massive était moindre lorsque des ballonnets occlusifs étaient placés, avant la naissance, dans les artères utérines (RC, 0,13; IC à 95 %, 0,03 ­ 0,68) et lorsque l'HP était menée par un chirurgien d'expérience spécialisé (RC, 0,23; IC à 95 %, 0,06 - 0,86). Conclusion : Bien que les taux globaux d'HP soient en hausse, la capacité de reconnaître la présence de pathologies placentaires pendant la période prénatale s'est soldée en un nombre moindre de cas d'hystérectomie postpartum de nature urgente. L'utilisation de ballonnets occlusifs dans les artères utérines et le fait d'avoir recours à un chirurgien d'expérience spécialisé dans la tenue d'interventions d'hystérectomie postpartum peuvent atténuer le taux global de morbidité grave.

Pregnancies in young adolescent mothers: a population-based study on 37 million births.

OBJECTIVES: Pregnancy in young adolescents is often understudied. The objective of our study was to evaluate the effect of young maternal age on adverse obstetrical and neonatal outcomes. METHODS: We conducted a population-based cohort study using the Center for Disease Control and Prevention's Linked Birth-Infant Death and Fetal Death data on all births in the US between 1995 and 2004. We excluded all births of gestational age under 24 weeks and those with reported congenital malformations or chromosomal abnormalities. Maternal age was obtained from the birth certificate and relative risks estimating its effect on obstetrical and neonatal outcomes were computed using unconditional logistic regression analysis. RESULTS: 37,504,230 births met study criteria of which 300,627 were in women aged <15 years with decreasing rates from 11/1,000 to 6/1,000 over a 10-year period. As compared to women 15 years and older, women <15 were more likely to be black and Hispanic, less likely to have adequate prenatal care, and more likely to not have had any prenatal care. In adjusted analysis, births to women <15 were more likely to be IUGR, born under 28, 32, and 37 weeks' gestation and to result in stillbirths and infant deaths. Prenatal care was protective against infant deaths in women < 15 years of age. CONCLUSION: Although public health initiatives have been successful in decreasing rates of young adolescent pregnancies, these remain high risk pregnancies that may benefit from centers capable of ensuring adequate prenatal care.

Prediction of growth discordance in twins with the use of abdominal circumference ratios.

OBJECTIVE: The purpose of this study was to assess the accuracy of sonographic prediction of twin birth weight discordance using the abdominal circumference ratio. STUDY DESIGN: This was a prospective cohort of diamniotic twin gestations that underwent serial ultrasound examinations every 2 to 4 weeks from 11 to 38 weeks of gestation. Birth weight discordance was defined as > or =25% difference in birth weight, relative to the larger twin. The sensitivity, specificity, and predictive values for the abdominal circumference ratio were assessed for the prediction of growth discordance. RESULTS: Of 503 diamniotic twin pregnancies, 64 pregnancies (12.7%) had discordant fetal growth. The abdominal circumference ratio could be measured consistently throughout gestation in 100% of twin pairs. Receiver operating curve analysis showed that the abdominal circumference ratio was a good predictor of birth weight discordance (area under the curve = 0.80). An abdominal circumference ratio cutoff of 0.93 yielded a sensitivity and specificity of 61% and 84%, respectively. CONCLUSION: Twin birth weight discordance may be predicted at any gestational age with an abdominal circumference ratio <0.93.