Recent trends in term trial of labor after cesarean by number of prior cesarean deliveries.

BACKGROUND: Cesarean delivery is a major source of maternal morbidity, and repeat cesarean delivery accounts for 40% of cesarean delivery, but recent data on the trial of labor after cesarean and vaginal birth after cesarean are limited. OBJECTIVE: This study aimed to report the national rates of trial of labor after cesarean and vaginal birth after cesarean by number of previous cesarean deliveries and examine the effect of demographic and clinical characteristics on these rates. STUDY DESIGN: This was a population-based cohort study using the US natality data files. The study sample was restricted to 4,135,247 nonanomalous singleton, cephalic deliveries between 37 and 42 weeks of gestation, with a history of previous cesarean delivery and delivered in a hospital between 2010 and 2019. Deliveries were grouped by number of previous cesarean deliveries (1, 2, or ≥3). The trial of labor after cesarean (deliveries with labor among deliveries with previous cesarean delivery) and vaginal birth after cesarean (vaginal deliveries among trial of labor after cesarean) rates were computed for each year. The rates were further subgrouped by history of previous vaginal delivery. Year of delivery, number of previous cesarean deliveries, history of previous cesarean delivery, age, race and ethnicity, maternal education, obesity, diabetes mellitus, hypertension, inadequate prenatal care, Medicaid payer, and gestational age were examined concerning the trial of labor after cesarean and vaginal birth after cesarean using multiple logistic regression. SAS software (version 9.4) was used for all analyses. RESULTS: The trial of labor after cesarean rates increased from 14.4% in 2010 to 19.6% in 2019 (P<.001). This trend was seen in all categories of number of previous cesarean deliveries. Moreover, vaginal birth after cesarean rates increased from 68.5% in 2010 to 74.3% in 2019. The trial of labor after cesarean and vaginal birth after cesarean rates were the highest for deliveries with a history of both 1 previous cesarean delivery and a vaginal delivery (28.9% and 79.7%, respectively) and the lowest for those with a history of ≥3 previous cesarean deliveries and no history of vaginal delivery (4.5% and 46.9%, respectively). Factors associated with the trial of labor after cesarean and vaginal birth after cesarean rates are similar, but several factors have different directions of effect, such as non-White race and ethnicity, which is associated with a higher likelihood of trial of labor after cesarean but a lower likelihood of successful vaginal birth after cesarean. CONCLUSION: More than 80% of patients with a history of previous cesarean delivery deliver by repeat scheduled cesarean delivery. With vaginal birth after cesarean rates increasing among those who attempt a trial of labor after cesarean, emphasis should be put on safely increasing the trial of labor after cesarean rates.

Development of the Sepsis-Associated Adverse Outcomes in Pregnancy Score.

OBJECTIVE: This study aimed to develop and evaluate a scoring system-called the Sepsis-Associated Adverse Outcomes in Pregnancy (SAAP) Score-to identify individuals with maternal infection that have composite maternal adverse outcomes (CMAO). STUDY DESIGN: Using the International Classification of Disease codes, we identified pregnant and postpartum (up to 6 weeks after birth) individuals admitted at our center with a primary diagnosis of infection. The primary outcome was CMAO which included any of the following: maternal intensive care unit admission, surgical intervention, vasopressor use, acute respiratory distress syndrome, pulmonary edema, mechanical ventilation, high-flow nasal cannula, disseminated intravascular coagulation, dialysis, organ failure, venous thromboembolism, or maternal death. Regularized logistic regression was used to identify variables that best discriminate CMAO status. Variables were chosen for inclusion following evaluation of statistical and clinical significance. Model performance was evaluated using area under the curve (AUC) with 95% confidence intervals (CIs), sensitivity, specificity, and predictive values. RESULTS: Of the 23,235 deliveries during the study period, 227 (0.9%) individuals met inclusion criteria and among them CMAO occurred in 39.2% (95% CI: 33.1-45.7%). The SAAP score consisted of six variables (white blood cell count, systolic blood pressure, respiratory rate, heart rate, lactic acid, and abnormal diagnostic imaging) with scores ranging from 0 to 11 and a score of ≥7 being abnormal. An abnormal SAAP score had an AUC of 0.80 (95% CI: 0.74-0.86) for CMAO. The sensitivity and specificity of the SAAP score for CMAO was 0.71 (95% CI: 0.60-0.80) and 0.73 (95% CI: 0.64-0.80), respectively. The positive predictive value was 0.62 (95% CI: 0.52-0.72) and negative predictive value was 0.79 (95% CI: 0.71-0.86). CONCLUSION: Pending external validation, the sixth variable SAAP score may permit early recognition of pregnant and postpartum individuals with infection who are likely to develop adverse maternal outcomes. KEY POINTS: · Sepsis is a leading cause of maternal morbidity and mortality.. · Early recognition improves maternal sepsis outcomes.. · The SAAP score may permit early recognition of maternal adverse outcomes due to infection..

Maternal Sepsis: A Review of National and International Guidelines.

Sepsis is a life-threatening syndrome caused by the body's response to infection. The Global Maternal Sepsis Study (GLOSS) suggests sepsis plays a larger role in maternal morbidity and mortality than previously thought. We therefore sought to compare national and international guidelines for maternal sepsis to determine their consistency with each other and the Third International Consensus for Sepsis and Septic Shock (SEPSIS-3). Using Cochrane Database of Systematic Reviews, PubMed, Google Scholar, and organization Web sites, we identified seven guidelines on maternal sepsis in the English language-The American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Society of Obstetric Medicine of Australia and New Zealand, Royal College of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland Institute of Obstetricians and Gynaecologists, and World Health Organization. Guidelines were reviewed to ascertain the commonality and variation, if any, in definitions of maternal sepsis, tools and criteria utilized for diagnosis, obstetric warning systems used, as well as evaluation and management of maternal sepsis. These variables were also compared with SEPSIS-3. All guidelines provided definitions consistent with a version of the SEPSIS, although the specific version utilized were varied. Clinical variables and tools employed for diagnosis of maternal sepsis were also varied. Evaluation and management of maternal sepsis and septic shock were similar. In conclusion, national and international maternal sepsis guidelines were incongruent with each other and SEPSIS-3 in diagnostic criteria and tools but similar in evaluation and management recommendations. KEY POINTS: · Definitions for maternal sepsis and septic shock are varied.. · Maternal sepsis guidelines differ in proposed criteria and tools.. · Maternal sepsis guidelines have similar management recommendations..

Clinical findings predictive of maternal adverse outcomes with pyelonephritis.

BACKGROUND: Pyelonephritis, a leading cause of infection during pregnancy, is associated with increased maternal adverse outcomes. Therefore, early recognition and intervention of pyelonephritis are important. Early recognition of pyelonephritis has historically been dependent on fever and costovertebral angle tenderness. However, the reliability of these findings to distinguish women who will develop maternal adverse outcomes is limited. OBJECTIVE: This study aimed to identify clinical variables on presentation that are predictive of maternal adverse outcomes associated with pyelonephritis during pregnancy. STUDY DESIGN: A retrospective cohort study of pregnant women admitted with pyelonephritis at a single hospital from October 1, 2015, to July 31, 2021, was conducted. The primary outcome was a composite maternal adverse outcome consisting of any of the following: maternal intensive care unit admission, surgical intervention, hypotension requiring vasopressors, acute respiratory distress syndrome, pulmonary edema, mechanical ventilation, high-flow nasal cannula, disseminated intravascular coagulation, altered mental status, dialysis, organ failure, venous thromboembolism, or maternal death. Differences in maternal characteristics and clinical signs and symptoms on admission were stratified by the presence or absence of a maternal adverse outcome. Categorical variables were analyzed using the Fisher exact test. Continuous data were analyzed with Wilcoxon rank-sum test. Sensitivity and specificity and likelihood ratios with 95% confidence intervals were calculated for the detection of maternal adverse outcomes by specified admission physical examination and laboratory findings. RESULTS: Of 97 women that met the inclusion criteria, 28 (28.9%) had maternal adverse outcomes. Moreover, 50 of 97 women (51.5%) had fever on presentation, with no difference between cohorts recognized. Admission vital signs were not significantly different between cohorts. Costovertebral angle tenderness was present in 78 of 97 women (80.4%) on presentation, with no difference between cohorts. Compared with women without a maternal adverse outcome, women with maternal adverse outcomes were more likely to have leukocytosis (18/28 [64.3%] vs 20/69 [29.0%]), thrombocytosis (3/28 [10.7%] vs 5/69 [7.2%]), bandemia (8/28 [28.6%] vs 7/69 [10.1%]), and an abnormal serum potassium (20/28 [71.4%] vs 32/63 [50.8%]). CONCLUSION: Admission vital signs may not reliably identify women with pyelonephritis at risk of maternal adverse outcomes. Laboratory studies, particularly a complete blood count and electrolytes, may provide a means of distinguishing those at risk of maternal adverse outcomes.

Body mass index and adverse outcomes among singletons with cerclage.

OBJECTIVE: To compare the neonatal and maternal adverse outcomes among women with cerclage and prepregnancy body mass index (BMI) < versus > 30 kg/m2 STUDY DESIGN: This retrospective cohort study utilized the U.S. Vital Statistics Datasets from 2011-2013. Inclusion criteria were women with non-anomalous singletons, with cerclage placement, without diabetes or hypertensive disorders, and who delivered at 20-41 weeks. The primary outcome was the composite neonatal adverse outcome (Apgar score below 5 at 5 min, birth injury, assisted ventilation for more than 6 h, neonatal seizure, or neonatal death). The secondary outcomes included the composite maternal adverse outcome (admission to intensive care unit, maternal transfusion, ruptured uterus, unplanned hysterectomy, or unplanned operating room procedure), chorioamnionitis, and cesarean delivery. Multivariable Poisson regression models with robust error variance were used, while adjusting for confounders. Adjusted relative risk with 95 % confidence intervals were calculated. RESULTS: Of the 22,466 live births that met the inclusion criteria during the study period, 6427 (28.6 %) had cerclage and prepregnancy BMI ≥ 30 kg/m2. The composite neonatal adverse outcome was significantly increased (aRR 1.45; 95 % CI 1.33-1.60) among women with cerclage and BMI ≥ 30 kg/m2 when compared to those with BMI < 30 kg/m2. The composite maternal adverse outcome was similar (aRR 0.93; 95 % CI 0.72-1.20) among the two groups. Chorioamnionitis (aRR 1.46; 95 % CI 1.24-1.72) and cesarean delivery (aRR 1.24; 95 % CI 1.19-1.29) were higher in women with cerclage and BMI ≥ 30 kg/m2. CONCLUSION: Among pregnancies with cerclage and delivery at 20-41 weeks, the risk of the composite neonatal adverse outcome was modestly increased in newborns delivered by women with BMI ≥ 30 kg/m2 than those delivered by women with BMI < 30 kg/m2. No significant difference was found in the risk of the composite maternal adverse outcome.

Successful Vaginal Delivery during Acute Small Bowel Obstruction: A Case Report and Review of the Literature.

Small bowel obstruction during pregnancy is rare and can be detrimental to both mother and fetus. In most cases, management eventually involves surgical intervention. Little is known regarding optimal mode of delivery in those with bowel obstruction during pregnancy. We present a case of vaginal delivery during acute small bowel obstruction as well as a review of recent literature regarding mode of delivery in the setting of bowel obstruction. Our case and literature review demonstrates that in pregnancies complicated by small bowel obstruction, successful vaginal delivery can be achieved in those with stable maternal-fetal status.

Association of Cerclage with Composite Adverse Outcomes among Women Delivered at 36 Weeks or Later.

OBJECTIVE: This study aimed to compare the maternal and neonatal adverse outcomes among singletons delivered at 36 weeks or later with cerclage during index pregnancy versus those without cerclage. STUDY DESIGN: This retrospective cohort study utilized the U.S. vital statistics datasets from 2011 to 2013. Inclusion criteria were women with nonanomalous singletons, with and without cerclage placement, without diabetes or hypertensive disorders, and delivered at 36 to 41 weeks. The coprimary outcomes were composite maternal and neonatal adverse outcomes. Composite maternal adverse outcome included admission to intensive care unit, maternal transfusion, ruptured uterus, unplanned hysterectomy, or unplanned operating room procedure. Composite neonatal adverse outcome included Apgar score less than 5 at 5 minutes, assisted ventilation for more than 6 hours, neonatal seizure, birth injury, or neonatal death. Secondary outcomes were chorioamnionitis and cesarean delivery. Multivariable Poisson's regression models with error variance were used while adjusting for confounders. Adjusted relative risk (aRR) with 95% confidence intervals (CIs) were calculated. RESULTS: Of the 8,508,228 women who met inclusion criteria, 0.2% had a cerclage and reached 36 weeks. Composite maternal (aRR: 2.04; 95% CI: 1.76-2.36) and neonatal (aRR: 1.28; 95% CI: 1.11-1.47) adverse outcomes were significantly higher among those with cerclage than those without cerclage. Chorioamnionitis (aRR: 1.47; 95% CI: 1.30-1.67) and cesarean delivery (aRR: 1.10; 95% CI: 1.08-1.12) were also significantly higher in women with cerclage than those without cerclage. CONCLUSION: There is an association between increased composite maternal and neonatal adverse outcomes among women with cerclage who delivered at 36 to 41 weeks as compared with those without cerclage. KEY POINTS: · Cerclage is associated with increased composite maternal adverse outcome in women at 36-41 weeks.. · Cerclage is associated with increased composite neonatal adverse outcome in women at 36-41 weeks.. · Increased chorioamnionitis and cesarean delivery rates are associated with cerclage in women at 36-41 weeks..

General Guidelines in the Management of an Obstetrical Patient on the Labor and Delivery Unit during the COVID-19 Pandemic.

Novel coronavirus disease 2019 (COVID-19) is a respiratory tract infection that was first identified in China. Since its emergence in December 2019, the virus has rapidly spread, transcending geographic barriers. The World Health Organization and the Centers for Disease Control and Prevention have declared COVID-19 as a public health crisis. Data regarding COVID-19 in pregnancy is limited, consisting of case reports and small cohort studies. However, obstetric patients are not immune from the current COVID-19 pandemic, and obstetric care will inevitably be impacted by the current epidemic. As such, clinical protocols and practice on labor and delivery units must adapt to optimize the safety of patients and health care workers and to better conserve health care resources. In this commentary, we provide suggestions to meet these goals without impacting maternal or neonatal outcomes. KEY POINTS: • Novel coronavirus disease 2019 (COVID-19) is a pandemic.• COVID-19 impacts care of obstetric patients.• Health care should be adapted for the COVID-19 pandemic.

Serous Papillary Adenocarcinoma of Unknown Primary in a Recurrent Paravaginal Cyst.

Cystic lesions located in the paravaginal region are rare. When present, paravaginal cysts are typically benign and are incidentally found on routine gynecological exams; however, rarely they can be malignant. Treatment options for paravaginal cancers are not well studied and early diagnosis may help improve prognosis in these patients. Our case describes a 55-year-old female with a recurrent paravaginal cyst that was remarkable for serous papillary adenocarcinoma despite biopsy and fluid cytology negative for malignancy. This case demonstrates that malignancy should be considered highly with a recurrent paravaginal cyst, especially when present over a short interval.

Bovine Pericardial Graft for Second-Trimester Cesarean Scar Dehiscence.

BACKGROUND: Cesarean scar dehiscence is rare in pregnancy. When it occurs late in pregnancy, management typically involves delivery of the fetus with concurrent uterine repair. However, consensus regarding management earlier in gestation is lacking. CASE: A 30-year-old African American woman, gravida 5 para 2113, presented with cesarean scar dehiscence confirmed by magnetic resonance imaging at 20 weeks of gestation. She desired pregnancy continuation and underwent repair of the dehiscence at 23 weeks of gestation using bovine pericardial graft. She subsequently underwent cesarean delivery at 35 weeks of a healthy neonate after going into preterm labor. CONCLUSION: Bovine pericardial graft is a viable option for repair of cesarean scar dehiscence in the second trimester.

Recurrent Wernicke's encephalopathy in pregnancy: A case report.

INTRODUCTION: Wernicke's encephalopathy (WE) is an acute neurologic syndrome resulting from a deficiency in thiamine, also known as Vitamin B1. Thiamine stores can be depleted rapidly in patients with severe hyperemesis. Treatment with thiamine typically results in complete resolution of the neurological abnormalities. CASE REPORT: A 15-year-old G2P0010 at 13.2 weeks gestation presented with altered mental status and transaminitis. She had a medical termination in her previous pregnancy following an admission for a similar clinical scenario. She was initially thought to have a postoperative surgical complication due to recent cholecystectomy, but further evaluation revealed thiamine depletion. Magnetic resonance imaging confirmed the diagnosis of WE. Repletion of thiamine and folic acid resulted in rapid clinical improvement. CONCLUSION: WE should be considered in the differential diagnosis of pregnant patients with hyperemesis and altered mental status. A prior history of WE increases the risk of recurrence during pregnancy. Severe hyperemesis during pregnancy increases the risk of thiamine deficiency and WE. Early thiamine supplementation may reduce the risk of WE in patients with a prior clinical history or in patients with severe hyperemesis gravidarum.

A report of Bell's Palsy triggered by leptomeningeal metastases from recurrent high grade serous ovarian cancer.

•CNS metastases involving leptomeninges (LM) are extremely rare in patients with ovarian cancer.•Prognosis for ovarian cancer patients with LM metastases is very poor and treatment is palliative in nature.•Chemotherapy is administered intrathecally via an Ommaya reservoir or intra-CSF via repeated lumbar punctures.•Early recognition of LM metastases can help maintain the patients' quality of life by minimizing neurological deficits.

Management of herpes zoster (shingles) during pregnancy.

An infection with the varicella-zoster virus (VZV) causes both varicella and herpes zoster (HZ). Although rare, the development of HZ does occur during pregnancy. Maternal HZ does not result in increased foetal mortality, and the passage of VZV to the foetus rarely occurs. However, HZ does increase maternal morbidity. Upon infection with HZ, patients typically present with a viral prodrome preceding the appearance of the characteristic zoster rash. HZ is usually diagnosed clinically by the zoster rash, but can also be confirmed by a polymerase chain reaction and an enzyme-linked immunosorbent assay. Pregnant women with an uncomplicated HZ should be treated with oral acyclovir. The major complications of HZ are subacute herpetic neuralgia and post-herpetic neuralgia. Other complications include zoster ophthalmicus, disseminated HZ and secondary bacterial infections. Regarding prophylaxis, the varicella and the zoster vaccines are not recommended for pregnant women, and it is important to advise non-immune pregnant women to avoid an exposure to VZV. Although HZ infection has a minimal effect on the foetus, maternal HZ and its complications cause a significant burden. It is important to focus care on the mother with appropriate treatment and management of complications as they develop.