Neighborhood disorder predicts lower serum vitamin D levels in pregnant African American women: A pilot study.

Pregnant African American women are more likely to live in neighborhoods with more disorder (e.g., vacant housing, littler, crime) and to have vitamin D deficiency due to their darker skin pigmentation and poor production of vitamin D [25(OH)D] from ultraviolet rays. However, no study has examined the potential link between neighborhood disorder and 25(OH)D status in African American pregnant women. Forty-one pregnant African American women completed validated questionnaires about perceived neighborhood disorder (6 items; 3-point scale; range 6-18) and with concurrent serum levels of 25-hydroxyvitamin D [25(OH)D] assessed during pregnancy at 18-24 weeks gestation. Higher levels of perceived neighborhood disorder were associated with lower levels of serum 25(OH)D. Pregnant African American women who report higher disorder in their neighborhood may spend less time outside. Health care providers should include assessment of perceived neighborhood disorder. Future research needs to evaluate the relationships among neighborhood disorder and 25(OH)D levels among pregnant African American women.

Wound complications in obese women after cesarean: a comparison of staples versus subcuticular suture.

OBJECTIVE: To compare wound complications between staples versus subcuticular suture for skin closure in obese women (body mass index (BMI)⩾30 kg m(-2)) after cesarean delivery (CD). STUDY DESIGN: We conducted a retrospective cohort study to compare wound complications between staples and subcuticular suture closure in women, with a prepregnancy BMI⩾30 kg m(-2) after CD between 2006 and 2011 at an inner-city teaching hospital. Wound complication was defined as a composite of wound disruption (hematoma or seroma) or infection diagnosed up to 6 weeks postpartum. Variables collected include age, parity, prior CDs, prior abdominal surgeries, incision type, chorioamnionitis, maternal comorbidities (hypertension, diabetes) and gestational age. RESULTS: Of the 1147 women included in the study, women with staple closure were older and had higher BMIs (40.6±9.3 versus 36.1±5.4) and were more likely to be multiparous, have a prior CD, diabetes and hypertension compared with women with subcuticular suture. The overall occurrence of wound complications was 15.5% (178/1147). Women with staples had higher wound complications compared with sutures (22.0% versus 9.7%) with a 2.27 unadjusted relative risk (RR) (95% confidence interval (CI), 1.7 to 3.0) and 1.78 adjusted RR (95% CI, 1.27 to 2.49) after controlling for confounders in the final analysis, including vertical skin incisions. CONCLUSIONS: In obese women, skin closure with staples at the time of CD is associated with a higher rate of wound complications compared with subcuticular suture. Skin closure with subcuticular suture over staples should be considered in obese women undergoing a CD regardless of skin incision type.

Weight gain in twin gestations: are the Institute of Medicine guidelines optimal for neonatal outcomes?

OBJECTIVE: To assess neonatal outcomes according to gestational weight gain (GWG) in twins. STUDY DESIGN: This was a retrospective cohort study of twins delivered at ⩾24 weeks. GWG was defined using the Institute of Medicine (IOM) guidelines as the referent. Birthweight and neonatal intensive-care unit (NICU) admissions were compared with ≥(2)- and analysis of variance tests, stratified by body mass index (BMI). RESULT: In all three BMI groups, mean birth weight of the larger and smaller twin increased as GWG increased, P<0.01. For the underweight/normal-weight group, both twins <2500 g, <1500 g and small for gestational age decreased significantly as GWG increased. Birthweight <2500 g increased in all groups with GWG below the IOM guidelines, P<0.01. In the multivariate analysis, both twins <2500 g were significantly decreased with GWG above IOM guidelines. There was no difference in NICU admissions with GWG above the IOM guidelines. CONCLUSION: GWG above the IOM guidelines may improve twin birth weights, with the findings most significant in underweight/normal-weight women.

Intrapartum cesarean delivery in nulliparas: risk factors compared by two analytical approaches.

OBJECTIVE: To determine risk factors for cesarean delivery in nulliparas at labor admission. STUDY DESIGN: Nulliparas with live-born, singleton gestations ⩾37 weeks in spontaneous or induced labor were analyzed from the Consortium on Safe Labor database in a retrospective observational study. Classification and regression tree (CART) and multivariate logistic regression analysis determined risk factors for cesarean delivery. RESULT: Of the 66 539 nulliparas, 22% had a cesarean delivery. In the CART analysis, the first cervical dilation exam was the first branch followed by body mass index (BMI). Cesarean deliveries occurred in 45%, 25%, 14% and 10% of deliveries at <1, 1 to 3, 4 and ⩾5 cm dilated, respectively. The BMI influence was most evident in the <1 cm dilation category with 26% of BMI <25 kg m(-2) and 66% of BMI ⩾40 kg m(-2) having a cesarean delivery. The fewest cesarean deliveries (5%) occurred in those ⩾5 cm and BMI <25 kg m(-2). In the multivariate regression analysis, first cervical dilation exam <1 cm (odds ratio (OR) 5.1, 95% confidence interval (CI): 4.5 to 5.7; reference ⩾5 cm) and BMI ⩾40 kg m(-2) (OR 5.1, 95% CI: 4.6 to 5.7; reference BMI <25.0 kg m(-2)) had the highest odds for cesarean delivery. CONCLUSION: Cervical dilation on admission followed by BMI were the two most important risk factors for cesarean delivery identified in both CART and multivariate regression analysis.

Induction of labor compared to dilation and evacuation for postmortem analysis.

OBJECTIVE: This study aimed to evaluate the ability to obtain autopsy and cytogenetics after midtrimester termination. METHODS: A retrospective cohort study of women undergoing termination, via induction or dilation and evacuation (D&E), at 16 0/7-23 6/7 weeks was performed. Exclusion criteria were elective termination, preterm labor, PPROM, and no autopsy or cytogenetic exam performed. The ability to obtain cytogenetics and autopsy as well as complications rates were compared between the two groups with Chi-square tests. RESULTS: Of the 469 women who met the inclusion criteria, 158 had an induction and 312 had a D&E. The induction of labor group had higher mean gestational ages, p < 0.01. Successful autopsy was more likely in the induction group, 94.3%, versus D&E group, 34.7%, p = 0.01. There was no difference in ability to obtain cytogenetics between the two groups, 89.1% in the induction group, and 92.3% in D&E group, p = 0.4. There was a difference in the total complication rates between the groups, 9.8% (26) in the induction versus 6.4% (20) in the D&E group, p < 0.01; however, there was no difference in major complications. CONCLUSIONS: Midtrimester terminations by induction were more likely to have successful autopsies when compared with D&E. The ability to obtain cytogenetics was similar regardless of termination mode.

The effects of labor and delivery on maternal and neonatal outcomes in term twins: a retrospective cohort study.

OBJECTIVE: To compare maternal and neonatal outcomes in twins undergoing a trial of labor versus pre-labor caesarean. DESIGN: Retrospective cohort study. SETTING: 19 US hospitals from the Consortium on Safe Labor. POPULATION: Of 2225 twin sets ≥36 weeks' gestation. METHODS: Maternal (abruption, estimated blood loss, postpartum haemorrhage, transfusion, chorioamnionitis, hysterectomy, ICU admission, death) and neonatal outcomes (birth injury, 5-minute Apgar <7, NICU admission, RDS, TTN, sepsis, asphyxia, NICU length of stay, death) were compared between the trial of labour and pre-labour caesarean groups with univariate and multivariate logistic and linear regression analyses. Similar analyses were performed for actual delivery modes. MAIN OUTCOME MEASURES: Maternal and neonatal outcomes. RESULTS: Among the 2225 twin sets, 1078 had a trial of labour, and 65.9% of those delivered vaginally. There was an increased risk for postpartum haemorrhage [OR 2.5, 95% confidence interval (CI) 1.4-4.5] and blood transfusion (OR 1.9, 95%CI 1.2-3.2) for the trial of labour compared with pre-labour caesarean groups. Birth injury only occurred in the trial of labour group, 1% Twin A, 0.4% Twin B. Both twins had a higher risk of 5-minute Apgar <7 with trial of labour compared to pre-labour caesarean (A: OR 3.9, 95%CI 1.05-14.5; B: OR 3.9, 95%CI 1.3-12.3). CONCLUSION: Term twins undergoing a trial of labour have increased maternal haemorrhage and transfusions along with neonatal birth trauma and lower Apgar scores, but these absolute neonatal occurrences were rare. Trial of labour in twins remains a safe and reasonable option in appropriately selected cases.

Maternal obesity: do patients understand the risks?

OBJECTIVE: To evaluate patient knowledge of the risks of maternal obesity and compare knowledge between non-obese and obese women. STUDY DESIGN: A face-to-face survey was administered to 105 women at their first prenatal visit. The survey assessed their knowledge of obesity-related risks during pregnancy, weight history and goals and health behaviors. Descriptive statistics described the entire sample. Student's t-test and chi(2) tests compared knowledge between non-obese (body mass index (BMI) of <30 kg m(-2)) and obese (BMI of > or =30 kg m(-2)) gravidas. RESULT: There were 56 (54%) non-obese and 47 (46%) obese participants. There were no significant differences between the weight groups with respect to age, race, insurance, education, tobacco use and primigravity. Overall, 49% participants knew that obesity increases risks in pregnancy. The knowledge of specific risks was similar in the non-obese (60% correct) and obese (64% correct) groups (P=0.76). Obese patients were more aware of the risk for diabetes (68 vs 96%, P<0.001). Obese gravidas expressed more interest in weight loss before another pregnancy (61 vs 81%, P=0.03), although the desired BMIs (22.1+/-2.3 vs 26.2+/-3.0 kg m(-2), P<0.001) were different for non-obese and obese women, respectively. Of all participants, 9% discussed the risks of maternal obesity with a provider before study participation and 75% wanted to participate in a study on weight loss before pregnancy to determine whether it leads to healthier pregnancies. CONCLUSION: Regardless of BMI category, patients required more knowledge about the risks of obesity in pregnancy, requested additional information and were motivated to lose weight before future pregnancies. Because obese women underestimated their optimal weight loss goals, it is necessary to target this group for further education.

The impact of tobacco smoking on perinatal outcome among patients with gestational diabetes.

OBJECTIVE: To determine the effects of tobacco use on perinatal outcomes among patients with gestational diabetes (GDM). STUDY DESIGN: This was a retrospective cohort study of singleton pregnancies with GDM and live births from 2003 to 2006. The primary outcome, large for gestational age (LGA) infants, was compared between smoking and nonsmoking groups. Secondary outcomes included cesarean deliveries, shoulder dystocia, birth trauma, peripartum complications, macrosomia, 5-min Apgar score < or =3, birth defects, and neonatal intensive care unit (NICU) admissions. chi(2) and Student t-tests compared the two groups; a P-value <0.05 was statistically significant and odds ratios (OR) were reported with 95% confidence intervals (CI). A multivariate logistic regression analysis controlled for variables known to affect outcomes in GDM. RESULT: We identified 915 patients with GDM, of which 130 (14.2%) smoked during pregnancy. Women who smoked during pregnancy were less likely to have LGA infants (22.4 vs 31.2%; OR, 0.61; 95% CI, 0.39 to 0.95). In a logistic regression analysis, the inverse relationship between smoking and LGA persisted (OR, 0.59; 95% CI, 0.36 to 0.97) after controlling for maternal age, multiparity, ethnicity, weight status before pregnancy, weight gain during pregnancy, and male gender. Preterm labor, preeclampsia, Cesareans, shoulder dystocia, and birth trauma were similar in both groups. PPROM was more likely to occur in nonsmokers (0 vs 4%, P=0.03), but postpartum hemorrhage was more common among smokers (OR, 2.3; 95% CI, 1.02 to 5.31). Macrosomia, low 5-min Apgar score, birth defects, and NICU admissions were similar between the groups. CONCLUSION: Patients with GDM who smoke during pregnancy were 40% less likely to have LGA infants. However, smoking was not protective of other common morbidities associated with GDM.

Low-molecular-weight heparin in pregnancy: peripartum bleeding complications.

OBJECTIVE: To compare bleeding complications in pregnant patients treated with low-molecular-weight heparin (LMWH) to untreated controls. STUDY DESIGN: A case-control study of patients from 2001 to 2005 who received prophylactic or therapeutic doses of LMWH during pregnancy was carried out. Indications for LMWH included current or prior thromboembolism, thrombophilia, or heart valve replacement. Controls were chosen in a 2:1 ratio to cases, matched for delivery route, and selected as the next two consecutive deliveries. The primary outcome was postpartum hemorrhage (PPH). Odds ratios (ORs) were calculated with 95% confidence intervals (CIs). RESULTS: Forty-nine women treated with LMWH delivered 55 infants. Current or prior thromboembolic disease was the anticoagulation indication in 15/55 (27.3%) and 26/55 (47%) of pregnancies, respectively. There were more obese gravidas (OR 3.91, CI 1.70 to 9.09) and labor induction was more common in the LMWH group, 25/55 (45%) vs 29/110 (26%), P=0.01. There was no difference in estimated blood loss (295.7+/-145.7 vs 308.6+/-111.9 cm(3), P=0.62 vaginal; 687.5+/-251.8 vs 765.0+/-313.2 cm(3), P=0.34 cesarean), PPH (6/55, 11% vs 9/110, 8.2% OR 1.37, CI 0.16 to 11.5) or transfusion (3/55, 5.4% vs 4/110, 3.6% OR 1.50, CI 0.3 to 7.48) between the cases and controls. There were two cases of postpartum pulmonary emboli, one with a maternal mortality. CONCLUSION: Bleeding complications, including PPH and transfusion, in patients treated with LMWH during pregnancy were not increased when compared to normal controls matched for delivery route.