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1.
Int J Gynecol Pathol ; 2019 Aug 19.
Artigo em Inglês | MEDLINE | ID: mdl-31433375

RESUMO

Incidental pathologic findings at the time of Cesarean section are exceedingly uncommon. Similarly, occult low-grade appendiceal mucinous neoplasms and other noninflammatory, non-neoplastic appendiceal pathologies are rare, although appendiceal neoplasia, most commonly well-differentiated neuroendocrine tumors, may be found during evaluation of acute appendicitis. Here we report the first case of incidental coincident low-grade appendiceal mucinous tumor and endometriosis involving the appendix at the time of Cesarean section. We highlight pitfalls in the histopathologic evaluation of these processes, particularly given the setting of decidualization of ectopic endometrial stroma, as well as the prognostic implications of low-grade appendiceal mucinous tumors to emphasize the importance of clinicopathologic correlation and careful intraoperative examination of the appendix and other visible structures during Cesarean section.

3.
Acta Obstet Gynecol Scand ; 98(11): 1386-1397, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31070780

RESUMO

Normal pregnancy leads to a state of chronically increased intra-abdominal pressure. Obstetric and non-obstetric conditions may increase intra-abdominal pressure further, causing intra-abdominal hypertension and abdominal compartment syndrome, which leads to maternal organ dysfunction and a compromised fetal state. Limited medical literature exists to guide treatment of pregnant women with these conditions. In this state-of-the-art review, we propose a diagnostic and treatment algorithm for the management of peripartum intra-abdominal hypertension and abdominal compartment syndrome, informed by newly available studies.

5.
Am J Perinatol ; 2019 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-30991440

RESUMO

OBJECTIVE: To examine whether labor before cesarean affects the risk of placenta accreta spectrum (PAS) disorders in a subsequent pregnancy. STUDY DESIGN: This is a secondary analysis of the Cesarean Registry, a prospective cohort study of women undergoing cesarean between 1999 and 2002. Women with one prior cesarean with known indications, which were categorized as likely associated with labor (labored cesarean) versus likely not associated with labor (unlabored cesarean), were included. Primary outcome was PAS disorder. RESULTS: Of 34,224 women, 60% had a "labored cesarean" and 40% had an "unlabored cesarean." Women with prior unlabored cesarean were more likely to have subsequent PAS disorder compared with women with a prior labored cesarean after adjusting for confounders (0.28 vs. 0.13%; adjusted odds ratio: 2.03; 95% confidence interval: 1.22-3.38). CONCLUSION: Prior unlabored cesarean is associated with an increased risk of PAS disorders in a subsequent pregnancy. This association may aid in risk stratification in women with suspected PAS disorders and help counsel about risks associated with cesarean on maternal request.

6.
Curr Opin Obstet Gynecol ; 31(2): 83-89, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30789842

RESUMO

PURPOSE OF REVIEW: Overprescribing opioids contributes to the epidemic of drug overdoses and deaths in the United States. Opioids are commonly prescribed after childbirth especially after caesarean, the most common major surgery. This review summarizes recent literature on patterns of opioid overprescribing and consumption after childbirth, the relationship between opioid prescribing and chronic opioid use, and interventions that can help reduce overprescribing. RECENT FINDINGS: It is estimated that more than 80% of women fill opioid prescriptions after caesarean birth and about 54% of women after vaginal birth, although these figures vary greatly by geographical location and setting. After opioid prescriptions are filled, the median number of tablets used after caesarean is roughly 10 tablets and the majority of opioids dispensed (median 30 tablets) go unused. The quantity of opioid prescribed influences the quantity of opioid used. The risk of chronic opioid use related to opioid prescribing after birth may seem not high (annual risk: 0.12-0.65%), but the absolute number of women who are exposed to opioids after childbirth and become chronic opioid users every year is very large. Tobacco use, public insurance and depression are associated with chronic opioid use after childbirth. The risk of chronic opioid use among women who underwent caesarean and received opioids after birth is not different from the risk of women who received opioids after vaginal delivery. SUMMARY: Women are commonly exposed to opioids after birth. This exposure leads to an increased risk of chronic opioid use. Physician and providers should judiciously reduce the amount of opioids prescribed after childbirth, although more research is needed to identify the optimal method to reduce opioid exposure without adversely affecting pain management.

7.
J Matern Fetal Neonatal Med ; 32(2): 193-197, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28854840

RESUMO

PURPOSE: We sought to examine if the method of pregnancy dating at five increasing term gestational ages is associated with increasing neonatal morbidity. MATERIALS AND METHODS: A cohort of women who underwent elective repeat cesarean delivery at ≥37 weeks' gestation were identified from the NICHD MFMU Network registry. We excluded women who were in labor, those carrying a fetus with a congenital anomaly, those with a non-reassuring fetal heart tracing, and those with preeclampsia, preexisting chronic hypertension or diabetes. Composite neonatal morbidity was defined for our study as any of the following: NICU admission, hypotonia, meconium aspiration, seizures, need for ventilator support, NEC, RDS, TTN, hypoglycemia, or neonatal death. We compared composite neonatal morbidity rates among infants born at five different gestational age cutoffs according to their method of pregnancy dating. RESULTS: At 39 and 40 weeks' gestation, the lowest rate of neonatal complications was seen in pregnancies dated by first trimester ultrasound (5.8% and 5.5%, respectively), while those with the highest neonatal morbidity rates were seen when dated by a second or third trimester ultrasound (8.1% and 6.0%, respectively); p < .001. Additionally within each pregnancy dating category, the neonatal morbidity rates declined from 37 to 40 weeks' gestation and then significantly increased at 41 + 0 weeks' gestation. CONCLUSION: Even with suboptimal dating methods, amongst women undergoing elective repeat cesarean delivery, neonatal morbidity was lowest when delivery occurred between 40 and 40 + 6 weeks gestation.


Assuntos
Recesariana/métodos , Recesariana/estatística & dados numéricos , Idade Gestacional , Doenças do Recém-Nascido/epidemiologia , Doenças do Recém-Nascido/etiologia , Ultrassonografia Pré-Natal , Adulto , Estudos de Coortes , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Morbidade , Gravidez , Terceiro Trimestre da Gravidez , Fatores de Risco , Fatores de Tempo , Ultrassonografia Pré-Natal/métodos , Ultrassonografia Pré-Natal/normas , Ultrassonografia Pré-Natal/estatística & dados numéricos
8.
Am J Perinatol ; 36(10): 1045-1053, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30500961

RESUMO

OBJECTIVE: Women with prediabetes are identified from screening for overt diabetes in early pregnancy, but the clinical significance of prediabetes in pregnancy is unclear. We examined whether prediabetes in early pregnancy was associated with risks of adverse outcomes. STUDY DESIGN: We conducted a retrospective cohort study of pregnant women enrolled in Kaiser Permanente Washington from 2011 to 2014. Early pregnancy hemoglobin A1C (A1C) values, covariates, and outcomes were ascertained from electronic medical records and state birth certificates. Women with prediabetes (A1C of 5.7-6.4%) were compared with those with normal A1C levels (<5.7%) for risk of gestational diabetes mellitus (GDM) and other outcomes including preeclampsia, primary cesarean delivery, induction of labor, large/small for gestational age, preterm birth, and macrosomia. We used modified Poisson's regression to calculate adjusted relative risks (RRs) and 95% confidence intervals (CIs). RESULTS: Of 7,020 women, 239 (3.4%) had prediabetes. GDM developed in 48% of prediabetic women compared with 11% of women with normal A1C levels (adjusted RR: 2.8, 95% CI: 2.4-3.3). Prediabetes was not associated with all other adverse maternal and neonatal outcomes. CONCLUSION: Prediabetes in early pregnancy is a risk factor for GDM. Future research is needed to elucidate whether early intervention may reduce this risk.

9.
Obstet Gynecol ; 132(3): 624-630, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30095773

RESUMO

OBJECTIVE: To evaluate whether individualized postdischarge oxycodone prescribing guided by inpatient opioid use reduces the number of unused opioid tablets after cesarean birth. METHODS: We conducted a randomized, controlled trial of women aged 18 years or older undergoing cesarean birth. Participants were randomized at discharge in a 1:1 ratio to a standard (30 tablets of 5 mg oxycodone) or an individualized oxycodone prescription (predicted based on each patient's inpatient opioid use). All women were contacted starting 14 days after cesarean birth to assess number of oxycodone tablets used and adequacy of pain control. The Tennessee Controlled Substance Monitoring Database was accessed to confirm dispensed opioids. The primary outcome was number of unused oxycodone tablets prescribed for pain control after cesarean birth. A total sample size of 160 women was necessary to detect a 30% difference in leftover tablets between groups with 80% power and α of 0.05. RESULTS: Between June 14, 2017, and August 26, 2017, we screened 323 women and randomized 172. Baseline characteristics and inpatient opioid use were similar between groups. Women in the individualized group were prescribed fewer tablets (14 [interquartile range 12-16] vs 30 [interquartile range 30-30], P<.001) and had 50% fewer unused tablets than women in the standard group (5 [interquartile range 1-8] vs 10 [interquartile range 0-22], P<.001). Overall, 13% (23/172) used no opioids after discharge and 26% (44/172) used all prescribed opioids. There were no differences between the standard and individualized groups in the proportion of women who used no opioids or all opioids and no difference in the proportion of dispensed opioids used (60% [interquartile range 23-100] vs 61% [29-89], P=.93). Women in the individualized group used only half the number of prescribed opioids as women in the standard group (8 [interquartile range 4-14] vs 15 [interquartile range 6-30], P<.001). Patient-reported pain outcomes did not differ significantly by group. CONCLUSION: Individualized opioid prescribing based on inpatient use reduces the number of unused oxycodone tablets compared with standard prescribing. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov, NCT03168425.


Assuntos
Analgésicos Opioides/administração & dosagem , Cesárea/efeitos adversos , Oxicodona/administração & dosagem , Dor Pós-Operatória/prevenção & controle , Adulto , Feminino , Humanos , Dor Pós-Operatória/etiologia , Alta do Paciente , Padrões de Prática Médica , Medicina de Precisão , Gravidez , Adulto Jovem
10.
Obstet Gynecol ; 130(5): 994-1000, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-29016512

RESUMO

OBJECTIVE: To examine whether labor compared with planned cesarean delivery is associated with increased maternal and neonatal morbidity. METHODS: We conducted a retrospective cohort study of all women with body mass indexes (BMIs) at delivery of 50 or greater delivering a live fetus at 34 weeks of gestation of greater between January 1, 2008, and December 31, 2015. Pregnancies with multiple gestations and major fetal anomalies were excluded. The primary outcome was a composite of maternal and neonatal morbidity and was estimated to be 50% in superobese women based on institutional data. A sample size of 338 women determined the study period and was selected to show a 30% difference in the incidence of the primary outcome between the two groups. Multivariate logistic regression adjusted for potential confounders. RESULTS: There were 344 women with BMIs of 50 or greater who met eligibility criteria, of whom 201 (58%) labored and 143 (42%) underwent planned cesarean delivery. Women who labored were younger, more likely to be nulliparous, and less likely to have pre-existing diabetes. Among women who labored, 45% underwent a cesarean delivery, most commonly for labor arrest (61%) or nonreassuring fetal status (28%). Composite maternal and neonatal morbidity was reduced among women who labored even after adjusting for age, parity, pre-existing diabetes, and prior cesarean delivery (adjusted odds ratio 0.42, 95% CI 0.24-0.75). In the subgroup of women (n=234) who underwent a cesarean delivery, whether planned (n=143) or after labor (n=91), there were no differences in maternal and neonatal morbidity except that severe maternal morbidity was increased in women (n=12) who labored (8.8% compared with 2.1%, relative risk 4.2, 95% CI 1.14-15.4). CONCLUSION: Despite high rates of cesarean delivery in women with superobesity, labor is associated with lower composite maternal and neonatal morbidity. Severe maternal morbidity may be higher in women who require a cesarean delivery after labor.


Assuntos
Cesárea/estatística & dados numéricos , Doenças do Recém-Nascido/epidemiologia , Obesidade Mórbida/complicações , Complicações do Trabalho de Parto/epidemiologia , Prova de Trabalho de Parto , Adulto , Cesárea/efeitos adversos , Feminino , Humanos , Recém-Nascido , Doenças do Recém-Nascido/etiologia , Morbidade , Complicações do Trabalho de Parto/etiologia , Razão de Chances , Paridade , Gravidez , Resultado da Gravidez , Estudos Retrospectivos
11.
Obstet Gynecol ; 130(1): 36-41, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28594766

RESUMO

OBJECTIVE: To characterize postdischarge opioid use and examine factors associated with variation in opioid prescribing and consumption. METHODS: We conducted a prospective observational cohort study by recruiting all women undergoing cesarean delivery during an 8-week period, excluding those with major postoperative morbidities or chronic opioid use. Starting on postoperative day 14, women were queried weekly regarding number of opioid pills used, amount remaining, and their pain experience until they had stopped opioid medication. Demographic and delivery information and in-hospital opioid use were recorded. The state Substance Monitoring Program was accessed to ascertain prescription-filling details. Morphine milligram equivalents were calculated to perform opioid use comparisons. Women in the highest quartile of opioid use (top opioid quartile use) were compared with those in the lowest three quartiles (average opioid use). RESULTS: Of 251 eligible patients, 246 (98%) agreed to participate. Complete follow-up data were available for 179 (71% of eligible). Most women (83%) used opioids after discharge for a median of 8 days (interquartile range 6-13 days). Of women who filled their prescriptions (165 [92%]), 75% had unused tablets (median per person 75 morphine milligram equivalents, interquartile range 0-187, maximum 630) and the majority (63%) stored tablets in an unlocked location. This amounts to an equivalent of 2,540 unused 5-mg oxycodone tablets over our study period. Women who used all prescribed opioids (n=40 [22%]) were more likely to report that they received too few tablets than women who used some (n=109 [61%]) or none (n=30 [17%]) of the prescribed opioids (33% compared with 4% compared with 5%, P<.001). The top quartile was more likely to be smokers than average users and consumed more opioid morphine milligram equivalents per hour of inpatient stay than average opioid users (1.6, interquartile range 1.1-2.3 compared with 1.0, interquartile range 0.5-1.4, P<.001). CONCLUSION: Most women-especially those with normal in-hospital opioid use-are prescribed opioids in excess of the amount needed.


Assuntos
Analgésicos Opioides/uso terapêutico , Cesárea , Dor Pós-Operatória/prevenção & controle , Alta do Paciente , Padrões de Prática Médica , Adulto , Analgésicos Opioides/provisão & distribução , Feminino , Humanos , Obstetrícia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Segurança do Paciente , Gravidez , Estudos Prospectivos , Tennessee
12.
Am J Perinatol ; 34(3): 223-228, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27398702

RESUMO

Objective We sought to evaluate whether maternal antepartum infection (excluding chorioamnionitis) is associated with cerebral palsy (CP). Study Design This is a secondary analysis from a multicenter trial in women at risk of preterm delivery who received antenatal magnesium sulfate versus placebo. We compared the risk of CP in the children of women who had evidence of antepartum infection over the course of pregnancy to those women who had no evidence of antepartum infection during pregnancy. Results Within a cohort of 2,251 women who met our inclusion criteria, 1,350 women had no history of infection in pregnancy and 801 women had a history of some type of antepartum infection during pregnancy. The incidence of CP was similar between the two groups (4.9 vs 5.0%; p = 0.917). After adjustment for maternal and obstetric confounders, we observed no significantly increased risk of CP among infants born to women with evidence of antepartum infection; (adjusted relative risk [aRR], 1.09 (0.72, 1.66); p = 0.68). Conclusion Compared with women with no evidence of antepartum infection during pregnancy, those women with infections excluding chorioamnionitis may not be at an increased risk of delivering an infant with CP.


Assuntos
Paralisia Cerebral/epidemiologia , Complicações Infecciosas na Gravidez/epidemiologia , Adulto , Feminino , Humanos , Incidência , Gravidez , Nascimento Prematuro/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
13.
Am J Perinatol ; 33(10): 977-82, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27120479

RESUMO

Objective The objective of this study is to examine whether a first trimester hemoglobin A1c (A1C) of 5.7 to 6.4% predicts an abnormal second trimester oral glucose tolerance test (OGTT). Methods We conducted a retrospective cohort study of all women screened with A1C through 13 (6/7) weeks' gestation between January 1, 2011, and December 31, 2012. Prediabetic women (A1C of 5.7-6.4%) were compared with women with a normal first trimester A1C (< 5.7%). The primary outcome was an abnormal 2-hour, 75-g OGTT as defined by the International Association of Diabetes and Pregnancy Study Groups. Results There were 2,812 women who met inclusion criteria of whom 6.7% (n = 189) were prediabetic. Women with prediabetes were more likely to have gestational diabetes mellitus (GDM) even after adjusting for potential confounders (29.1 vs. 13.7%; adjusted relative risk, 1.48; 95% confidence interval, 1.15-1.89). There were no statistically significant differences in secondary outcomes except that women with prediabetes had less excessive gestational weight gain. A prediabetic-range A1C in the first trimester was associated with a 13% sensitivity and a 94% specificity for predicting GDM Conclusion Although women with prediabetes by first trimester A1C are significantly more likely to have GDM, the low sensitivity of an A1C in this range renders it a poor test to identify women who will develop GDM.


Assuntos
Diabetes Gestacional/sangue , Diabetes Gestacional/epidemiologia , Hemoglobina A Glicada/análise , Estado Pré-Diabético/sangue , Estado Pré-Diabético/epidemiologia , Primeiro Trimestre da Gravidez/sangue , Adulto , California/epidemiologia , Feminino , Idade Gestacional , Teste de Tolerância a Glucose , Humanos , Análise Multivariada , Gravidez , Segundo Trimestre da Gravidez/sangue , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco
14.
Am J Perinatol ; 33(2): 172-9, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26344009

RESUMO

OBJECTIVE: To examine whether women with prediabetes benefit from early treatment for gestational diabetes mellitus (GDM). STUDY DESIGN: Women with a glycosylated hemoglobin A1C (A1C) of 5.7 to 6.4% at <14 weeks were recruited. Participants were randomized to usual care or treatment for GDM with diet, blood glucose monitoring, and insulin as needed. The primary outcome was a 75-g oral glucose tolerance test at 26 to 28 weeks. Secondary outcomes included cesarean delivery, birthweight, weight gain, and A1C change. RESULTS: Between May 2012 and June 2014, 95 women were enrolled and 83 had data for analysis; 42 were randomized to treatment and 41 to usual care. The groups were similar in baseline characteristics with 40% obese. There was no difference in the primary outcome (treatment 45.2% vs. control 56.1%; relative risk [RR] 0.80; 95% confidence interval [CI] 0.53-1.24) except that women in the treatment group had a significantly lower A1C over time than women in the control group (p = 0.04). Nonobese women (n = 50) treated for GDM experienced a 50% reduction in GDM compared with controls (29.6 vs. 60.9%; RR 0.49; 95% CI 0.25-0.95). CONCLUSION: Early treatment for women with a first-trimester A1C of 5.7 to 6.4% did not significantly reduce the risk of GDM except in nonobese women.


Assuntos
Peso ao Nascer , Diabetes Gestacional/prevenção & controle , Dieta para Diabéticos/métodos , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Estado Pré-Diabético/terapia , Adulto , Cesárea/estatística & dados numéricos , Diabetes Gestacional/diagnóstico , Diabetes Gestacional/metabolismo , Diagnóstico Precoce , Intervenção Médica Precoce , Feminino , Teste de Tolerância a Glucose , Hemoglobina A Glicada/metabolismo , Humanos , Recém-Nascido , Obesidade/complicações , Estado Pré-Diabético/complicações , Estado Pré-Diabético/diagnóstico , Estado Pré-Diabético/metabolismo , Gravidez , Primeiro Trimestre da Gravidez , Segundo Trimestre da Gravidez , Diagnóstico Pré-Natal , Ganho de Peso
15.
Am J Obstet Gynecol ; 214(3): 362.e1-7, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26454124

RESUMO

BACKGROUND: Women of advanced maternal age (AMA) are at increased risk for cesarean delivery compared to non-AMA women. However, it is unclear whether this association is altered by parity and the presence or absence of a trial of labor. OBJECTIVE: We sought to examine modes of delivery and maternal outcomes among AMA women stratified by parity and the presence or absence of a trial of labor. STUDY DESIGN: This is a retrospective cohort study of all women delivering singletons births at ≥20 weeks' gestation in the state of California from 2007 through 2011. Data were extracted from maternal discharge data linked to infant birth certificate records. We compared non-AMA women (age 20-34 years, reference group) to AMA women who were classified as follows: age 35-39, 40-44, 45-49, and ≥50 years). The primary outcome was route of delivery (cesarean vs vaginal) stratified by parity and whether a trial of labor occurred (prelabor vs intrapartum cesarean delivery). The association between a trial of labor and perinatal morbidity was also studied. RESULTS: There were 1,346,889 women who met inclusion criteria, which included 181 (0.01%) women who were age ≥50 years at the time of delivery. Overall, 34.7% underwent a cesarean delivery and this risk differed significantly by age group (30.5%, 20-34 years; 40.5%, 35-39 years; 47.3%, 40-44 years; 55.6%, 45-49 years; 62.4%, >50 years). Nulliparous women age ≥50 years were significantly less likely to undergo a trial of labor compared to the reference group (relative risk [RR], 0.44; 95% confidence interval [CI], 0.32-0.62). Furthermore, nulliparous women age ≥50 years were significantly more likely to experience an intrapartum cesarean delivery (RR, 2.61; 95% CI, 1.31-5.20), however the majority (74%) who underwent a trial of labor experienced a vaginal delivery. Compared to the reference group, women age ≥50 years were 5 times more likely to experience severe maternal morbidity (1.7% vs 0.3%; RR, 5.08; 95% CI, 1.65-15.61) and their infants 3 times more likely to require neonatal intensive care unit admission (14.9% vs 5.2%; RR, 3.1; 95% CI, 2.2-4.4), however these outcomes were not associated significantly with having undergone a trial of labor, a cesarean delivery following labor, or a prelabor cesarean delivery. Similar trends were observed among multiparous women. CONCLUSION: Compared to non-AMA women, women age ≥50 years with a singleton pregnancy experience significantly higher rates of cesarean delivery. However the majority of those who undergo a trial of labor will have a vaginal delivery. Neither a trial of labor nor a prelabor cesarean delivery is significantly associated with maternal or neonatal morbidity. These data support either approach in women of extremely AMA.


Assuntos
Cesárea/estatística & dados numéricos , Idade Materna , Prova de Trabalho de Parto , Adulto , Fatores Etários , Feminino , Humanos , Pessoa de Meia-Idade , Paridade , Gravidez , Estudos Retrospectivos , Fatores de Risco
16.
Obstet Gynecol ; 125(3): 643-8, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25730228

RESUMO

OBJECTIVE: To describe the rate of classical hysterotomy in twin pregnancies across gestational age and examine risk factors that increase its occurrence. METHODS: This is a secondary analysis of the Cesarean Registry, a cohort study of women who underwent a cesarean delivery or a trial of labor after cesarean delivery at 19 academic centers between 1999 and 2002. Our study included all women with twin pregnancies and a recorded hysterotomy type who underwent cesarean delivery between 23 0/7 and 41 6/7 weeks of gestation. Primary exposures were gestational age at delivery and combined birth weight of twin A and twin B. Multivariate logistic regression was used to study factors thought to influence hysterotomy type including maternal age, body mass index (BMI) at delivery, obesity (BMI 30 or higher), nulliparity, labor, prior cesarean delivery, emergent delivery, and fetal presentation at delivery. RESULTS: Of 1,820 women meeting inclusion criteria, 125 (7%) underwent a classical hysterotomy. The risk of classical hysterotomy was greatest at 25 weeks of gestation (41%) and declined thereafter. The adjusted odds ratio (OR) for cesarean delivery declined as gestation age advanced (OR 0.87, 95% confidence interval 0.78-0.98). African American race and emergent delivery were associated risk factors for classical hysterotomy at 32 weeks of gestation or greater. CONCLUSION: Among women with twin pregnancies who deliver by cesarean, the incidence of classical hysterotomy is inversely related to gestational age but does not exceed 50% at any week; African American race and emergent delivery are associated risk factors at 32 weeks of gestation or greater. LEVEL OF EVIDENCE: II.


Assuntos
Cesárea/métodos , Cesárea/estatística & dados numéricos , Gravidez de Gêmeos , Sistema de Registros/estatística & dados numéricos , Adulto , Estudos de Coortes , Feminino , Idade Gestacional , Humanos , Histerotomia/métodos , Histerotomia/estatística & dados numéricos , Gravidez , Fatores de Risco , Adulto Jovem
18.
Obstet Gynecol ; 124(4): 684-9, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25198267

RESUMO

OBJECTIVE: To examine the relationship between body mass index (BMI, kg/m) and incision-to-delivery interval and total operative time at cesarean delivery. METHODS: Women with singleton gestations undergoing uncomplicated primary and repeat cesarean deliveries were identified from the Maternal-Fetal Medicine Units Network Cesarean Registry. Women were classified by BMI category at time of delivery (normal 18.5-24.9, overweight 25.0-29.9, obese 30.0-39.9, and morbidly obese 40 or greater). Incision-to-delivery interval and total operative times during cesarean delivery were compared among the three groups. Primary outcome was prolonged incision-to-delivery interval as defined by 90th percentile or greater of the study population or 18 minutes or longer. RESULTS: Of the 21,372 women included in the analysis, 9,928 were obese (46.5%) and 2,988 (14.0%) were morbidly obese. Longer operative times were found among women with overweight (median [interquartile range] incision-to-delivery: 9.0 [6.0] and total operative time: 45.0 [21.0] minutes), obese (10.0 [7.0]; 48.0 [22.0] minutes), and morbidly obese BMIs (12.0 [8.0]; 55.0 [26.0] minutes) compared with women with normal BMI at delivery (9.0 [5.0]; 43.0 [20.0] minutes) (P<.001). Morbidly obese women had a more frequent incision-to-delivery interval that was 18 minutes or longer (n=602 [20%] compared with 127 [6%] in normal BMI). After adjustments including number of prior cesarean deliveries, incision-to-delivery interval 18 minutes or longer was significantly related to obese (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.31-2.03) and morbidly obese (OR 2.81, 95% CI 2.24-3.56) BMI at delivery. CONCLUSION: Increasing BMI is related to increased incision-to-delivery interval and total operative time at cesarean delivery with morbidly obese BMI exposing women to the highest risk of prolonged incision-to-delivery interval. LEVEL OF EVIDENCE: : II.


Assuntos
Índice de Massa Corporal , Cesárea/métodos , Obesidade/complicações , Duração da Cirurgia , Resultado da Gravidez , Adulto , California , Cesárea/efeitos adversos , Recesariana/efeitos adversos , Recesariana/métodos , Estudos de Coortes , Intervalos de Confiança , Feminino , Seguimentos , Idade Gestacional , Humanos , Obesidade Mórbida/complicações , Gravidez , Sistema de Registros , Medição de Risco , Resultado do Tratamento
19.
Obstet Gynecol ; 124(2 Pt 1): 332-7, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25004349

RESUMO

OBJECTIVE: To compare 24-hour urinary protein excretion in twin and singleton pregnancies not complicated by hypertension. METHODS: We prospectively evaluated mean 24-hour urinary protein excretion in twin and singleton pregnancies between 24 0/7 weeks and 36 0/7 weeks of gestation. Women with urinary tract infections, chronic hypertension, pregestational diabetes, and renal or autoimmune diseases were excluded. Collection adequacy was assessed by urinary creatinine excretion adjusted for maternal weight. RESULTS: Adequate samples were obtained from 50 twin and 49 singleton pregnancies at a mean gestational age of 30 weeks. At collection, the two groups were similar with regard to maternal age, gestational age, body mass index, and blood pressure. Mean urinary protein excretion was higher in twin compared with singleton pregnancies (269.3±124.1 mg compared with 204.3±92.5 mg, P=.004). Proteinuria (300 mg/day protein or greater) occurred in 38.0% (n=19) of twin and 8.2% (n=4) of singleton pregnancies (P<.001). After adjusting for confounding variables, the difference in mean total protein excretion remained significant (P=.004) and twins were more likely to have proteinuria compared with singleton pregnancies (adjusted odds ratio 9.1, 95% confidence interval 2.1-38.5). Nineteen participants developed a hypertensive disorder at a mean of 7.7 weeks after the urine collection (range 2.6-14.5 weeks). After excluding these women, proteinuria was present in 43% of twin and 7% of singleton pregnancies (P<.001). CONCLUSION: Mean 24-hour urinary protein excretion in twin pregnancies is greater than in singletons. These data suggest a reevaluation of the diagnostic criteria for preeclampsia in twin pregnancies. LEVEL OF EVIDENCE: II.


Assuntos
Gravidez de Gêmeos/urina , Proteinúria/urina , Adulto , Creatinina/sangue , Feminino , Humanos , Hipertensão Induzida pela Gravidez/urina , Gravidez , Gravidez de Gêmeos/sangue , Estudos Prospectivos , Proteinúria/sangue
20.
Obstet Gynecol ; 122(4): 845-50, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24084543

RESUMO

OBJECTIVE: To examine the likelihood of classical hysterotomy across preterm gestational ages and to identify factors that increase its occurrence. METHODS: This is a secondary analysis of a prospective observational cohort collected by the Maternal-Fetal Medicine Network of all women with singleton gestations who underwent a cesarean delivery with a known hysterotomy. Comparisons were made based on gestational age. Factors thought to influence hysterotomy type were studied, including maternal age, body mass index, parity, birth weight, small for gestational age (SGA) status, fetal presentation, labor preceding delivery, and emergent delivery. RESULTS: Approximately 36,000 women were eligible for analysis, of whom 34,454 (95.7%) underwent low transverse hysterotomy and 1,562 (4.3%) underwent classical hysterotomy. The median gestational age of women undergoing a classical hysterotomy was 32 weeks and the incidence peaked between 24 0/7 weeks and 25 6/7 weeks (53.2%), declining with each additional week of gestation thereafter (P for trend <.001). In multivariable regression, the likelihood of classical hysterotomy was increased with SGA (n=258; odds ratio [OR] 2.71; confidence interval [CI] 1.78-4.13), birth weight 1,000 g or less (n=467; OR 1.51; CI 1.03-2.24), and noncephalic presentation (n=783; OR 2.03; CI 1.52-2.72). The likelihood of classical hysterotomy was decreased between 23 0/7 and 27 6/7 weeks of gestation and after 32 weeks of gestation when labor preceded delivery, and increased between 28 0/7 and 31 6/7 weeks of gestation and after 32 weeks of gestation by multiparity and previous cesarean delivery. Emergent delivery did not predict classical hysterotomy. CONCLUSIONS: Fifty percent of women at 23-26 weeks of gestation who undergo cesarean delivery have a classical hysterotomy, and the risk declines steadily thereafter. This likelihood is increased by fetal factors, especially SGA and noncephalic presentation. LEVEL OF EVIDENCE: : II.


Assuntos
Idade Gestacional , Histerotomia/estatística & dados numéricos , Sistema de Registros , Adulto , Feminino , Humanos , Modelos Logísticos , Gravidez , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
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