High-Order Parity Improves the Perinatal Outcome of Twin Deliveries.

OBJECTIVE: Twin gestations are associated with an increased risk of obstetric and perinatal complications. We studied the association between parity and the rate of maternal and neonatal complications in twins deliveries. STUDY DESIGN: We performed a retrospective analysis of a cohort of twin gestations delivered between 2012 and 2018. Inclusion criteria consisted of twin gestation with two nonanomalous live fetuses at ≥24 weeks' gestation and no contraindications to vaginal delivery. Women were divided into three groups based on parity: primiparas, multiparas (parity of 1-4), and grand multiparas (parity ≥5). Demographic data were collected from electronic patient records and included maternal age, parity, gestational age at delivery, need for induction of labor, and neonatal birth weight. The primary outcome was mode of delivery. Secondary outcomes were maternal and fetal complications. RESULTS: The study population included 555 twin gestations. One hundred and three were primiparas, 312 were multiparas, and 140 were grand multiparas. Sixty-seven (65%) primiparas delivered the first twin vaginally, as did 294 (94%) multiparas and 133 (95%) grand multiparas (p <0.05). Thirteen (2.3%) women required delivery of the second twin by cesarean section. Among those who delivered both twins vaginally, there was no significant difference in the average time interval between the delivery of the first and the second twins between the groups. The need for transfusion of blood products was higher in the primiparous group compared with the other two groups (11.6 vs. 2.5 and 2.8%, p < 0.05). The rate of adverse maternal composite outcomes was higher among primiparous women compared with multiparous and grand multiparous (12.6, 3.2, and 2.8%, respectively, p < 0.05). The gestational age at delivery was earlier in the primiparous group compared with the other two groups, and the rate of preterm labor at <34 weeks' gestation was higher among the primiparas. The rate of second twin's 5-minute Apgar's score <7 and the composite adverse neonatal outcome among the primiparous group were significantly higher than the multiparous and grand multiparous groups. CONCLUSION: Our study demonstrates that there is an association between high-parity and good obstetric outcomes in twin pregnancies; high parity seems to serve as a protective, rather than a risk factor for adverse maternal and neonatal outcomes. KEY POINTS: · There is an association between high-parity and good obstetric outcome in twin pregnancies.. · High parity serves as a protective factor for adverse maternal outcomes in twin deliveries.. · High parity serves as a protective factor for adverse neonatal outcomes in twin deliveries..

Obstetric Complications and Pregnancy Outcome Among Grand Multiparous Women.

OBJECTIVE: To determine whether there are differences between grand multiparous and non-grand multiparous women regarding obstetric risk factors, obstetric compli- cations, and pregnancy out- come. STUDY DESIGN: A retro- spective case control study was conducted between the years 2011-2012. The study group included grand. mul- tiparous women'(≥5 previous deliveries). The control group included non-grand multiparous women (<5 deliveries) who gave birth immediately after the grand multiparous woman and matched according to parity. RESULTS: Prenatal care was less adequate in the grand multiparous group (p<0.001). A higher rate of maternal anemia was found in the grand multiparous group as compared to the multiparous group (p<0.001). Grand multiparity was associated with higher rates of amniot- ic fluid disorders such as oligohydramnios, polyhydram- nios, and meconium-stained amniotic fluid (p<0.001). Grand multiparity was also associated with higher. birth weight and a lower rate. of instrumental delivery (p<0.001). Higher parity was not a risk factor for di- abetic disorders, hypertension, and cesarean delivery. CONCLUSION: Grand multiparity is a risk factor for inadequate prenatal care, maternal anemia, and amni- otic fluid disorders and is .associated with lower rates of instrumental deliveries and higher birth weight. However, it does not increase the risk for diabetes, hypertension, and cesarean .deliveries.

Is Parity a Risk Factor for Late Preterm Birth? Results from a Large Cohort Study.

Most preterm births occur in the late preterm period. While prematurity-related adverse outcomes are significantly diminished when birth occurs during this period, these infants are still at increased risk of complications. Parity affects the incidence of obstetric complications. The purpose of this study was to determine whether parity impacts the risk of spontaneous late preterm birth (SLPTB) and associated complications. A retrospective observational cohort study was conducted. Patients were divided into three study groups according to parity. The primary outcome was the rate of SLPTB in each group. Secondary outcomes were unplanned cesarean delivery (UCD), prolonged third stage of labor respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), intraventricular hemorrhage (IVH), neonatal hypoglycemia, duration of NICU admission, neonatal death, and composite adverse neonatal outcome (CANO). Primiparas were more likely to have SLPTB, UCD, and CANO compared to multiparas (2.6% vs. 1.9% OR 1.5 [1.3-1.7] p < 0.01) (4.1% vs. 1.3% OR 2.7 [1.2, 5.9] p < 0.01) (8.5% vs. 4.2 OR 2.1 [1.3-3.5] p = 0.002) and grandmultiparas (2.6% vs. 1.7% OR 1.4 [1.2-1.5] p < 0.001) 8.5% vs. 4.4% OR 2.0 [1.1, 3.8], p = 0.01) but no difference in UCD compared to grandmultiparas (4.1% vs. 3.3% OR 1.2 [0.6-2.7] p = 0.28). Primiparas are at increased risk of SLPTB and UCD, and this is accompanied by an increased risk of adverse neonatal outcomes.

Safety and Efficacy of Cervical Ripening and Induction of Labor Using Prostaglandin E1 in Primiparas, Multiparas and Grand Multiparas.

Objective: To compare the efficacy and safety of cervical ripening and induction of labor with prostaglandin E1 among primiparas, multiparas and grand multiparas. Study design: This was a retrospective cohort study. Results: Between January and December 2017, 1713 women underwent cervical ripening and induction of labor with prostaglandin E1: 523 were primiparas, 656 were multiparas, and 534 were grand multiparas. Four hundred and seventy-nine (91.6%) primiparas delivered vaginally as did 640 (97.6%) multiparas and 521 (97.6%) grand multiparas. Forty-four (8.4%) primiparas underwent cesarean delivery compared to 16 (2.4%) multiparas and 13(2.4%) grand multiparas. Induction to delivery interval was significantly longer in primiparas (29.7 ± 22.8 h). There were no cases of uterine rupture, and the rates of postpartum hemorrhage and endometritis were similar among the three groups. Neonatal outcomes including Apgar score < 7 and umbilical artery pH < 7.1 were not significantly different between the groups. Conclusion: Using prostaglandin E1 for cervical ripening and labor induction is efficient and safe in primiparas, multiparas and grand multiparas.

Safety of vaginal delivery in women infected with COVID-19.

BACKGROUND: There is limited data regarding the safety of vaginal delivery in women infected with COVID-19. Our goal was to assess the safety of vaginal delivery in women infected with COVID-19 and the risk of neonatal infection. METHODS: This was a single medical center cohort study. Data were collected about the outcome of twenty-one women with laboratory-confirmed COVID-19 infection who delivered between March 23, 2020, and May 8, 2020. RESULTS: Twenty-one gravidas were diagnosed with COVID-19 infection. None required admission to the intensive care unit (ICU) and there were no fatalities. Seventeen delivered vaginally and four by caesareans. Apgar scores of all neonates were 9 at 1 min and 10 at 5 min. One neonate was diagnosed with COVID-19 infection 24 h after birth. CONCLUSIONS: Vaginal delivery in women infected with COVID-19 is not associated with a significant risk of neonatal infection.

Titers of SARS CoV-2 antibodies in cord blood of neonates whose mothers contracted SARS CoV-2 (COVID-19) during pregnancy and in those whose mothers were vaccinated with mRNA to SARS CoV-2 during pregnancy.

OBJECTIVE: We compared neonatal immunity after vaccination against SARS-CoV-2 during pregnancy to that achieved after maternal infection. STUDY DESIGN: We tested cord blood from women infected with SARS-CoV-2 during pregnancy (group 1, n = 29), women who were vaccinated during pregnancy (group 2, n = 29) and from women not infected and not vaccinated (Group 3, n = 21) for titers of antibodies to both SARS-CoV-2 spike and 'N' proteins. RESULTS: Seventy-nine women were included: Antibodies against SARS-CoV-2 spike protein were detected in all samples from Group 1 and 2. Antibodies to the 'N' protein were detected in 25/29 samples in Group 1. None of the samples from Group 3 had antibodies to either protein. Mean titers of SARS-CoV-2 antibodies were significantly higher in Group 2 than in Group 1 (p < 0.05). CONCLUSIONS: Neonates born to mothers vaccinated during pregnancy have higher antibody titers and may therefore have more prolonged protection than those born to women infected during pregnancy.

Frontomaxillary facial angles in screening for trisomy 21 at 14-23 weeks' gestation.

OBJECTIVE: The objective of the study was to investigate the potential value of the frontomaxillary facial (FMF) angle in second-trimester ultrasound screening for trisomy 21. METHODS: We examined stored images of fetal profiles taken before amniocentesis at 14-24 weeks from 100 euploid fetuses and 34 with trisomy 21. The FMF angles between the upper surface of the upper palate and the frontal bone (FMF(bone)) and the skin over the forehead (FMF(skin)) were measured. RESULTS: In the euploid group the FMF angles decreased with gestation. In the fetuses with trisomy 21, the FMF(bone) and FMF(skin) angles were 79.4% and 87.9% above the 95th percentile for gestation of the respective values from the euploid group. In trisomy 21 fetuses, there was no significant difference in FMF angles between those with nasal bone hypoplasia (n = 19) and those without (n = 15). CONCLUSION: The FMF angle is substantially higher in trisomy 21 than euploid fetuses. Measurement of the FMF angles is likely to prove a useful method in prenatal screening for trisomy 21 in the second trimester.

Long-Term Effects of Pregnancy Complications on Maternal Health: A Review.

Background: Most pregnancy-related medical complications appear to resolve at delivery or shortly thereafter. Common examples are preterm labor, placental abruption, preeclampsia, and gestational diabetes. Women who developed such complications are known to be at increased risk of developing similar complications in future pregnancies. It has recently become evident that these women are at an increased risk of long term medical complications. Methods: A search through scientific publications in English regarding the association of obstetric complications and long-term maternal illness. Results: There is a clear association between various obstetric complications and long-term effects on maternal health. Conclusions: Women with a history of adverse pregnancy outcomes are at increased risk of cardiovascular and metabolic diseases later in life. Data increasingly links maternal vascular, metabolic, and inflammatory complications of pregnancy with an increased risk of vascular disease in later life.

Pregnancy-related changes in the size of uterine leiomyomas.

OBJECTIVE: To describe the effects of pregnancy on the growth of leiomyomas using sonographic measurements of leiomyomas taken longitudinally during pregnancy. STUDY DESIGN: The study population included asymptomatic gravidas with singleton pregnancies in whom we identified uterine leiomyomas. We included all women whose leiomyomas were measured at least twice during the pregnancy. In a subgroup of women we also compared the size of leiomyomas before and after the index pregnancy. Using real-time sonography, we measured each leiomyoma in 3 axes and averaged the measurements. During subsequent studies we calculated the percent change in the size of each tumor. We assessed complications related to the presence of these tumors. RESULTS: We evaluated 137 leiomyomas in 72 women (average, 2.3 +/- 1.8 per woman). Each underwent an average of 3.7 +/- 2.1 scans. The average gestational age at the time of first assessment was 14.4 +/- 5.4 weeks. The average diameter of the leiomyomas at the first study was 34.2 +/- 23 mm. On average, there was no significant change in the size of leiomyomas during pregnancy. We found that the size, location and our ability to visualize leiomyomas varied significantly during pregnancy. Four of the 72 women had obstetric complications related to the presence of leiomyomas. CONCLUSION: The findings of our longitudinal sonographic assessment of 137 uterine leiomyomas suggest that despite the commonly held belief that they tend to enlarge during the course of pregnancy, this phenomenon is in fact quite rare.

Perinatal outcome associated with sonographically detected globular placenta.

OBJECTIVE: To evaluate the association between the sonographic appearance of globular placenta and perinatal outcome. STUDY DESIGN: We prospectively followed the pregnancy course and perinatal outcome in women with globular placentas (hyperechoic, thick and highly vascular placentas with edges that lack the typical "tapering" appearance) during routine sonographic study. RESULTS: Fourteen women were included. In 7 women the globular appearance of the placenta normalized spontaneously, and perinatal outcome was good. The other 7 experienced poor perinatal outcomes. There were no significant differences between the 2 groups. Among pregnancies in which the globular placental appearance persisted, 3 resulted in fetal demise; 3 women had severe intrauterine growth restriction and oligohydramnios and underwent cesarean deliveries at 26, 27 and 31 weeks, respectively; and 1 patient had premature preterm rupture of membranes and underwent a cesarean delivery due to placental abruption. CONCLUSION: In half the pregnancies complicated by the sonographic appearance of a globular placenta, this shape spontaneously normalized, and the perinatal outcome was normal. However, when the globular appearance of the placenta persisted, the condition was associated with a poor perinatal outcome. Pregnancies complicated by a globular placenta should be followed closely.

Decreasing infectious morbidity in cesarean delivery by changing gloves.

OBJECTIVE: To assess whether changing the entire surgical team's gloves intraoperatively, after delivery of the placenta, would reduce the rate of postcesarean wound infection. STUDY DESIGN: Women who underwent cesarean delivery were randomized to a group where the surgical team changed the surgical gloves after delivery of the placenta or to a control group, where surgical gloves were not changed during the cesarean procedure. RESULTS: Ninety-two patients were randomized to 2 groups of 46 patients each. The group where the surgical team changed their gloves had significantly less serosanguineous drainage 24 hours after surgery (3 vs. 8 patients, 8.3% vs. 22.2%, P = .2, RR 2.7, CI 0.7, 12.4) and fewer wound infections (2 vs. 9 women, 5.5% vs. 25%, P = .05, RR 4.5, CI 0.982, 29.8). CONCLUSION: Obstetricians may decrease the number of postcesarean wound infections by having the entire team change surgical gloves after delivery of the placenta.

First Trimester Ultrasound in Prenatal Diagnosis-Part of the Turning Pyramid of Prenatal Care.

First-trimester sonographic assessment of the risk of chromosomal abnormalities is routinely performed throughout the world, primarily by measuring fetal nuchal translucency thickness between 11-13 weeks' gestation, combined with assessment of serum markers. The development of high-frequency transvaginal transducers has led to improved ultrasound resolution and better visualization of fetal anatomy during the first-trimester. Continuous improvement in ultrasound technology allows a thorough detailed assessment of fetal anatomy at the time of the nuchal translucency study. Using transabdominal or transvaginal sonography, or a combination of both approaches, it is now possible to diagnose a wide range of fetal anomalies during the first trimester. Multiple studies reported early diagnosis of major fetal anomalies after demonstrating the association of increased nuchal translucency thickness with structural defect in chromosomally normal and abnormal fetuses. Normal sonographic findings provide reassurance for women at high risk while detection of fetal malformation during the first trimester enables discussion and decisions about possible treatments and interventions, including termination of pregnancy, during an early stage of pregnancy.

Incidence of respiratory disorders in neonates born between 34 and 36 weeks of gestation following exposure to antenatal corticosteroids between 24 and 34 weeks of gestation.

We studied the effect of antenatal corticosteroids on the incidence of respiratory disorders in singleton neonates born between 34 and 36 weeks of gestation. Retrospective analysis was conducted of the incidence of respiratory distress syndrome (RDS) and other respiratory disorders (need for mechanical ventilation, continuous positive airway pressure, and prolonged oxygen therapy) among singleton neonates delivered between 34 and 36 weeks of gestation who were exposed to antenatal corticosteroids, compared with neonates who were not exposed. Statistical analyses included two-tailed T tests, two-way analysis of variance for continuous data, and chi-square analysis for ratios. A probability of 0.05 was considered significant. Between January 1, 2000, and December 31, 2004, 1078 neonates were born between 34 and 36 weeks of gestation. Information regarding antenatal corticosteroids was available in 1044: 574 neonates (53.2%) were exposed to antenatal corticosteroids and 470 (43.6%) were not. One thousand and eighteen neonates were admitted to the neonatal intensive care unit. Respiratory disorders were diagnosed in 140 of those exposed to antenatal steroids (24.4%) and in 382 of the nonexposed (81.3%) ( P < 0.0001). Two hundred and ten neonates (20.6%) developed RDS: Of those, 43 were exposed to antenatal corticosteroids and 167 were not (incidence of RDS was 7.5% and 35.5%, respectively; P = 0.0001). The beneficial effects of corticosteroids were similar in both genders. It appears that the exposure of singleton pregnancies to antenatal corticosteroids between 24 and 34 weeks of gestation is associated with a significantly lower incidence of respiratory disorders among neonates born at 34 to 36 weeks of gestation. Further studies are needed to determine whether administering antenatal steroids to women experiencing preterm labor after 34 weeks of gestation would be associated with a similar beneficial effect.

Serial sonographic growth assessment in pregnancies complicated by an isolated single umbilical artery.

Pregnancies complicated by an isolated single umbilical artery (SUA) are thought to be at increased risk for intrauterine growth restriction (IUGR). The management of these pregnancies often includes serial sonographic assessments of fetal growth. The goal of our study was to test the validity of this assertion. We conducted a longitudinal sonographic assessment of intrauterine fetal growth in pregnancies complicated by a SUA. We included pregnancies where fetal growth was assessed three or more times, and the presence of SUA was repeatedly demonstrated. Pregnancies with fetal anomalies and multiple gestations were excluded. IUGR was defined as an estimated fetal weight (EFW) < or = 10th percentile of the normal ranges established by Hadlock. Between January 1999 and December 2005, we identified 273 pregnancies with SUA, for an overall incidence of 0.48% within the total population of patients examined at our institution. One hundred and thirty-five pregnancies did not meet our inclusion criteria. Of the 138 we analyzed, four pregnancies (2.9%) were found to have EFW < or = 10th percentile. We concluded that the occurrence of IUGR in pregnancies complicated by an isolated SUA is not increased. Serial sonographic assessments of fetal growth do not appear to be indicated in the management of such pregnancies.

Pregnancy outcome in isolated single umbilical artery.

Our objective was to determine whether the rate of small for gestational age (SGA) infants and adverse perinatal outcome are increased in pregnancies diagnosed with an isolated single umbilical artery (SUA). We compared 297 pregnancies with a SUA diagnosed on routine obstetrical ultrasound with 297 pregnancies with a three-vessel cord control. Pregnancies complicated by major fetal anomalies were excluded. The rate of SGA, fetal death, and neonatal outcomes were compared between the two groups. Data analysis were performed using the T-test and chi-square test. The sample size had 80% power to detect a 50% difference between groups assuming a SGA rate of 20% in the SUA group and 10% in the control, alpha = 0.05. Among the SUA group, in 21 neonates (7.1%) the presence of a SUA could not be confirmed by postnatal examination, and 21 (7.1%) had major congenital anomalies, leaving 255 for final analysis. In the control group, 8 of the 297 (2.7%) had major congenital anomalies, leaving 289 for final analysis. The incidence of SGA neonates was 35 of 255 (13.7%) in the isolated SUA group compared with 38 of 289 (13.1%) in the control group ( P = 0.93). The composite perinatal outcomes (fetal death and/or SGA) were also similar between the groups (16.1% versus 14.5%; P = 0.72). We concluded that pregnancies with isolated SUA have a similar rate of SGA to those with 3VC. When a SUA is identified antenatally, a targeted ultrasound is warranted to rule out associated anomalies. Serial antepartum ultrasound for fetal growth is not necessary in managing pregnancies complicated by isolated SUA.