Re-laparotomy following cesarean delivery – risk factors and outcomes

Introduction: Re-laparotomy following caesarean delivery (CD) is a rare yet serious complication. The aim of this study was to identify risk factors, diagnostic features and outcomes following re-laparotomy.

Materials and methods: This retrospective cohort study reviewed cases of re-laparotomy following CD performed at Hadassah-Hebrew University Medical Center. Occurrences were identified via the electronic medical record database.

Results: During the study period, 17?213 women underwent CD, of which 55 (0.3%) underwent re-laparotomy during the same hospitalization. Main indications for re-laparotomy were intra-peritoneal bleeding (62%) and wound infection/dehiscence (22%). During re-laparotomy, the bleeding source was found and ligated in 85% of the cases. Age, parity, previous CD, induction of labor, anesthesia type and operative duration were significant risk factors for re-laparotomy. In a selected group of patients, trial of conservative treatment was made. However, in 76% of these women a re-laparotomy was required.

Discussion: Risk factors for re-laparotomy following CD should be identified, thus enabling more intensified monitoring of patients considered at risk for this complication. When intra-peritoneal bleeding following CD is suspected, conservative management has a high failure rate and should be reserved for a selected group of stable patients.     

Meconium-stained amniotic fluid – risk factors and immediate perinatal outcomes among SGA infants

Objective: To detect factors that are associated with meconium-stained amniotic fluid (MSAF) among deliveries of small for gestational age (SGA) neonates and to identify perinatal outcomes of deliveries of SGA infants complicated with MSAF.

Methods: A population-based study comparing deliveries of SGA neonates with and without MSAF was conducted. Deliveries occurred during the years 1988–2007 at the Soroka University Medical Center. Risk factors for MSAF among SGA infants were evaluated. Incidence of adverse pregnancy outcomes were compared between deliveries of SGA neonates with and without MSAF.

Results: During the study period 9583 deliveries were of SGA neonates. Of these, 16.6% (n?=?1597) were complicated with MSAF. Among SGA neonates, older maternal age, multiparty, lack of prenatal care and weight were significantly associated with MSAF. Having delivered an SGA infant with MSAF was associated with decreased rates of induction of labor and increased rates of labor dystocia, delivery by cesarean section and fetal distress. Using multivariable regression models, having delivered an SGA infant with MSAF was independently associated with fetal distress.

Conclusion: Among SGA neonates, deliveries complicated with MSAF are associated with additional adverse pregnancy outcomes.     

Third- and fourth-degree perineal tears – incidence and risk factors

Abstract

Objective: To assess the incidence and risk factors for third- and fourth-degree perineal tears (34DPT), and to identify subgroups of women who are at especially high risk for 34DPT.

Methods: A cohort study of women who underwent vaginal delivery in a single tertiary medical center between 1999 and 2011, (58?937 deliveries). Women diagnosed with 34DPT following delivery were compared to control group. Multivariate logistic regression analysis and tree classification analysis were used to identify combinations of risk factors which were associated with considerable risk for 34DPT.

Results: Overall, 356 (0.6%) deliveries were complicated by 34DPT (340 (95.5%) third-degree tears and 16 (4.5%) fourth-degree tears). Independent predictors of 34DPT were: forceps delivery (odds ratio (OR)?=?5.5, confidence interval (CI) 3.9–7.8), precipitate labor (OR?=?5.2, CI 2.9–9.2), persistent occiput posterior position (OR?=?2.6, CI 1.6–4.3), vacuum extraction (OR?=?1.9, CI 1.4–2.6) as well as large for gestational age (LGA) infant and gestational age?>?40 weeks. Fourth-degree tears were associated with forceps delivery (OR?=?12.5, CI 2.3–66.2), precipitate labor (OR?=?9.7, 95%-CI 1.2–75.4) and LGA infant (OR?=?7.4, 95%-CI 1.7?–1.5). Overall, the predictability of 34DPT was limited (R^2?=?0.4). In subgroups of women with certain combinations of risk factors the risk of 34DPT ranged from 10% to 25%.

Conclusion: Despite the limited predictability of 34DPT by individual risk factors, the use of combinations of risk factors may assist obstetricians in identifying women who are at especially high risk for 34DPT.     

Pregnancy-induced hypertonia and preeclampsia – risk factors and prediction possibilities

Summary Pregnancy-induced hypertension and preeclampsia account for nearly 25 % of perinatal morbidity and mortality and are a leading cause of maternal death in developed countries. Consequently, early detection of women with a higher risk is helpful for intensified prenatal care. Since therapeutic options exist in some cases, screening for risk factors is required. Risk factors include parity, medical history, and family history. Laboratory tests of haemostasis and the detection of autoimmune disease complete adequate screening. More than 100 methods have been tested for the prediction of preeclampsia in the second trimester. Results obtained by Doppler ultrasound appear to be more reliable than most clinical parameters. However, no test presently available can really serve as a useful early marker of developing preeclampsia. More specific methods detecting endothelial dysfunction and platelet activation are being developed and might provide improved prediction.      

Birth trauma – risk factors and short-term neonatal outcome

Abstract

Objective: The ability to predict birth trauma (BT) based on the currently recognized risk factors is limited and there is little information regarding the short-term neonatal outcome following BT. We aimed to identify risk factors for BT and to evaluate the effect of BT on short-term neonatal outcome.

Methods: A retrospective, cohort, case–control study of all cases of BT in a single tertiary center (1986–2009). The control group included the two subsequent full-term singleton neonates who did not experienced BT. Short-term neonatal outcome was compared between the groups including Apgar scores, NICU admission, duration of hospitalization and neurologic, respiratory and metabolic morbidity.

Results: Of the 118?280 singleton full-term newborns delivered during the study period, 2874 were diagnosed with BT (24.3/1000). The most frequent types of BT were scalp injuries (63.9%, 15.5/1000) and clavicular fracture (32.1%, 7.7/1000). The following factors were found to be independent risk factors for BT: instrumental delivery (OR 7.5, 95% CI 6.3–8.9), birth weight, delivery during risk hours, parity, maternal age and neonatal head circumference. Cesarean delivery was the only factor protective of BT (OR 0.2, 95% CI 0.2–0.3). Neonates in the study group had a prolonged length of hospital stay (3.3 versus 2.7?d, p?=?0.001), were more likely to be admitted to the NICU (3.9% versus 1.9%, p?<?0.001), and had a higher rate of jaundice (11.9% versus 7.1%, p?<?0.001) and neurological morbidity (4.7% versus 2.3%, p?<?0.001).

Conclusion: Instrumental delivery appears to be responsible for most cases of neonatal BT.     

Prediction of postpartum blood transfusion – risk factors and recurrence

Abstract

Objective: The aim was to find clinically useful risk factors for postpartum transfusion and to assess the joint predictive value in a population of women with a first and second delivery.

Methods: All Danish women with a first and second delivery from January 2001 to September 2009 who gave birth in a hospital that reported transfusion of red blood cells to a national database: A total of 96 545 women were included.

Results: Retained placental tissue explained more than all other risk factors in vaginal deliveries. Retained placental tissue at first delivery was associated with postpartum transfusion at a second vaginal delivery, and may also be used as an early predictor in parallel with a history of either placental abruption, postpartum transfusion or caesarean delivery. The positive predictive values of having more than one risk factor was low (2.2%–2.7%).

Conclusions: Prediction of postpartum transfusion is difficult. Retained placental tissue is the strongest predictor of postpartum blood transfusion in vaginal deliveries. Retained placental tissue is usually diagnosed for the first time when the bleeding starts, which limits the clinical value of prediction. We need tools for an early diagnosis of retained placenta to intervene early before transfusion is needed.     

Prenatal diagnosis of amniotic band syndrome – risk factors and ultrasonic signs

Objective: The aim of this study was to describe our experience with amniotic band syndrome (ABS), define specific sonographic characteristics and common features.

Methods: Patients diagnosed with ABS underwent detailed ultrasound evaluation at the time of diagnosis and during follow-up. Their ultrasound examinations and medical records concerning the current pregnancy and past medical records were analyzed.

Results: Ten pregnancies were diagnosed with ABS. Most pregnancies were diagnosed at the beginning of the second trimester. Two cases were bichorionic twin pregnancies involving one of the fetuses and these were the only women who continued their pregnancies to term. The other eight cases with ABS chose to terminate their pregnancies. One pregnancy was conceived following trachelectomy. We found a significantly higher rate of prior uterine surgeries (p?=?0.008) in patient with ABS compared to control. In three cases, all above 15 weeks of gestation, a small vestige at the distal part of the amputated limb was observed.

Conclusions: ABS diagnosed in early pregnancy can be a sporadic event. However, there is a higher risk of ABS in pregnancies preceded by uterine procedures. The ultrasonic vestige sign at the amputated limb may contribute to the diagnosis of ABS.     

Is there association between ABO blood group and the risk factors of unfavorable outcomes of pregnancy?

There are four major blood groups in human based on the presence of A and B antigens. ABO gene encodes A and B antigens on the surface of red blood cells and there are reported relations between this blood phenotype and pregnancy outcomes in the women. In this study, medical records of 792 healthy pregnant women were investigated and their age and blood test results including blood group with fasting blood sugar, hemoglobin, hematocrit, urea, creatinine and red blood cell counts were analyzed in statistical package for the social sciences. The RBC count in AB blood type was significantly higher than A and O blood group, also FBS level in the people with AB blood group was meaningfully higher than A group. But the mean of HGB and HCT were not significantly different between groups. The serum urea in the AB group was higher than the three other groups and also it was significantly higher in B compared to O and A blood groups. The serum creatinine in the AB group was higher than the three other groups too. Also it was significantly higher in the B group compared to A blood groups. These results indicate that the ABO blood group may have association with some of the risk factors of the unfavorable outcomes of pregnancy and it may be one of the prognostic tools, also it addresses more extensive studies.     

The incidence and risk factors for retained placenta after vaginal delivery – a single center experience

Abstract

Objective: We aimed to determine the incidence and risk factors for retained placenta immediately after vaginal delivery in a single, university-affiliated tertiary center.

Methods: A case-control study. Women who delivered vaginally and diagnosed with suspected retained placenta were compared to control group of women with spontaneous vaginal delivery with spontaneous non-complicated placental separation between the years 2007 and 2012. Eligibility was limited to singleton fetuses in vertex presentation with no history of more than one cesarean section, stillbirth or major fetal anomaly.

Results: Overall, 33?925 women delivered vaginally, of them, 491 (1.4%) underwent revision of uterine cavity due to suspected retained placenta. Women with retained placenta were characterized by a higher rate of previous cesarean section (OR 1.71, 95% CI 1.23–2.36), previous abortions, lower parity (OR 0.79, 95% CI 0.68–0.91), lower gestational age at delivery. Hypertensive disorders, oligohydramnios and labor and delivery interventions as induction of labor (OR 1.84, 95% CI 1.30–2.59), neuro-axial analgesia (OR 1.60, 95% CI 1.27–2.00) and vacuum delivery (OR 1.89, 95% CI 1.48–2.41) were independently associated with uterine revision for retained placenta.

Conclusion: Risk factors for manual revision due to retained placenta can be recognized. This data should be taken into consideration in the assessment of women immediately after delivery.     

Combined vaginal-cesarean delivery of twins: risk factors and neonatal outcome – a single center experience

Objective: We aimed to characterize risk factors for combined twin delivery and assess neonatal outcome.

Methods: This was a retrospective cohort study of all women admitted for trial of labor (TOL) with twin gestation, in a single, tertiary, university-affiliated medical center. Eligibility was limited to gestations with twin A delivered vaginally.

Results: During the study period, 44?263 women delivered in our center, of whom 1307 (2.9%) delivered twins. Overall, 221 out of 247 women (89.5%) undergoing TOL delivered twin A vaginally. Parturients who delivered twin B by cesarean delivery (n?=?23) were compared with those delivered twin B vaginally (n?=?198). Multivariate analysis demonstrated that risk factors combined delivery were included non-cephalic twin B at admission (aOR 11.5, 95% CI 3.8–34.9, p?<?0.001) or after delivery of twin A (aOR 17.7, 95% CI 6.6–47.2, p?<?0.001), and dichorionic–diamniotic (DCDA) twins (aOR 8.9, 95% CI 1.8–44.0, p?=?0.008). Spontaneous version of a cephalic twin B was not found to increase the risk (above the baseline risk of non-cephalic twin B) for combined delivery. Combined delivery was associated with slightly higher risk for hemorrhagic-ischemic encephalopathy of twin B (4.3% versus 0%, p?=?0.003).

Conclusion: Non-cephalic twin B at admission or following delivery of twin A poses higher risk for combined delivery. Neonatal outcome of twin B following combined delivery are comparable with those of vaginal delivery.     

Labor as a bacteriuric event—assessment and risk factors

Objective. Little is known regarding the prevalence of early postpartum bacteriuria. We sought to evaluate the incidence of bacteriuria following labor and to identify risk factors predisposing to this condition.

Methods. Three hundred and fifty parturients were recruited, 301 were included in the analysis. Women receiving antibiotic drugs during delivery were excluded. Urine cultures were obtained from the study group before delivery and prior to discharge. Data regarding management of labor was collected prospectively.

Results. Positive urine cultures were present on admission in 5.4% of women, whereas 12.9% had a positive urine culture at discharge (p < 0.003). Bacteriuria was acquired during labor in 12.7% of patients who had negative cultures on admission. Escalating number of digital vaginal examinations (p = 0.04), recurrent bladder catheterization (p = 0.05), duration of epidural anesthesia (p = 0.002), and vacuum delivery (p = 0.02) correlated significantly with an increased risk for acquiring bacteriuria.

Conclusion. Labor is a bacteriuric event. Iatrogenic interventions can predispose parturients with sterile urine cultures to postpartum bacteriuria.     

Environmental endocrine disruptors and breast cancer: new risk factors?

Human epidemiological studies and experimental animal data strongly suggest that xenobiotics with estrogenic activity may participate in to the increasing incidence of breast cancer, the most frequent cancer all around the world. Several reports have since 15 years reported positive correlations between blood or peritumoral adipose tissue levels of persistent organic compounds including organochloride pesticides and breast cancer risk. Moreover, fetal or perinatal exposition to low doses of such endocrine disruptors induce premalignant or malignant transformation of adult mammary gland in rodents. However, this environmental endocrine disrupter hypothesis still needs to be demonstrated. Further human studies are needed which will consider the exposition window, the association of several xenoestrogens, the molecular mechanisms involved and the possible individual genetic susceptibility in order to identify pertinent biomarkers and to define acceptable environmental concentration levels for agricultural or industrial chemical new products to be used.     

Trends and risk factors of stillbirth in New Jersey 1997–2005

Introduction: The purpose of this study was to examine the trends in the rates of stillbirth by race and ethnicity and to determine the risk factors of stillbirth. Methods: We used New Jersey data (1997–2005) for live births and fetal deaths. Cox proportional hazards model was used to estimate the risk of stillbirth associated with maternal risk factors and pregnancy complications. Results: The rate of stillbirth was 4.4/1000 total births (3.4 for white and 7.9 for black non-Hispanics and 4.4 for Hispanics/1000 total births). The rates of stillbirth decreased from 3.8 in 1997 to 2.7/1000 total births in 2005 for white non-Hispanics but remained unchanged for other race/ethnicity groups. Adjusted relative risks for the risk factors associated with stillbirth were 1.3 (95% CI, 1.2–1.4) for maternal age ≥ 35 years, 1.9 (95% CI, 1.7–2.1) for black non-Hispanics, 2.8 (95% CI, 2.4–3.3) for no prenatal care, 40.2 (95% CI, 36.9–43.9) for placental abruption, 5.3 (95% CI, 3.4–8.2) for eclampsia, 3.5 (95% CI, 2.8–4.3) for diabetes mellitus and 1.7 (95% CI, 1.3–2.2) for preeclampsia. Conclusion: There was a decline in the rate of stillbirth but there were persistent racial disparities with the highest rates of stillbirth for black non-Hispanics.     

Very and moderate preterm births: are the risk factors different?

Objective To describe the risk factors for very pretenn births and to compare the strengths of the associations between these risk factors and very and moderate preterm births.
Design A case-control study.
Setting Fifteen European countries.
Methods Between 1994 and 1997, 1675 very preterm births, 3652 moderate preterm births and an unmatched control group of 7965 births at term were included. Odds ratios for very and moderate preterm births (related to socioeconomic status, behavioural factors, maternal age, body mass index and obstetric history) were estimated and compared using polytomous logistic regression.
Results Underprivileged social situation, older maternal age and adverse previous pregnancy outcomes were significantly related to very and moderate preterm births. However, these factors were more strongly associated with very preterm births than with moderate preterm births, for both spontaneous and induced deliveries. Smoking during pregnancy, young maternal age and low body mass index were significantly related to very and moderate spontaneous preterm births, but no significant difference in odds ratios was observed between the two outcomes.
Conclusion These results suggest that risk factors for very and moderate preterm births are similar, but the strength of the associations differ, especially for social factors and obstetric history.     

Very and moderate preterm births: are the risk factors different?

OBJECTIVE: To describe the risk factors for very preterm births and to compare the strengths of the associations between these risk factors and very and moderate preterm births. DESIGN: A case-control study. SETTING: Fifteen European countries. METHODS: Between 1994 and 1997, 1675 very preterm births, 3652 moderate preterm births and an unmatched control group of 7965 births at term were included. Odds ratios for very and moderate preterm births (related to socioeconomic status, behavioural factors, maternal age, body mass index and obstetric history) were estimated and compared using polytomous logistic regression. RESULTS: Underprivileged social situation, older maternal age and adverse previous pregnancy outcomes were significantly related to very and moderate preterm births. However, these factors were more strongly associated with very preterm births than with moderate preterm births, for both spontaneous and induced deliveries. Smoking during pregnancy, young maternal age and low body mass index were significantly related to very and moderate spontaneous preterm births, but no significant difference in odds ratios was observed between the two outcomes. CONCLUSION: These results suggest that risk factors for very and moderate preterm births are similar, but the strength of the associations differ, especially for social factors and obstetric history.     

What factors affect intracytoplasmic sperm injection outcomes?

Within the last decade, intracytoplasmic sperm injection (ICSI), a new assisted reproductive technique that allows for the direct injection of spermatozoa into the oocyte, has become available to infertile couples. While most studies indicate that ICSI has success rates similar to those of traditional in vitro fertilization, there are many concerns about the safety of the procedure, including increased risks of chromosomal and developmental abnormalities in children conceived by ICSI. Factors that contribute to these increased risks have not been well elucidated. The purpose of this paper is to review the latest literature concerning 1) the adverse outcomes associated with ICSI; and 2) factors that affect the success rates of ICSI (with emphasis on paternal factors). TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to explain the procedure, intracytoplasmic sperm injection (ICSI), to outline the data surrounding chromosomal and developmental outcomes after ICSI, and to list and explain the potential factors that influence ICSI.     

Obstetric anal sphincter injury,risk factors and method of delivery – an 8-year analysis across two tertiary referral centers

Abstract

Objective: Obstetric anal sphincter injury (OASIS) represents a major cause of maternal morbidity and is a risk factor for the development of fecal incontinence. We set out to analyze the incidence of OASIS and its association with mode of delivery in two large obstetric hospitals across an 8-year study period.

Methods: This was a prospective observational study carried out at two large tertiary referral centers serving a single urban population, from 2003 to 2010. Incidence of OASIS was examined as well as the influence of parity and mode of delivery on the occurrence of OASIS.

Results: During the study period, there were 100?307 vaginal deliveries at the two hospitals. There was a total of 2121 cases of OASIS from 2003 to 2010, giving an incidence of 2.1% of vaginal deliveries. Patients were more likely to suffer an OASIS when having a forceps delivery than when having a normal vaginal delivery (8.6% versus 1.3%, p?<?0.0001, OR: 7.1, CI: 6.4–7.9). Vacuum delivery also carried an increased risk of sphincter injury compared with normal delivery (3.7% versus 1.3%, p?<?0.0001, OR: 2.9, CI: 2–2.6). About 16.7% of infants delivered were macrosomic (birthweight?>?4?kg). The rate of episiotomy during the study was 19.1%.

Conclusion: These results demonstrate that OASIS remains an important cause of maternal morbidity in contemporary obstetric practice. These results will likely be of value in risk management planning and patient debriefing in what is a highly litigious area of obstetrics.     

Maternal serum concentrations of angiogenic and antiangiogenic factors in threatened miscarriage at 7–12 weeks’ gestation and the risk of adverse pregnancy outcomes

ObjectiveTo assess the ability of first trimester maternal serum (FTMS) soluble Fms-like tyrosine kinase (sFlt-1)/placental growth factor (PlGF) ratio in the first trimester threatened miscarriage (FTTM) to predict fetal loss in early pregnancy and adverse pregnancy outcomes when pregnancy continued to ?30 weeks to start suitable antenatal care as early as possible.DesignA case control prospective cross-sectional study.Material and methods320 cases of TM, 7–12 weeks’ gestation and 320 normal controls 7–12 weeks’ gestation without vaginal bleeding and other manifestations of FTTM and delivered at ?30 weeks’ gestation were enrolled in the study. All were primigravidae. Estimation of FTMS sFlt-1 and PlGF in the first trimester of TM and controls by enzyme-like immunosorbent assay (ELISA) and follow up of them till delivery were done. Adverse pregnancy outcomes encountered were gestational hypertension (GH), preeclampsia (PE), intrauterine growth restriction (IUGR), abruptio placentae, spontaneous preterm labor (PTL), placenta previa, preterm premature rupture of membranes (PPROM) and retained placenta.ResultsAll adverse pregnancy outcomes were significantly (P < 0.05) higher in FTTM than in controls (44.52% vs. 17.5%). In FTTM MS concentrations of sFlt-1 and PlGF and sFlt-1/PlGF ratio were markedly reduced if fetal loss was encountered. sFlt-1/PlGF ratio <51.71 (cut-off point) predicted fetal loss with sensitivity 90.32%, specificity 98.47%, positive predicted value 93.33% and negative predictive value 97.60%. Patients that developed adverse pregnancy outcomes related to impaired placentation as GH, PE, IUGR, PTL <34 weeks’ gestation and abruptio placentae had reduced FTMS PlGF and increased sFlt-1/PlGF ratio, in both FTTM and controls. Soluble Flt-1/PlGF ratio >74.6 (cut-off point) predicted these adverse pregnancy outcomes with sensitivity 88.70%, specificity 95.40, positive predictive value 90.16% and negative predictive value 94.68% – adverse pregnancy outcomes not related to placental impairment as PLT >34 weeks’ gestation, PPROM, placenta previa and retained placenta were not predicted by sFlt-1/PlGF ratio because in these conditions FTMS concentration of these factors were normal.Conclusions1-Adverse outcomes late in pregnancy (?30 weeks’ gestation) were more common in FTTM. 2-Diminished FTMS concentration of sFlt-1 and PlGF as well as sFlt-1/PlGF ratio <51.71 may predict fetal loss in FTTM. 3-In FTTM and normal controls FTMS PlGF was reduced and sFlt-1/PlGF ratio >74.6 may predict development of adverse outcomes characterized by impaired placentation. 4-Adverse pregnancy outcomes not related to impaired placentation were associated with normal FTMS concentration of sFlt-1 and PlGF and were not predicted by sFlt-1/PlGF ratio.