Breech presentation at term and associated obstetric risks factors—a nationwide population based cohort study

Purpose

The aim of this study was to estimate whether breech presentation at term was associated with known individual obstetric risk factors for adverse fetal outcome.

Methods

This was a retrospective, nationwide Finnish population-based cohort study. Obstetric risks in all breech and vertex singleton deliveries at term were compared between the years 2005 and 2014. A multivariable logistic regression model was used to determine significant risk factors.

Results

The breech presentation rate at term for singleton pregnancies was 2.4%. The stillbirth rate in term breech presentation was significantly higher compared to cephalic presentation (0.2 vs 0.1%). The odds ratios (95% CIs) for fetal growth restriction, oligohydramnios, gestational diabetes, a history of cesarean section and congenital fetal abnormalities were 1.19 CI (1.07–1.32), 1.42 CI (1.27–1.57), 1.06 CI (1.00–1.13), 2.13 (1.98–2.29) and 2.01 CI (1.92–2.11).

Conclusions

The study showed that breech presentation at term on its own was significantly associated with antenatal stillbirth and a number of individual obstetric risk factors for adverse perinatal outcomes. The risk factors included oligohydramnios, fetal growth restriction, gestational diabetes, history of caesarean section and congenital anomalies.

     

Is a change in the vaginal flora associated with an increased risk of preterm birth?

OBJECTIVE: The purpose of this study was to determine if a change in the vaginal flora was associated with an increased risk of preterm birth, and to determine if metronidazole therapy before 32 weeks increased the risk of preterm birth. STUDY DESIGN: We compared cultures taken at 23 to 26 weeks of gestation with cultures taken at delivery from women enrolled in the Vaginal Infections and Preterm Birth study to analyze the association of changes in the vaginal flora with preterm birth. RESULTS: Metronidazole therapy before 32 weeks was associated with an increased risk of preterm birth (OR 1.5, 95%CI 1.05-2.1) in an unadjusted model. A change to heavy growth of Escherichia coli or Klebsiella pneumoniae at delivery was found to be associated with preterm birth (OR 2.4, 95%CI 1.6-3.8). After controlling for race, parity, prepregnancy weight <100 pounds, smoking or drinking during pregnancy, Trichomonas vaginalis, bacterial vaginosis, chlamydia, mycoplasmas, group B streptococcus, metronidazole therapy before 32 weeks, vaginal pH >5.0, and an increase in E coli or K pneumoniae , only prepregnancy weight <100 pounds (adjusted odds ratio [AOR] 2.07, 95%CI 1.01-4.21) and increased E coli or K pneumoniae in the vagina at delivery (AOR 2.99, 95%CI 1.37-6.53) were found to be significantly associated with preterm birth. CONCLUSION: An increase in E coli or K pneumoniae in the vagina is an independent risk factor for preterm birth. Changes in the vaginal flora may explain the increased risk of preterm birth seen with vaginal clindamycin or oral metronidazole therapy.     

A prospective study of the parent–baby bond in men and women 15 months after birth

Objective: To prospectively examine the impact of parental mental health (PTSD, depression and anxiety), the couple’s relationship quality and the infant temperament on the parent–baby bond in first-time mothers and fathers. Background: Evidence suggests that poor parental mental health, difficult infant temperament and/or lower quality of the couple’s relationship may impede the parent–baby bond. However, little research has included both parents or followed these measures across time. Methods: 75 women and 66 men completed questionnaire measures during pregnancy, 3 and 15 months postpartum, assessing mental health symptoms, the parent–baby bond, the couple’s relationship and infant characteristics. The response rates at different time-points were 90%, 77% and 70%. Results: The parent–baby bond was associated with parental mental health, the couple’s relationship and infant characteristics. The most important predictors of the parent–baby bond three months postpartum for both men and women were the couple’s relationship during pregnancy and their baby’s temperament at three months. At 15 months postpartum, after accounting for the parent–baby bond at 3 months, only concurrent infant temperament remained a significant predictor for women. However, men’s bond with their baby at 15 months was predicted by their relationship with their partner in pregnancy and concurrent affective symptoms. Few significant gender differences were found, apart from women reporting more mental health symptoms than men. Conclusion: This study highlights the significance of the couple’s relationship in pregnancy and the infant’s temperament on the development of the parent–baby bond. Future research is needed to examine this in larger more representative samples.     

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.     

Early neonatal morbidities and associated modifiable and non-modifiable risk factors in a cohort of infants born at 34–35 weeks of gestation

Objective: To ascertain the most common early morbidities in a cohort of infants born at 34–35 weeks gestation and to identify the risk factors associated with these morbidities.

Methods: Retrospective analysis of data collected prospectively for all 235 infants born at 34–35 weeks of gestation during an eight-month period at a single tertiary medical center. Study group infants (SG) were compared with 470 term infants (TI), matched both for gender and for mode of delivery.

Results: Jaundice requiring phototherapy (32%), respiratory disease (19.1%) and cyanotic episodes (15.7%) were the most frequent early morbidities, followed by hypoglycemia, temperature instability and feeding intolerance. The risk of having a complication was 13.3-times higher in the SG compared with the TI group (95% CI 8.9–19.6, p?0.001). Modifiable interventions associated with these morbidities were antenatal steroids, MgSO₄ and mode of delivery. Non-modifiable factors were maternal age, parity, twins and gender.

Conclusions: Jaundice requiring phototherapy, respiratory disease and cyanotic episodes are the most frequent early morbidities among infants born at 34–35 weeks. Medically modifiable factors were found to be associated with the above morbidities. Whether specific recommendations for the care of these infants will affect early morbidities needs to be studied in controlled prospective studies.     

Cord clamping time in spontaneously breathing preterm neonates in the first minutes after birth: impact on cerebral oxygenation – a prospective observational study

Objective: To analyse impact of delayed cord clamping (DCC60sec) on cerebral regional tissue oxygenation (crSO2) and fractional tissue oxygen extraction (cFTOE) in spontaneously breathing preterm neonates during the first 15?min after birth.

Methods: Two-centre observational study, crSO2 and cFTOE was monitored in neonates with DCC60sec or early cord clamping (ECC?<?30?s).

Results: Seventy-six infants (birth weight and gestational age 1736?±?508?g and 31.8?±?2.5 weeks) were included. DCC was associated with lower initial crSO2 and higher cFTOE and lower initial Apgar-score and heart rate.

Conclusion: Attending practitioners should be aware that DCC might impact initial immediate transition in spontaneously breathing preterm neonates.     

Efficacy and safety of late-start Corifollitropin-alfa administration for controlled ovarian hyperstimulation in IVF: a cohort,case–control study

ObjectiveTo investigate efficacy and safety of a controlled ovarian stimulation (COS) protocol in which a single dose of Corifollitropin-alfa (CFα) was administered on day 4 of a GnRH-antagonist cycle.DesignCohort case–control study.SettingUniversity Hospital.PatientsOne hundred twenty-two normally cycling women expected to be normal responders to COS.InterventionsIn 61 patients, CFα (100–150 μg) was injected subcutaneously on day 4 of a spontaneous menstrual cycle; a GnRH-antagonist was added from day 8 (fixed protocol; 0.25 mg/day). If needed to complete follicular maturation, recombinant FSH (rFSH) daily injections (150/200 IU/day) were given from day 11. A control group of 61 matched women was stimulated with daily subcutaneous injections of rFSH (100–150 U/day) from day 4 of the cycle, and received GnRH-antagonist (0.25 mg/day) from day 8. IVF or ICSI was performed according to the sperm characteristics, and 1–2 embryos were transferred in utero under US guidance on day 2.ResultsNo cycle was cancelled and the mean number of retrieved COCs was comparable in patients and controls. About 60 % of CF-alfa treated women had no need of daily rFSH addition, and the mean number of injections/cycle was significantly lower in the CF-alfa group than in controls (p < 0.05). The ongoing PR/transfer was 36.8 % in CF-alfa group and 37.5 % in controls. No patient developed severe OHSS, and the incidence of moderate OHSS was similar in cases and controls.ConclusionsCFα may be started on day 4 of the cycle obtaining results comparable to those of a COS using day 4-start daily rFSH, with significantly less injections and a similar risk of OHSS.     

Decline in βhCG levels between days 0 and 4 after a single dose of methotrexate for ectopic pregnancy predicts treatment success: a retrospective cohort study

In current protocols for the medical management of ectopic pregnancies, the first indication of treatment response is obtained no sooner than day 7. We examined whether human chorionic gonadotrophin (βhCG) trends between days 0 and 4 after methotrexate provide an earlier indication of the likely outcome. Of 33 patients where serum βhCG dropped between days 0 and 4 after methotrexate, the ectopic pregnancy was resolved in 88% of cases without further treatment. Of 12 women where serum βhCG rose between days 0 and 4, only 42% had treatment success. A fall in βhCG between days 0 and 4 after treatment with methotrexate for ectopic pregnancy predicts a high likelihood of treatment success.     

Good practices according to WHO’s recommendation for normal labor and birth and women’s assessment of the care received: the “birth in Brazil” national research study, 2011/2012

Background

The World Health Organization recommends good practices for the conduct of uncomplicated labor and birth, with the aim of improving the quality of and assessment by women of childbirth care. The aim of this study was to evaluate the association between adoption of good practices according to WHO’s recommendation for normal labor and birth and assessment by women of the care received.

Methods

Birth in Brazil is a national hospital-based study with countrywide representation consisting of 23,894 mothers and their newborns, conducted between February 2011 and October 2012. The present study analysed a subsample of this national survey. Postpartum women classified as low risk during pregnancy who had experienced either spontaneous or induced labor were included in this study, totalling 4102 mothers. To estimate the association between assessment by women of the childbirth care received (dependent variable) and good practices according to WHO’s recommendation during normal labor and birth (independent variables), a multinomial logistic regression analysis was used and crude and adjusted odds ratios calculated with their 95 % confidence intervals.

Results

The good practices associated with positive assessment of the care received by women during labor and birth included the partner’s presence, privacy in the birthing place, time available to ask questions, clarity of information received, and empathic support from caregivers during labor and birth. Freedom of movement, free nutrition offered, choice of companions, nonpharmacological analgesia, skin-to-skin contact and breastfeeding in the childbirth room were not associated with the assessment by women of the care received.

Conclusions

Our findings reveal the importance to mothers of their relationship with the team of caregivers during labor and birth. Therefore, caregiver teams must be qualified within a more humanistic vision of childbirth health care.

     

The impact of route of delivery and presentation on twin neonatal and infant mortality: a population-based study in the USA, 1995–97

Objective: We examined whether the route of delivery for near-term (???34 weeks' gestation) twins, as candidates for vaginal delivery, affected neonatal and infant mortality rates. We further evaluated whether these mortality rates were modified by fetal presentation.

Methods: A population-based retrospective cohort study based on the matched multiple births data in the USA (1995–97) was performed. Analyses were restricted to non-malformed liveborn twins delivered at ??34 weeks' gestation. Twins with breech–breech and breech–vertex presentations were excluded, since they are not candidates for vaginal delivery. Neonatal mortality rates (death within the first 27 days) and post-neonatal mortality rates (death between 28 and 365 days) per 1000 twin live births, by route of delivery and fetal presentation, were derived. The associations between neonatal mortality, post-neonatal mortality and the route of delivery for vertex–breech versus vertex–vertex presentations were expressed based on relative risks (RR) and 95% confidence intervals (CI) derived from logistic regression models based on the method of generalized estimating equations.

Results: Of the 177?622 twins analyzed, 87% (n?=?154?531) presented as vertex-vertex. Fifty-five per cent (n?=?97?692) of twins were both delivered vaginally, 41% (n?=?72?825) were both delivered by Cesarean section and, of the remaining 4% (n?=?7105), the first twin was delivered vaginally and the second by Cesarean section. Twins with vertex–breech presentations delivered by Cesarean–cesarean sections, as well as those with vertex–vertex presentations delivered vaginally, had the lowest neonatal mortality rate (1.6 per 1000 live births). The highest neonatal mortality rate in the vertex–breech pairs occurred with vaginal–Cesarean deliveries (2.7 per 1000 live births). Among twins with vertex–vertex presentations, twins delivered via the vaginal–Cesarean route experienced the highest neonatal mortality (3.8 per 1000 live births). The RR for neonatal mortality in this group was 2.24 (95% CI 1.35, 3.72) compared with twins both delivered vaginally.

Conclusion: Route of delivery and fetal presentation both confer an impact on twin infant mortality rates. Strategies to reduce discordant routes in complicated vaginal deliveries may lead to improved neonatal survival.     

A prospective, case–control study on the lipid profile and the cardiovascular risk of menopausal women on oestrogen plus progestogen therapy in a northern Italy province

Purpose

To evaluate the effects of oestrogen plus progestogen therapy (EPT) on the lipid metabolism of menopausal patients.

Methods

We conducted a prospective study on 223 patients with clinical and blood chemistry diagnosis of menopause, who were eligible for hormone therapy and a follow-up period lasting at least 5 years. We selected a control group. Patients attended annual or 6-monthly visits for the duration of the 5-year follow-up period. For each patient, total-cholesterol, HDL-cholesterol, LDL-cholesterol and triglyceride values were considered at the first visit and after 5 years. We compared these values of the above parameters in relation to time and EPT and the repercussions that the presence/absence of replacement therapy had in terms of lipid profile alteration between the groups studied.

Results

Of the 223 patients eligible for enrolment, 178 made up the study group (EPT Group) and 45 made up the control cohort (N-EPT-Group). At the first visit, median value was (EPT-Group vs. N-EPT-Group): cholesterol was 240 versus 226 mg/dL, LDL-cholesterol 169 versus 174 mg/dL, HDL-cholesterol 60 mg/dL in both groups, triglyceride 125 versus 92 mg/dL (p:n.s). Five years later, median value was (EPT-Group versus N-EPT-Group): cholesterol 225 versus 236 mg/dL (p < 0.001), LDL-cholesterol 125 versus 184 mg/dL (p < 0.001), HDL-cholesterol 64 versus 68 mg/dL (p:n.s.), triglyceride 72 versus 94 mg/dL (p:n.s.). No adverse effects of EPT were observed.

Conclusions

Thorough risk/benefit assessment, associated with initially low doses and without rigid cutoffs, particularly when started early, EPT can be made a valid means of cardiovascular prevention, specifically because it positively alters the lipid profile of menopausal women.