The association between Mullerian anomalies and short-term pregnancy outcome

Objective: To determine the association between Mullerian anomalies (MuAs) and short-term perinatal outcome.

Study design: A retrospective cohort study, comparing pregnancy outcome in women with and without MuAs matched by age, number of fetuses and parity in a 1:2 ratio.

Results: Among 243 women with MuAs, 156 (64.2%) had bicornuate uterus, 38 (15.6%) had septate uterus, 27 (11.1%) had unicornuate uterus and 22 (9.1%) had didelphic uterus. Compared to controls (n?=?486), women with MuAs had higher rates of previous preterm deliveries (PTDs) (20.2 versus 5.9%, p?<?0.001) and previous cesarean section (CS) (50.6% versus 12.5%, p?<?0.001). Women with MuAs had higher rates of PTDs?<37 weeks (25.1% versus 6.1%, p?<?0.001) and?<32 weeks (4.1% versus 0.6%, p?=?0.001), preterm premature rupture of membranes (PPROM) (12.8% versus 2.7%, p?<?0.001) and small for gestational age (SGA) infants (12.3 versus 6.8%, p?=?0.01). There was higher rate of CS in the MuA group (82.3 versus 22.1%, p?<?0.001), mainly due to higher rates of malpresentation and previous CS. In multivariate analysis, MuA was associated with SGA (2.04, 1.15–3.63), PTDs?<37 weeks (3.72, 1.79–7.73), PTDs?<32 weeks (7.40, 1.54–35.56), PPROM (6.31, 3.04–13.12), malpresentation (21.62, 12.49–37.45) and retained placenta (4.13, 1.73–9.86). No increased risk was observed in the rate of in-labor CS (0.52, 0.21–1.30, p?=?0.16). When the rate of adverse outcomes was stratified according to MuAs subtypes, women with unicornuate uterus had the highest rate of breech presentation at delivery (55.6%) and women with didelphy uterine had the highest proportion of PTDs?<37 weeks (40.9%).

Conclusion: Women with MuAs are at increased risk for adverse pregnancy outcome, mainly PTDs?+?and PPROM, SGA infants and CS due to malpresentation. However, the risk of in-labor CS is not increased compared to the general population.     

Is induction of labor risky for twins compare to singleton pregnancies?

Abstract

Objective: The aim of this study was to investigate whether induction of labor in twin pregnancies is associated with higher rates of maternal complications as compared to singletons.

Method: A retrospective population-based study was conducted to compare maternal complications following induction of labor in twin pregnancies and singletons at Soroka University Medical Center, Be'er-Sheva, Israel, between 1988 and 2010. Stratified analysis using a multiple logistic regression model was performed to control for confounders.

Results: The study population included 25?913 patients following induction of labor, of these 191 (0.73%) were in twin pregnancies. Induction of labor in twin pregnancies was not associated with adverse maternal outcomes such as cervical tears, third degree perineal tears, uterine rupture, peripartum hysterectomy, post-partum hemorrhage or retained placenta. However, labor induction in twins was significantly associated with cesarean deliveries (31.2% versus 17.1%; p?<?0.001).

Using a multivariable analysis controlling for confounders, induction at twins was an independent risk factor for cesarean delivery (CD; adjusted OR?=?2.2, 95% CI 1.7–2.7, p?<?0.001).

Conclusion: Induction of labor in twin pregnancies does not increase the risk for maternal complications. However, it is an independent risk factor for CD.     

Pre-induction cervical ripening: comparing between two vaginal preparations of dinoprostone in women with an unfavorable cervix

Abstract

Objective: Prostaglandin E2 (PGE2-Dinoprostone) is accepted for both ripening of the cervix and induction of labor. As conflicting data exist concerning the efficiency and safety of different treatment modalities, we aimed to compare slow-release vaginal insert PGE2 with serial vaginal tablets of PGE2 for cervical ripening and induction of labor.

Methods: A retrospective cohort study comparing all pregnancies who underwent induction of labor by either a single slow-release vaginal insert of 10?mg PGE2 (study group) to a historical control group of women who were treated with serial administration of 3?mg vaginal PGE2 tablets in a 2:1 ratio, matched by parity.

Results: Overall, 639 women were enrolled (213 treated with PGE2 tablets and 426 with slow-release vaginal inserts). Vaginal insert was associated with shorter initiation-to-ripening interval (12.4?±?7.7 versus 18.6?±?15.2?h, p?<?0.001) and a higher rate of delivery within 24?h (61.5 versus 51.6%, p?=?0.018). Vaginal insert was associated with an increased rate of tachysystole (8.0 versus 3.1%, p?<?0.01); however, the rates of cesarean section or operative delivery due to non-reassuring fetal heart rate (NRFHR) were similar. On multivariable analysis, slow-release vaginal insert was independently associated with a higher rate of delivery within 24?h (OR 1.50, 95% CI 1.04–2.18).

Conclusion: Slow-release PGE2 vaginal insert achieves cervical ripening and subsequently delivery over a shorter time period than PGE2 tablets, without increasing uterine hyperstimulation rate.     

Myometrial elasticity determined by elastosonography to predict preterm labor

Abstract

Aim: To determine the utility of elastosonography (ES) combined to cervical length measurement to predict preterm labor.

Methods: One hundred twenty-seven women with pregnancies between 21 to 36 weeks of gestation without any risk factor for preterm labor were included in the study. All subjects underwent sonographic evaluation including fetal biometry, cervical length measurement and ES of uterine myometrium. Subcutaneous tissue was the reference point for ES evaluation. Tissue strain ratio values were obtained from all patients.

Results: Cervical length was a significant predictor for preterm delivery (AUC?=?0.958, p?<?0.001). Optimal cut-off value was obtained at 30?mm with 92% sensitivity and 81% specificity. Elastosonographic strain ratio was also a significant predictor for preterm delivery (AUC?=?0.827, p?<?0.001). Optimal cut-off value was obtained at 4.7 with 79% sensitivity and 91% specificity. In linear regression analysis, strain ratio (R^2?=?0.61, beta?=?0.171, p?=?0.03) and cervical length (R^2?=?0.61, beta?=??0.516, p?<?0.001) were significantly associated with preterm delivery. Cervical length?<?30?mm [39.1 (95 CI, 6.6–231.5, p?<?0.001)] and strain ratio?>?4.7 [24.5 (95 CI, 4.1–146.5, p?<?0.001)] were the risk factors for preterm delivery.

Conclusion: Elastosonographic evaluation of uterine myometrium was found to be significantly correlated with cervical length but cervical length measurement is a better predictor for preterm labor than ES.     

Pregnancy outcomes after failed cervical ripening with prostaglandin E2 followed by Foley balloon catheter

Objective: To study pregnancy outcomes of cervical ripening with Foley catheter, in women who failed to respond to prostaglandin-E2 (PGE2).

Methods: A retrospective cohort study of all patients with a singleton pregnancy, who underwent cervical ripening with vaginal PGE2, between 2013 and 2014, was performed. Patients who failed to respond to a total dose of 6–9 mg PGE2, defined as no change in Bishop score, underwent subsequent ripening with Foley catheter (non-responders group). Data were compared to patients who achieved sufficient response to a total dose of up to 9 mg PGE2 (responders group).

Results: Compared with the responders group (n?=?813), patients in the non-responders group (n?=?49) had higher rates of nulliparity (p?<?0.001), pre-induction cervical dilation ≤1?cm (p?=?0.004), pre-induction cervical effacement?≤50% (p?=?0.01) and birth weight >4000?g (p?=?0.02). A significantly higher cesarean delivery rate was observed in the non-responders group (51 versus 12.3%, p?<?0.001). Failed ripening with PGE2 was found to be independently associated with cesarean delivery (aOR?=?5.11, 95% CI?=?2.72–9.62).

Conclusions: The need for an additional cervical ripening method after failure with PGE2 is associated with a very high risk of cesarean delivery. This is particularly significant in nulliparous women, women carrying large fetuses, and women presenting with a low Bishop score.     

Pregnancy outcome in patients with fibromyalgia syndrome

Objective.?To investigate pregnancy outcome of patients with fibromyalgia syndrome (FMS).

Methods.?A retrospective cohort study comparing pregnancies of women with and without FMS was conducted. Multivariable logistic regression models was performed to control for confounders

Results.?Deliveries of 112 women with FMS were compared with a control group of 487 deliveries of women without FMS. Parturients with FMS had higher rates of intrauterine growth restriction (IUGR; 7.1% vs. 1.0%, p?=?0.001), recurrent abortions (9.8% vs. 1.8%, p?<?0.001), gestational diabetes mellitus (14.3% vs. 7%, p?=?0.012), and polyhydramnios (12.5% vs. 1.6%, p?<?0.001). These patients had lower rates of preterm deliveries (PTD; 6.3% vs. 16.7%, p?=?0.018). No significant differences were noted between the groups regarding the rates of cesarean deliveries (CD) (15.2% vs. 21.2%, p?= 0.149) and perinatal outcomes such as low Apgar scores (<7) at 1 and 5?min (4.5% vs. 6.7%, p?=?0.292 and 1.2% vs. 0.6%, p?=?0.372; respectively). Using two multiple logistic regression models, the positive association between FMS and IUGR (adjusted OR?=?4.1, 95% CI 1.2–13.2; p?=?0.02) and the negative association with PTD (OR?=?0.3, 95% CI 0.2–0.6; p?=?0.001) remained significant.

Conclusion.?FMS is an independent risk factor for intrauterine growth restriction. Nevertheless, it is associated with lower rates of preterm deliveries.     

Outcomes following rescue cerclage in twin pregnancies*

Objective: Our aim was to compare perinatal outcomes in twin pregnancies complicated by premature asymptomatic cervical dilatation treated with rescue cerclage and expectant management.

Methods: A retrospective cohort study was conducted at a single tertiary referral center between 2003 and 2014 and included all women with twins found to have a dilated cervix with intact membranes before 25-week gestation. Pregnancy outcomes were compared between women with rescue cerclage and those managed expectantly. A total of 36 women were eligible for the study, 27 (75.0%) of whom had a rescue cerclage compared to 9 (25.0%) women managed expectantly. Student’s t-test was used to compare continuous variables between the groups and the chi-square and Fisher’s exact tests were used for categorical variables as appropriate. Statistical analysis was performed with the SPSS v21.0 software (IBM Corp; Armonk, NY). Differences were considered significant when the p value was less than .05.

Results: Among the 27 women with a rescue cerclage, the mean gestational age at time of cerclage insertion was 21.5?±?2.6 weeks. The intervention and control groups were similar with respect to the degree of cervical dilatation at presentation (2.6?±?1.3 versus 3.0?±?1.5?cm, p?=?.5). Women in the cerclage group gave birth at a more advanced gestation (28.9?±?6.1 versus 24.2?±?2.6?weeks, respectively, p?=?.03) and were less likely to give birth at <34 and <28?weeks (66.7 versus 100.0%, p?=?.046, and 59.3 versus 100.0%, p?=?.02, respectively). The mean latency from the placement of cerclage to delivery was 7.3?±?5.5 weeks. Similar findings were observed when analysis was limited to women with cervical dilatation of ≤3?cm at presentation.

Conclusions: In asymptomatic women with twin pregnancies and cervical dilatation before 25?weeks of gestation, rescue cerclage can prolong pregnancy and improve perinatal outcomes when compared to expectant management.     

Bleeding complications in pregnancies with low-lying placenta

Objective: To evaluate pregnancy outcomes with low-lying placenta according to the distance from placenta to cervical os.

Methods: Retrospective cohort study of singleton pregnancies with low-lying placenta (placenta edge within 20?mm of internal os on transvaginal sonography) delivered at our hospital from 2002 to 2012, excluding suspected placenta accreta and vasa previa. Vaginal delivery was offered in the absence of another indication for cesarean. Outcomes were stratified according to placenta-os distance ≤10?mm and 11–20?mm.

Results: Of 98 pregnancies with low-lying placenta, 41% had placenta-os distance ≤10?mm and 59% placenta-os distance 11–20?mm. Fifty-four percent had a trial of labor. Six (15%) with placenta-os ≤10?mm and 21 (36%) with placenta-os 11–20?mm delivered vaginally, p?=?0.02. Bleeding necessitating cesarean occurred in 25%, and postpartum hemorrhage in 43%; neither complication associated with placenta-os distance. Third-trimester bleeding prior to delivery hospitalization was reported in 44% and associated with later bleeding requiring cesarean in 51% versus 4% of those without third-trimester bleeding, p?<?0.001.

Conclusion: Whereas low-lying placenta does not contraindicate labor, we found significant risk for bleeding complications, regardless of the planned mode of delivery. Placenta-os distance did not significantly affect outcomes in our series.     

Cervical fluid calreticulin and cathepsin-G in pregnancies complicated by preterm prelabor rupture of membranes

Objective: The study aimed to determine the cervical calreticulin and cathepsin-G concentrations in pregnancies complicated by preterm prelabor rupture of membranes (PPROM) with respect to the presence of microbial invasion of the amniotic cavity (MIAC) and intra-amniotic inflammation (IAI).

Methods: Eighty women with singleton pregnancies complicated by PPROM were included in this study. Cervical and amniotic fluids were obtained at the time of admission, and concentrations of calreticulin and cathepsin-G in cervical fluid were determined using ELISA. The MIAC was defined as a positive PCR analysis for Ureaplasma species, Mycoplasma hominis, and/or Chlamydia trachomatis and/or by positivity for the 16S rRNA gene. IAI was defined as amniotic fluid bedside IL-6 concentrations ≥745?pg/mL

Result: Neither women with MIAC nor with IAI had different cervical fluid concentrations of calreticulin (with MIAC: median 18.9?pg/mL vs. without MIAC: median 14.7?pg/mL, p?=?0.28; with IAI: median 14.3?pg/mL vs. without IAI: median 15.6?pg/mL, p?=?0.57;) or of cathepsin-G (with MIAC: median 30.7?pg/mL vs. without MIAC: median 24.7?pg/mL, p?=?0.28; with IAI: median 27.3?pg/mL vs. without IAI: median 25.1?pg/mL, p?=?0.80) than women without those complications. No associations between amniotic fluid IL-6 concentrations, gestational age at sampling, and cervical fluid calreticulin and cathepsin-G concentrations were found.

Conclusions: Cervical fluid calreticulin and cathepsin-G concentrations did not reflect the presence of MIAC or IAI in women with PPROM.     

Pregnancy in patients with sickle cell disease: maternal and perinatal outcomes

Objective: To compare obstetrical, hematological and neonatal outcomes of pregnant women with or without sickle cell disease (SCD).

Methods: A prospective study of 60 pregnancies of 58 women with SCD (29 SCD-SS and 29 SCD-SC) compared with 192 pregnancies in 187 healthy pregnant women was carried out from January 2009 to August 2011.

Results: Compared to controls, the SCD group had higher rate of preterm delivery (p?p?p?=?0.003), and urinary infection (p?=?0.001, OR?=?3.31, CI 1.63–6.73), higher prevalence of small for gestational age babies (p?=?0.019, OR?=?2.66, CI 1.15–6.17), and more frequent baby admissions to progressive care unit (p?p?=?0.056). All adverse events were more frequent in the SS subgroup. Babies from the SS subgroup had the lowest weight at birth (2080?g) compared to SC (2737?g; p?Conclusion: SCD pregnant women – especially those in the SS subgroup – are more prone to experience perinatal and maternal complications in comparison with pregnant women without SCD.     

A comparison of obstetrical outcomes with labor induction agents used at term

Abstract

Objective: To compare the obstetrical outcomes of term pregnancies induced with one of four commonly used labor induction agents.

Methods: This is a retrospective cohort study of induced deliveries between 1 August 1995 and 31 December 2007 occurring at the Los Angeles County?+?University of Southern California Medical Center. Viable, singleton, term pregnancies undergoing induction were identified. Exclusion criteria included gestational age less than 37 weeks, previous cesarean delivery, breech presentation, stillbirth, premature rupture of membranes, and fetal anomaly. Induction methods studied were oxytocin, misoprostol, dinoprostone and Foley catheter. Our primary outcome was cesarean delivery rate among the four induction agents. Secondary outcomes included rate of failed induction, obstetrical complications, and immediate neonatal complications.

Results: A total of 3707 women were included in the study (1486 nulliparous; 2221 multiparous). Outcomes were compared across induction methods using Chi-square Tests (Pearson or Fisher’s, as appropriate). Among the nulliparous patients, there was no statistical difference among the four induction agents with regards to cesarean delivery rate (p?=?0.51), frequency of failed inductions (p?=?0.49), the cesarean delivery frequency for “fetal distress” (p?=?0.82) and five minute Apgar score <7 (p?=?0.24). Among parous patients, the cesarean delivery rate varied significantly by induction method (p?<?0.001), being lowest among those receiving misoprostol (10%). Those receiving oxytocin and transcervical Foley catheter had cesarean rates of 22%, followed by dinoprostone at 18%. The rate of failed inductions was 2% among those receiving misoprostol, compared to 7–8% among those in the other groups (p?<?0.01). Although cases of “fetal distress” between the four induction agents was not significantly different amongst multipara women, the cesarean delivery indication for “fetal distress” was higher among multipara receiving misoprostol (p?=?0.004). There was no difference among the different induction agents with regards to five minute Apgar <7 (p?=?0.34).

Conclusion: Among nulliparous women, all induction methods have similar rate of cesarean delivery. The use of misoprostol appears to be associated with a lower risk of cesarean birth among parous women induced at our institution.     

Vaginal birth after Cesarean delivery: predicting success,risks of failure

Objectives: To identify predictors of successful trial of labor in women after one low transverse Cesarean delivery and no prior deliveries, and to assess perinatal morbidity associated with a failed vaginal birth after Cesarean delivery (VBAC).

Methods: Retrospective chart review of women with one low transverse Cesarean delivery in their first pregnancy who delivered their next pregnancy at our institution. Clinical characteristics and intrapartum data were reviewed to identify predictors of successful VBAC. Perinatal outcomes were reviewed to assess morbidity associated with VBAC attempt and failed VBAC.

Results: Of 768 women studied, 522 (68%) attempted VBAC and 344 (66%) of these were successful. Uterine rupture occurred in 0.8% of the VBAC group. On initial examination, women with cervical dilation >?1?cm, effacement >?50% and station lower than –?1 were more likely to deliver vaginally. Women with successful VBAC?had more spontaneous labor (85.2 vs. 76.4%, p?=?0.02) and less oxytocin use (49.7 vs. 70.8%, p?<?0.0001). There were no differences in outcomes between failed and successful VBAC, except more frequent 1-min Apgar scores <?5 (10.1 vs. 4.1%, p?=?0.01) and increased endometritis (9.6 vs. 2%, p?=?0.0002) with failed VBAC. Compared with elective repeat Cesarean delivery, VBAC attempt was associated with amnionitis (5.9 vs. 0%, p?<?0.0001) and low 1- and 5-min Apgar scores (6.1 vs. 2.4%, p?=?0.03 and 2.3 vs. 0%, p?=?0.01, respectively), but not endometritis, admission to a neonatal intensive care unit (NICU), ventilation, intraventricular hemorrhage (IVH) or seizures. Failed VBAC?had more amnionitis (7.3 vs. 0%, p?<?0.0001), postpartum fever (11.2 vs. 2.4%, p?=?0.0003) and endometritis (9.6 vs. 2.0, p?=?0.0007) than elective repeat Cesarean delivery and was associated with low 1- and 5-min Apgar scores (10.1 vs. 2.4%, p?<?0.001 and 2.8 vs. 0%, p?=?0.01, respectively), but not NICU admission, ventilation, IVH or seizures.

Conclusions: Favorable initial pelvic examination, spontaneous labor and a lack of oxytocin use are associated with successful VBAC in women with a single prior low transverse Cesarean delivery and no prior vaginal deliveries. While attempted VBAC and failed VBAC?have more maternal infectious morbidity and lower Apgar scores, infant outcomes are similar to those of elective repeat Cesarean delivery.     

The impact of unicornuate uterus on perinatal outcomes after IVF/ICSI cycles: a matched retrospective cohort study

Objective: To evaluate the impact of unicornuate uterus on perinatal outcomes after in vitro fertilization and/or intracytoplasmic sperm injection (IVF/ICSI) cycles.

Methods: We performed a retrospective cohort study including 160 women with unicornuate uterus and 1:1 matched controls with normally shaped uterus. They received IVF/ICSI treatment during January 2009 and December 2011. The perinatal outcomes were followed up till December 2014.

Results: There were no significant differences in pregnancy rate, clinical pregnancy rate or live birth rate (53.6 versus 52.7, 41.4 versus 43.5, 33.8% versus 31.8%) between unicornuate uterus group and controls. Their biochemical pregnancy rate (22.8 versus 17.5%) and miscarriage rate (16.0 versus 18.8%) were similar. No significant differences were identified in preterm birth rate (18.3 versus 11.8%), birthweight (3.24?±?0.60 versus 3.33?±?0.54?kg) or birth length (50.47?±?2.33 versus 50.06?±?2.40?cm) among the singletons. However, lower gestational age (35.56?±?2.68 versus 36.71?±?1.73, p?=?.019), higher preterm birth rate (55.0 versus 34.4%, p?=?.038), lower birthweight (2.33?±?0.58 versus 2.69?±?0.38?kg, p?=?.001), lower birth length (45.33?±?2.46 versus 48.88?±?2.06?cm, p?=?.000), as well as higher rate of very low birthweight (13.2% versus 0, p?=?.007) were found for the twins from unicornuate uterus group.

Conclusions: The results indicated unimpaired pregnancy and perinatal outcomes for women with unicornuate uterus conceiving one fetus. However, close attention should be paid to twin pregnancy in unicornuate uterus owing to increased risks of prematurity and low birthweight. Selected single embryo transfer is recommended for women with unicornuate uterus undergoing IVF/ICSI cycles.     

Pregnancies complicated by both preeclampsia and growth restriction between 34 and 37 weeks’ gestation are associated with adverse perinatal outcomes

Objective: To determine whether adverse outcomes were more common in late preterm pregnancies complicated by preeclampsia and growth restriction compared to those affected by preeclampsia alone.

Methods: This was a retrospective cohort study of 8927 singleton pregnancies with preeclampsia. Pregnancies with small for gestational age (SGA) neonates (birth weight <10th percentile) were compared to those appropriate for gestational age (AGA) neonates. Maternal outcomes included cesarean delivery (CD) rate, CD for fetal heart rate (FHR) abnormalities, abruption, postpartum hemorrhage (PPH), maternal transfusion, acute renal failure, and peripartum cardiomyopathy. Neonatal outcomes studied included respiratory distress syndrome (RDS), jaundice, hypoglycemia, seizure, asphyxia, neonatal death, and intrauterine fetal demise (IUFD).

Results: Women with preeclampsia and SGA infants were more likely to experience abruption (5.3% versus 3.0%, p?p?p?p?p?p?p?=?0.015), and IUFD (1.5% versus 0.3%, p?Conclusions: Preeclamptic women and their neonates were more likely to experience adverse perinatal outcomes when SGA pregnancies were compared to those with AGA neonates.     

Effect of fetal gender on induction of labor failure rates

Purpose: To evaluate gender effect on induction of labor (IoL) failure rates stratified by indication to delivery.

Methods: Retrospective cohort analysis of singleton pregnancies 34–42 weeks undergoing cervical ripening using controlled-release PGE2 vaginal insert. IoL Indications were divided into: (1) maternal; (2) hypertensive disorders; (3) premature rupture of membrane or (4) fetal (growth abnormalities, oligohydramnios, postdate, etc,). IoL failure was defined as: (1) Bishop-score ≤7 after 24?hours of PGE2; (2) cesarean delivery due to failed induction; (3) fetal distress followed by PGE2 removal and emergent cesarean. IoL failure rates were stratified by neonatal gender and indication to induction. Logistic regression analysis was utilized to control outcomes to potential confounders.

Results: Overall, 1062 pregnancies were included – 521 (49%) had male fetuses. IoL indications did not differ by gender. IoL failure rate was 20.1% (213/1062) – 76% for unfavorable Bishop-score after PGE2 removal; 5.2% for failed induction and 18.8% for fetal-distress while on PGE2. Overall, 14.3% delivered by cesarean section. There were no differences in IoL failure as a group or by indications to induction stratified by fetal gender (21.7% vs. 18.5%, male vs. females, p?Conclusions: IoL failure rate is not affected by fetal gender regardless of indication to induction.     

The association between maternal race and adverse outcomes in twin pregnancies with similar healthcare access

Objective: To compare twin pregnancy outcomes between white and nonwhite women with similar access to health care.

Methods: Retrospective cohort study of all twin pregnancies delivered by a single maternal–fetal medicine practice from 2005–2016. All patients had private health insurance and equal access to physician care. Outcomes were compared between white and nonwhite women using logistic regression to adjust for differences at baseline.

Results: Of the 858 women included, 730 (85.1%) were white and 128 (14.9%) were nonwhite. Univariate analysis demonstrated that nonwhite women had higher rates of preterm birth <32 weeks (12.5 versus 6.7%, p?=?.022), cesarean delivery (78.1% versus 61.4% of all women, p?p?p?=?.029) and gestational diabetes (23.2% versus 7.3%, p?Conclusions: Nonwhite women with twin pregnancies have an increased risk of adverse outcomes that cannot be explained by access to care. Although improving access to care is an important goal for health care systems, our data suggest that this alone will not eliminate all disparities in health care outcomes between women of different races.     

The role of serial measurements of cervical length in asymptomatic women with triplet pregnancy

Objective: To assess the predictive accuracy of serial measurements of cervical length (CL) for preterm birth in asymptomatic women with triplet pregnancy.

Methods: A retrospective study of women with triplets who underwent serial sonographic measurements of CL until 28–32 weeks of gestation. The predictive accuracy of CL for preterm birth was determined at 4 periods along gestation: 18–20 weeks (period 1), 21–24 weeks (period 2), 25–27 weeks (period 3) and 28–32 weeks (period 4).

Results: A total of 431 measurements of CL from were analyzed. CL decreased in a linear manner across gestation: 40.8?±?7.1?mm, 36.5?±?8.4?mm, 29.9?±?11.4?mm and 25.0?±?11.8?mm in periods 1, 2, 3 and 4, respectively. The difference in CL between women who did and did not deliver prematurely was small before 25 weeks (periods 1&;2) but became more pronounced later in pregnancy (periods 3&;4), mainly due to a rapid cervical shortening between periods 2 and 3 (shortening rate ?29.0?±?20.0% vs. ?12.6?±?20.5%, respectively, p?=?.01). The best predictors of preterm birth were either a single measurement of CL during period 3 or the degree of cervical shortening between periods 2 and 3.

Conclusions: Care providers should be aware of the limited predictive value of cervical length before 25?+?0 weeks in triplet pregnancies.     

The impact of total parenteral nutrition support on pregnancy outcome in women with hyperemesis gravidarum

Abstract

Objective: To assess pregnancy outcome among women with hyperemesis gravidarum (HEG) with and without total parenteral nutrition (TPN) support.

Study design: A retrospective study of all pregnant women with singleton pregnancies who were hospitalized due to HEG between 1997 and 2011. Pregnancy outcome was compared with a control group without HEG matched by maternal age and parity in a 3:1 ratio.

Results: Overall 599 women were admitted during the study period with the diagnosis of HEG and subsequently delivered in our center. Of those, 122 (20.4%) received TPN support. Women in the HEG group were characterized by a higher rate of severe preeclampsia (1.3% versus 0.5%, p?=?0.04), and a higher rate of preterm delivery at less than 37 and 34 weeks (10.9% versus 6.9%, p?<?0.001 and 4.7% versus 1.6%, p?<?0.001, respectively). Neonates in the HEG group were characterized by a lower birth weight (3074?±?456?g versus 3248?±?543?g, p?<?0.001), higher rate of birth weight?<?10th percentile (12.7% versus 6.8%, p?<?0.001), and a higher rate of neonatal morbidity (8.7% versus 3.8%, p?<?0.001). These associations persisted after adjustment for potential confounders, and were of most notable among women with HEG who did not receive TPN support.

Conclusion: HEG is an independent risk factor for adverse pregnancy outcome. TPN support during early pregnancy is associated with a decreased risk for perinatal morbidity.     

Postdates induction with an unfavorable cervix and risk of cesarean*

Objective: To determine the risk of cesarean delivery associated with postdates induction (≥41 weeks) compared to term induction (37–40w6d) among women with an unfavorable cervix, and to examine the risk factors associated with cesarean among women undergoing postdates induction.

Methods: A planned secondary analysis of a large prospective cohort study on induction (n?=?854) was performed. Women with a singleton gestation, intact membranes, and an unfavorable cervix (Bishop score of ≤6 and dilation ≤2?cm) who were undergoing a term (≥37 weeks) induction for any indication were included. Women with a prior cesarean were excluded. The primary outcome was cesarean delivery. Relative risk of cesarean was estimated using a modified Poisson’s regression model.

Results: There was a significantly increased risk of cesarean for women undergoing postdates induction (n?=?154) compared to women 37–40w6d (n?=?700), (46.8 versus 26.0%, p?p?Conclusions: Women ≥41 weeks undergoing an induction with an unfavorable cervix are at a significantly increased risk of cesarean compared to women 37–40w6d, with nulliparity, obesity, and cervical dilation <1?cm being independent risk factors. These data can be used to augment patient counseling and support the ongoing discussion regarding the risk of post dates induction.