Maternal obesity and rate of cesarean delivery in Djibouti

Objective

To calculate the prevalence of maternal obesity and to determine the relation between obesity and cesarean delivery in an urban hospital in Djibouti.

Methods

In an observational cohort study, all women who had a live birth or stillbirth between October 2012 and November 2013 were considered for inclusion. Body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) was calculated throughout pregnancy, and women with a BMI of at least 30.0 were deemed to be obese. Multivariate logistic regression analyses were used to evaluate the relation between cesarean and obesity.

Results

Overall, 100 (24.8%) of 404 women were obese before 14 weeks of pregnancy, as were 112 (25.2%) of 445 before 22 weeks, and 200 (43.2%) of 463 at delivery. Obesity before 22 weeks was associated with a 127% excess risk of cesarean delivery (adjusted odds ratio 2.27; 95% CI 1.07–4.82; P = 0.032). Similar trends were found when the analyses were limited to the subgroup of women without a previous cesarean delivery or primiparae.

Conclusion

Prevalence of maternal obesity is high in Djibouti City and is related to an excess risk of cesarean delivery, even after controlling for a range of medical and socioeconomic variables.     

Titrated oral misoprostol solution versus vaginal misoprostol for labor induction

Objective

To determine the efficacy and safety of a titrated oral misoprostol solution compared with vaginal misoprostol tablets for labor induction.

Methods

A randomized, triple-blind, multicenter clinical trial was conducted between March 2010 and June 2011. Women with a single gestation (n = 200) were randomized to receive a titrated oral misoprostol solution (initial misoprostol dose 20 μg/hour; dose increased by 20 μg/hour every 6 hours up to 80 μg/hour for a maximum of 48 doses) or vaginal misoprostol tablets (25 μg of misoprostol every 6 hours for a maximum of 8 doses). Risk ratios (RR) and 95% confidence intervals (CIs) were calculated for maternal and perinatal outcomes.

Results

The frequencies of vaginal delivery not achieved within 12 hours (RR 0.87; 95% CI, 0.62–1.22) and within 24 hours (RR 1.11; 95% CI, 0.83–1.49) were similar in the 2 groups. No differences were found in terms of uterine hyperstimulation, unfavorable cervix at 12 and 24 hours, oxytocin augmentation, tachysystole, epidural analgesia, adverse effects, and perinatal outcome. Approximately 70% of the women preferred the oral solution.

Conclusion

A titrated oral misoprostol solution was as effective and safe for labor induction as vaginal misoprostol tablets.ClinicalTrial.gov: NCT00 992524     

Ayuno vs. dieta líquida. Estudio aleatorizado controlado para evaluar la duración de la labor de parto,tasa de cesáreas y satisfacción con la labor

Aim

To evaluate the benefits of allowing oral intake of clear liquids in terms of labor duration, the cesarean section rate, and personal satisfaction.

Methods

A randomized controlled trial was carried out to assess the effects of a clear liquid diet in a low risk population. The primary outcome was labor duration. The secondary outcome was the incidence of cesarean section. A satisfaction survey was performed within the first 2 h after delivery to evaluate the patient's perception of labor.

Results

A total of 348 patients were randomized. The mean duration of labor was 257.75 min in the liquid diet group and 288.40 min in the fasting group (p = NS). There was no statistically significant difference (per-protocol analysis and intention-to-treat analysis) in the cesarean section rate.Patients reported greater satisfaction when allowed to drink during labor than when fasting.

Conclusion

A clear liquid diet during labor did not alter the duration of labor or the cesarean section rate. Allowing a liquid diet during labor was associated with a better perception of the birth process and a higher degree of satisfaction.     

Obstetrician gender and the likelihood of performing a maternal request for a cesarean delivery

Objective

To examine the relationship between obstetrician gender and the likelihood of maternal request for cesarean section (CS) within different healthcare institutions (medical centers, regional hospitals, district hospitals, and obstetric and gynecology clinics).

Study design

Five years of population-based data from Taiwan covering 857,920 singleton deliveries without a clinical indication for a CS were subjected to a multiple logistic regression to examine the association between obstetrician gender and the likelihood of maternal request for a CS.

Results

After adjusting for physician and institutional characteristics, it was found that male obstetricians were more likely to perform a requested CS than female obstetricians in district hospitals (OR = 1.53) and clinics (OR = 2.26), while obstetrician gender had no discernible associations with the likelihood of a CS upon maternal request in medical centers and regional hospitals.

Conclusions

While obstetrician gender had the greatest association with delivery mode decisions in the lowest obstetric care units, those associations were diluted in higher-level healthcare institutions.     

Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa

Objective

To assess the association between cesarean delivery rates and pregnancy outcomes in African health facilities.

Methods

Data were obtained from all births over 2-3 months in 131 facilities. Outcomes included maternal deaths, severe maternal morbidity, fresh stillbirths, and neonatal deaths and morbidity.

Results

Median cesarean delivery rate was 8.8% among 83 439 births. Cesarean deliveries were performed in only 95 (73%) facilities. Facility-specific cesarean delivery rates were influenced by previous cesarean, pre-eclampsia, induced labor, referral status, and higher health facility classification scores. Pre-eclampsia increased the risks of maternal death, fresh stillbirths, and severe neonatal morbidity. Adjusted emergency cesarean delivery rate was associated with more fresh stillbirths, neonatal deaths, and severe neonatal morbidity—probably related to prolonged labor, asphyxia, and sepsis. Adjusted elective cesarean delivery rate was associated with fewer perinatal deaths.

Conclusion

Use of cesarean delivery is limited in the African health facilities surveyed. Emergency cesareans, when performed, are often too late to reduce perinatal deaths.     

“Early rupture of membranes” after the spontaneous onset of labor as a risk factor for cesarean delivery

Objective

The objective of this study was to examine if patients with “early rupture of membranes (ROM)” after spontaneous onset of labor are at increased risk of cesarean section.

Study design

The rate of cesarean section was examined in 447 term singleton nulliparas who were admitted after the spontaneous onset of labor. The cases were divided into 2 groups: (1) “early ROM”, defined as ROM at a cervical dilatation <4 cm (n = 109); and (2) “late ROM”, ROM at a cervical dilatation ≥4 cm (n = 338).

Results

(1) “Early ROM” occurred in 24.4% of the cases and the overall cesarean section rate was 5.6%; (2) there were no significant differences in the clinical characteristics including prepregnancy BMI, proportion of complicated pregnancies, total duration of labor, proportion of regional anesthesia, gestational age at delivery, and birthweight between the two groups of cases. However gravidas with “early ROM” were of advanced maternal age and had less cervical dilation on admission, shorter duration of 1st stage of labor, and more frequent use of oxytocin augmentation; (3) patients with “early ROM” had a threefold higher rate (11.9% vs. 3.6%) of cesarean section and a fourfold higher rate (11.9% vs. 3.0%) of cesarean section due to failure of progress than did those with “late ROM” (p < 0.005 for each); (3) 92% (23/25) of cesarean sections were performed due to failure to progress; and (4) there was no significant difference in the rate of histologic chorioamnionitis between the two groups of cases.

Conclusion

“Early ROM” after the spontaneous onset of labor is a risk factor for cesarean section in term singleton nulliparas.     

Resultados perinatales en 492 presentaciones podálicas: cesárea vs. parto vaginal

Objective

To analyze the perinatal results in our hospital comparing vaginal delivery and cesarean section in breech presentation singleton pregnancies at term.

Material and Methods

All live ante-partum singleton fetuses in breech presentation, at 37 to 41+6 weeks and days who delivered between July 2006 and August 2010 were included in the study. We compared perinatal results between cesarean section and vaginal delivery.

Results

There were no differences in Apgar score at 5 minutes < 7, pH umbilical cord < 7, base deficits and lactate, neonatal intensive care unit admission or perinatal mortality.

Conclusions

With appropriate maternal and fetal conditions and a qualified medical team, a breech vaginal delivery could be propose obtaining good perinatal outcomes.     

Adnexal masses encountered during cesarean delivery

Objective

To outline and discuss the clinical features and outcomes of adnexal masses that were treated during cesarean delivery at a tertiary referral hospital located in Ankara, Turkey.

Methods

The operating room and pathology department databases for 2007–2012 were retrospectively reviewed for surgically managed adnexal masses during cesarean delivery. Clinicopathologic characteristics and maternal and neonatal outcomes were assessed.

Results

Adnexal masses occurred in 151 women (0.3% of all cesarean deliveries). Most (54.9%) masses were incidentally discovered during cesarean delivery. The mean mass size was 5.3 ± 3.7 cm (range, 3–30 cm). The majority (96.7%) of the women underwent excision of the mass and ovarian repair. Most masses were benign, with dermoid cysts constituting the most common diagnosis (23.8%). Rare tumors such as thecoma, hyperreactio luteinalis, hemangioma, and benign Brenner tumor were also encountered. Three (2.0%) women were postoperatively diagnosed with ovarian cancer. Preterm delivery and neonatal intensive care unit admission rates were 15.9% and 11.9%, respectively. There were no serious neonatal morbidities and no neonatal mortality.

Conclusion

Adnexal masses encountered during cesarean delivery generally have a favorable prognosis in terms of maternal and fetal outcome.     

Demand and supply factors affecting the rising overmedicalization of birth in India

Objective

To understand the interaction between health systems and individual factors in determining the probability of a cesarean delivery in India.

Methods

In a retrospective study, data from the 2007–2008 District Level Household and Facility Survey was used to determine the risk of cesarean delivery in six states (Punjab, Delhi, Maharashtra, Andhra Pradesh, Kerala, and Tamil Nadu). Multilevel modeling was used to account for district and community effects.

Results

After controlling for key risk factors, the analysis showed that cesareans were more likely at private than public institutions (P < 0.001). In terms of demand, higher education levels rather than wealth seemed to increase the likelihood of a cesarean delivery. District-level effects were significant in almost all states (P < 0.001), demonstrating the need to control for health system factors.

Conclusion

Supply factors might contribute more to the rise in cesarean delivery than does demand. Further research is needed to understand whether the quest for increased institutional deliveries in a country with high maternal mortality might be compromised by pressures for overmedicalization.     

Iron prophylaxis in pregnancy: Intravenous route versus oral route

Objective

To assess and compare the efficacy and safety of two and three doses of intravenous iron sucrose with daily oral ferrous sulphate in the prophylaxis of iron deficiency anaemia in pregnant women.

Study design

260 women with singleton pregnancy who met inclusion criteria and who gave informed consent were randomised between the 21st and 24th week into either the intravenous iron group or the oral iron group. Of 130 women in the intravenous iron group, 75 women received two doses of 200 mg iron sucrose and 55 three doses of 200 mg iron sucrose. The first dose was administered between the 21st and 24th gestational weeks, the second between the 28th and 32nd and the third between the 35th and 37th. The women of the oral group were given oral tablets of 80 mg ferrous sulphate daily, beginning on the day of study enrolment and stopping on the day of delivery.

Results

There was a non-significant trend to a higher frequency of responders (haemoglobin ≥ 11 g/dl) in the intravenous iron group (75 vs. 80%). There was a significant difference of repleted iron stores before delivery (ferritin > 50 μg/l) in the group with three intravenous iron doses in comparison to the oral iron group (49 vs. 14%; p < 0.001). No differences were observed in regard to maternal and perinatal outcomes.

Conclusions

There was no clinically significant difference in the haematological, maternal and foetal outcomes in the parenteral route of iron prophylaxis in pregnant women.     

Advanced maternal age and adverse perinatal outcomes in an Asian population

Objective

To investigate (1) whether there is an increasing trend in the mean maternal age at the birth of the first child and in the group of women giving birth at age 35 or older, and (2) the association between advanced maternal age and adverse perinatal outcomes in an Asian population.

Study design

We conducted a retrospective cohort study involving 39,763 Taiwanese women who delivered after 24 weeks of gestation between July 1990 and December 2003. Multivariable logistic regression was used to adjust for potential confounding variables.

Results

During the study period, the mean maternal age at the birth of the first child increased from 28.0 to 29.7 years, and the proportion of women giving birth at age 35 or older increased from 11.4% to 19.1%. Compared to women aged 20–34 years, women giving birth at age 35 or older carried a nearly 1.5-fold increased risk for pregnancy complications and a 1.6–2.6-fold increased risk for adverse perinatal outcomes. After adjusting for the confounding effects of maternal characteristics and coexisting pregnancy complications, women aged 35–39 years were at increased risk for operative vaginal delivery (adjusted odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2–1.7) and cesarean delivery (adjusted OR 1.6, 95% CI 1.5–1.7), while women aged 40 years and older were at increased risk for preterm delivery (before 37 weeks of gestation) (adjusted OR 1.7, 95% CI 1.3–2.2), operative vaginal delivery (adjusted OR 3.1, 95% CI 2.0–4.6), and cesarean delivery (adjusted OR 2.6, 95% CI 2.2–3.1). In those women who had a completely uncomplicated pregnancy and a normal vaginal delivery, advanced maternal age was still significantly associated with early preterm delivery (before 34 weeks of gestation), a birth weight <1500 g, low Apgar scores, fetal demise, and neonatal death.

Conclusion

In this population of Taiwanese women, there is an increasing trend in the mean maternal age at the birth of the first child. Furthermore, advanced maternal age is independently associated with specific adverse perinatal outcomes.     

Ejercicio físico y los resultados del embarazo

Introduction

The beneficial effects of physical exercise on health in general are well known. However, less is known about the effects of exercise on the highly important process of pregnancy. The greatest uncertainty concerns whether both processes —exercise and pregnancy— can coexist, without maternal-fetal conflicts and without altering pregnancy outcome. Currently, an increasing number of women wish to continue some form of exercise during pregnancy.

Objective

To determine the influence of moderate aerobic exercise in the second and third trimesters of pregnancy on pregnancy outcome.

Material and method

We performed a randomized, controlled, open trial in 142 pregnant women. There were 72 women in the treatment group and 70 on the control group. The maternal variables studied were gestational age, weight gain, oral glucose load (O'Sullivan's test), type of delivery, hemoglobin level before delivery, and mean blood pressure during the course of pregnancy. The fetal variables studied were birth weight, length, head circumference, Apgar test at 1 and 5 min, and umbilical cord pH value.

Results

No statistically significant differences were found between the two groups (p < 0.05). However, in the treatment group (exercise), mean (± SD) maternal weight gain (11.4 ± 3.7 kg) and birth weight (3165.3 ± 431.8 g) were lower than in the control group (12.3 ± 3.3 kg and 3307.4 ± 474.2 g).

Conclusion

Moderate aerobic exercise during the second and third trimesters of pregnancy seems not to alter pregnancy outcomes.     

Histological chorioamnionitis is associated with cerebral palsy in preterm neonates

Objective

To determine the interaction between histological chorioamnionitis and unexplained neonatal cerebral palsy among low birth weight infants.

Study design

We studied 141 preterm infants below 1500 g delivered between 2000 and 2010. Clinical data, neonatal neuroimaging, laboratory results, the histopathological features of the placenta and gastric smear within the first hour of delivery, were evaluated.

Results

Cerebral palsy was detected in 11 out of 141 preterm newborns (7.8%). The incidence of silent histological chorioamnionitis was 33.6% (43 of 128 cases). Chorioamniontis was significantly associated with the risk of unexplained cerebral palsy (p = 0.024). There were also significant correlations between maternal genital infections and chorioamnionitis (p = 0.005), and between maternal infections and a positive smear of neonatal gastric aspirates (p = 0.000). The rate of cesarean section was 67.4% (95 out of 141 deliveries), and elective cesarean section was performed in 68 cases.

Conclusion

Intrauterine exposure to maternal infection was associated with a marked increase in the risk of cerebral palsy in preterm infants.     

A clinical review of maternal bacteremia

Objective

To carry out a 4-year review of cases of bacteremia among obstetric patients.

Methods

In a retrospective review, all cases of maternal bacteremia between 2009 and 2012 were identified from the laboratory database of Coombe Women and Infants University Hospital, Dublin, Ireland. The clinical records of each case were assessed.

Results

During the study period, 37 584 obstetric patients attended the hospital. There were 58 cases of bacteremia: 19 were diagnosed prepartum, 20 intrapartum, and 19 postpartum. There were no maternal deaths. Two cases resulted in septic shock. Four cases were associated with early pregnancy loss, and 2 with stillbirth. Fifty-four cases occurred among 34 956 women who delivered a neonate weighing 500 g or more (0.15%). Escherichia coli most frequently caused prepartum and postpartum bacteremia, whereas Streptococcus agalactiae (β-hemolytic, Lancefield group B) most frequently caused intrapartum bacteremia. There was no association between the development of bacteremia and maternal risk factors including employment status, obesity, parity, smoking status, and maternal age. Most organisms cultured were sensitive to first-line antibiotics; there were no cases of bacteremia caused by multi-drug resistant organisms.

Conclusion

The incidence of maternal bacteremia in the study population was low and was usually associated with good maternal and fetal outcomes.     

A comparison of trends in cesarean delivery in Paraguay between 1995 and 2008

Objective

To identify maternal factors associated with the rise in the cesarean delivery rate in Paraguay.

Methods

Retrospective analysis of the 1995 and the 2008 National Survey on Demographic and Sexual and Reproductive Health data using multivariable logistic regression.

Results

In 2008, 1094 (37.3%) deliveries were cesarean compared with 781 (19.3%) in 1995. Home births had decreased by 72.9%, accounting for 33.3% of the change in the proportion of cesarean deliveries. Private facilities were associated with an increased odds ratio of cesarean delivery of 2.60 (95% confidence interval [CI], 2.02–3.34) and 4.89 (95% CI, 3.67–6.51) in 1995 and 2008, respectively, and accounted for 32.8% of the increase in cesarean deliveries between 1995 and 2008. Cesarean delivery was also associated with a prior cesarean, insurance status, and maternal higher educational and economic status.

Conclusion

Between 1995 and 2008 the cesarean delivery rate in Paraguay almost doubled. More than one-third of deliveries were cesarean. Shifts toward facility- (particularly private) based deliveries and repeat cesarean for women with a previous cesarean influenced this increase. Practice guidelines, regulation, and oversight of facilities, along with education and information for pregnant women, are needed to curb unnecessary and potentially harmful surgical delivery interventions.     

Prevalence and risk factors for early postpartum anemia

Objective

To assess the prevalence and evaluate the most important risk factors for early postpartum anemia.

Study design

The perinatal process data of 43 807 women delivering between 1993 and 2008 (90.1% of all deliveries) in the largest university obstetric department in Germany were analyzed, and the associations of Hb < 8 g/dl with maternal characteristics, pregnancy risks, delivery mode and estimated delivery blood loss were calculated. Multivariable logistic regression models were applied to compute odds ratios. Additionally, the impact of these risk factors for delivery blood loss was estimated with multivariable linear regression analysis.

Results

Twenty-two percent of mothers had Hb < 10 g/dl, and 3% had Hb < 8 g/dl. The adjusted odds ratios (OR) for Hb < 8 g/dl were 4.8 (p = 0.001) for placenta previa, 2.9 (p < 0.001) for mothers of African origin, 2.7 (p < 0.001) for diagnosed anemia in pregnancy, 2.2 (p < 0.001) for multiple pregnancy, and 2.1 (p = 0.021) for bleeding in late pregnancy. However, the delivery blood loss was the most important risk factor for postpartum anemia. The adjusted OR for an estimated blood loss of 500–1000 ml was 15.3 (p < 0.001), and for a loss of >1000 ml was 74.7 (p < 0.001).

Conclusion

The estimated obstetric blood loss is the most important risk factor for severe postpartum anemia, and the volume of blood lost is especially high in cesarean deliveries, which should be considered when electing delivery procedures. Also, measures to boost iron stores in pregnancy should be established.     

Offspring birth weight and maternal fasting lipids in women screened for gestational diabetes mellitus (GDM)

Objectives

Maternal lipid metabolism is altered during pregnancy but little is known about the influence of these alterations on either intrauterine fetal development or maternal wellbeing. The purpose of this study was to examine the relationship between both fasting cholesterol and triglycerides and offspring birth weight in women screened selectively for gestational diabetes mellitus (GDM).

Study design

In a prospective observational study in a University Maternity Hospital, women were recruited at their convenience when they were screened for GDM with a diagnostic 75 g oral glucose tolerance test (OGTT). An additional sample was taken for a lipid profile at the time the fasting glucose was obtained. Clinical and socio-demographic details were recorded.

Results

Of the 189 women recruited, the mean age was 32 years, 35.4% (n = 67) were primigravidas, 44.1% (n = 82) were obese and 11.6% (n = 22) had an abnormal OGTT. On univariate analysis, increasing birth weight was correlated positively with multiparity, first trimester body mass index (BMI), GDM and hypertriglyceridaemia but not with cholesterol levels. On multivariate analysis, increased birth weight correlated positively only with hypertriglyceridaemia.

Conclusions

This study provides further evidence that maternal hypertriglyceridaemia is important in programming intrauterine fetal growth and raises questions about whether women should be screened selectively for dyslipidaemia before, during and after pregnancy.     

Route of delivery following successful external cephalic version

Objective

To evaluate the delivery route and the indications for cesarean delivery after successful external cephalic version (ECV).

Methods

A retrospective matched case–control study was conducted at a hospital in Lisbon, Portugal, between 2002 and 2012. Each woman who underwent successful ECV (n = 44) was compared with the previous and next women who presented for labor management and who had the same parity and a singleton vertex pregnancy at term (n = 88). The outcome measures were route of delivery, indications for cesarean delivery, and incidence of nonreassuring fetal status.

Results

Attempts at ECV were successful in 62 (46%) of 134 women, and 44 women whose fetuses remained in a cephalic presentation until delivery were included in the study. The rates of intrapartum cesarean delivery and operative vaginal delivery did not differ significantly between cases and controls (intrapartum cesarean delivery, 9 [20%] vs 16 [18%], P = 0.75; operative vaginal delivery, 14 [32%] vs 19 [22%], P = 0.20). The indications for cesarean delivery after successful ECV did not differ; in both groups, cesarean delivery was mainly performed for labor arrest disorders (cases, 6 [67%] vs controls, 13 [81%]; P = 0.63).

Conclusion

Successful ECV was not associated with increased rates of intrapartum cesarean delivery or operative vaginal delivery.