Idiopathic bleeding during the second half of pregnancy as a risk factor for adverse perinatal outcome.

OBJECTIVE: To investigate pregnancy outcome in women suffering from idiopathic vaginal bleeding (IVB) during the second half of pregnancy. METHODS: A comparison between patients admitted to the hospital due to bleeding during the second half of pregnancy and patients without bleeding was performed. Patients lacking prenatal care as well as multiple gestations were excluded from the analysis. Stratified analyses using the Mantel-Haenszel technique and a multiple logistic regression model were performed to control for confounders. RESULTS: During the study period, 173,621 singleton deliveries occurred at our institute. Of these, 2077 (1.19%) were complicated with bleeding upon admission during the second half of pregnancy. After excluding cases with bleeding due to placental abruption, placenta previa, cervical problems, etc., 67 patients were classified as having IVB (0.038%). Independent risk factors associated with IVB, using a backward, stepwise multivariable analysis were oligohydramnios (OR=6.2; 95% CI 3.1-12.7; p < 0.001), premature rupture of membranes (OR=3.4; 95% CI 1.8-6.2; p < 0.001), intrauterine growth restriction (IUGR, OR 5.6; 95% CI 2.5-12.2; p < 0.001), and Jewish ethnicity (OR=1.9; 95% CI 1.0-3.5; p=0.036). These patients subsequently were more likely to deliver preterm (<37 weeks, 56.7% vs. 7.3%; mean gestational age of 33.6+/-5.7 weeks vs. 39.2+/-2.1 weeks; p < 0.001) and by cesarean delivery (CD, 35.8% vs. 12.1%, OR=4.0; 95% CI 2.4-6.6; p < 0.001). Higher rates of low Apgar scores (<7) at 1 and 5 minutes were noted in these patients (OR=10.3; 95% CI 5.9-17.8; p < 0.001 and OR=17.8; 95% CI 7.1-44.5; p < 0.001, respectively). Moreover, perinatal mortality rate among patients admitted due to idiopathic bleeding was significantly higher as compared to patients without bleeding (9.6% vs. 1.2%, OR=8.4; 95% CI 3.3-21.2; p < 0.001). However, when controlling for preterm delivery, using the Mantel-Haenszel technique, the association lost its significance. CONCLUSION: Idiopathic vaginal bleeding during the second half of pregnancy is a risk factor for adverse perinatal outcome, mostly due to its significant association with preterm delivery. Careful surveillance, including fetal monitoring, is suggested in these cases in order to reduce the adverse perinatal outcome.     

Short stature--an independent risk factor for Cesarean delivery

OBJECTIVE: The present study was aimed to investigate pregnancy outcome of patients with short stature (height<155 cm), and specifically to elucidate if patients with short stature are at an increased risk for Cesarean section (CS) even after controlling for labor dystocia. METHODS: A population-based study comparing pregnancy outcome of patients with and without short stature, was performed. Deliveries occurred during the years 1988-2002, in a tertiary medical center. Stratified analyses, using the Mantel-Haenszel technique, and a multiple logistic regression model were performed to control for confounders. RESULTS: During the study period, 159,210 deliveries occurred. Of these, 5822 (3.65%) were of patients with short stature. Patients with short stature had statistically significant higher rates of CS compared with patients>or=155 cm (21.3% versus 11.9%, odds ratio (OR)=2.0; 95% confidence interval (CI): 1.9-2.1; P<0.001). Furthermore, there patients had higher rated of previous deliveries by CS (17.5% versus 10.3%, OR=1.8; 95% CI: 1.7-2.0; P<0.001), intrauterine growth restriction (IUGR, 3.2% versus 1.9%, OR=1.7; 95% CI: 1.4-1.9; P<0.001), premature rupture of membranes (PROM, 7.1% versus 5.6%, OR=1.3; 95% CI: 1.2-1.4; P<0.001), failed induction (0.7% versus 0.4%, OR=2.0; 95% CI: 1.5-2.8; P<0.001), labor dystocia (6.1% versus 3.5%, OR=1.8; 95% CI: 1.6-2.0; P<0.001), mal-presentations (7.6% versus 6.1%, OR=1.3; 95% CI: 1.1-1.4; P<0.001), and cephalopelvic disproportion (CPD, 0.9% versus 0.3%, OR=2.6; 95% CI: 1.9-3.4; P<0.001). No significant differences were noted between the groups regarding perinatal complications such as low birth-weight, meconium-stained amniotic fluid, perinatal mortality, and low Apgar scores at 5 min. Controlling for possible confounders such as previous CS, IUGR, PROM, failed induction, labor dystocia, mal-presentations and CPD, using the Mantel-Haenszel technique, did not change the significant association between short stature and CS. Moreover, a multiple logistic regression model was constructed with CS as the outcome variable, controlling for all these confounders. The model found short stature to be an independent risk factor for CS (OR=1.7; 95% CI: 1.6-1.9; P<0.001). CONCLUSION: Short stature is an independent risk factor for Cesarean delivery. Further studies investigating the actual indication for CS should be performed in order to make an informed recommendation regarding the preferred mode of delivery in short parturient women.     

Obstetric characteristics and perinatal outcome of pregnancies with uterine leiomyomas

OBJECTIVE: To determine the rate, obstetric characteristics and perinatal outcome of pregnancies with uterine leiomyomas. STUDY DESIGN: A population-based study comparing all singleton deliveries between the years 1988 and 1999 in women with and without uterine leiomyomas was performed. Patients lacking prenatal care were excluded from the analysis. Multivariable analysis, adjusting for possible confounders, such as maternal age, parity and gestational age, was performed to investigate associations between uterine leiomyomas and selected outcomes. RESULTS: There were 105,909 singleton deliveries with 690 (0.65%) complicated by uterine leiomyomas during the study period. Using a multivariable analysis, the following conditions were significantly associated with uterine leiomyomas: nulliparity (odds ratio [OR]=4.0, 95% confidence interval [CI] 3.3-4.7, P<.001), chronic hypertension (OR=1.9, 95% CI 1.6-2.4, P<.001), hydramnios (OR=1.5, 95% CI 1.2-2.0, P<.001), diabetes mellitus (OR=1.4, 95% CI 1.1-1.7, P=.001) and advanced maternal age (OR=1.2, 95% CI 1.1-1.2, P<.001). Higher rates of perinatal mortality (2.2% vs. 1.2%, OR=1.8, 95% CI 1.1-3.2, P<.001) were found in the uterine leiomyoma group as compared to the control group. While adjusting for maternal age, parity, gestational age and malpresentation, pregnancies with uterine leiomyomas had higher rates of cesarean deliveries (OR=6.7, 95% CI 5.5-8.1, P<.001), placental abruption (OR=2.6, 95% CI 1.6-4.2, P<.001) and preterm deliveries (<36 weeks' gestation, OR=1.4, 95% CI 1.1-1.7, P=.009) as compared to pregnancies without uterine leiomyomas. Conversely, no significant differences were noted regarding perinatal mortality (OR=1.4, 95% CI 0.7-2.8, P=.351) after controlling for maternal age, parity and gestational age using a multivariable analysis. CONCLUSION: Uterine leiomyomas increase the risk of adverse pregnancy outcomes, thus emphasizing the importance of appropriate intrapartum management of these high-risk pregnancies.     

Risk of maternal postpartum readmission associated with mode of delivery

OBJECTIVE: To determine whether cesarean and operative vaginal deliveries are associated with an increased risk of maternal rehospitalization compared with spontaneous vaginal delivery. METHODS: A population-based cohort study was conducted by using the Canadian Institute for Health Information's Discharge Abstract Database between 1997/1998 and 2000/2001, which included 900,108 women aged 15-44 years with singleton live births (after excluding several selected obstetric conditions). RESULTS: A total of 16,404 women (1.8%) were rehospitalized within 60 days after initial discharge. Compared with spontaneous vaginal delivery (rate 1.5%), cesarean delivery was associated with a significantly increased risk of postpartum readmission (rate 2.7%, odds ratio [OR] 1.9, 95% confidence interval [CI] 1.8-1.9); ie, there was 1 excess postpartum readmission per 75 cesarean deliveries. Diagnoses associated with significantly increased risks of readmission after cesarean delivery (compared with spontaneous vaginal delivery) included pelvic injury/wounds (rate 0.86% versus 0.06%, OR 13.4, 95% CI 12.0-15.0), obstetric complications (rate 0.23% versus 0.08%, OR 3.0, 95% CI 2.6-3.5), venous disorders and thromboembolism (rate 0.07% versus 0.03%, OR 2.7, 95% CI 2.1-3.4), and major puerperal infection (rate 0.45% versus 0.27%, OR 1.8, 95% CI 1.6-1.9). Women delivered by forceps or vacuum were also at an increased risk of readmission (rates 2.2% and 1.8% versus 1.5%; OR forceps: 1.4, 95% CI 1.3-1.5; OR vacuum: 1.2, 95% CI 1.2-1.3, respectively). Higher readmission rates after operative vaginal delivery were due to pelvic injury/wounds, genitourinary conditions, obstetric complications, postpartum hemorrhage, and major puerperal infection. CONCLUSION: Compared with spontaneous vaginal delivery, cesarean delivery, and operative vaginal delivery increase the risk of maternal postpartum readmission. LEVEL OF EVIDENCE: II-2.     

The clinical significance of bleeding during the second trimester of pregnancy

OBJECTIVE: This study aimed at investigating the clinical importance and pregnancy outcome in women suffering from bleeding during the second half of their pregnancies. METHODS: A population-based study including all deliveries between the years 1988 and 2005 was conducted. Comparison was performed between patients with and without vaginal bleeding during the second half of pregnancy. Pregnancies, which terminated before 22 weeks, multiple gestations and women lacking prenatal care were excluded from the analysis. Stratified analyses, using the Mantel-Haenszel technique, and a multiple logistic regression model were performed to control for confounders. RESULTS: During the study period, 175,093 singleton deliveries occurred in our institute. Of these, 2,010 (1.1%) were complicated with bleeding upon admission during the second half of pregnancy. The cases were mostly attributed to placental abruption (63.5%; n = 1,276) and placenta previa (36.5%; n = 734). Independent risk factors associated with bleeding, using a backward, stepwise multivariate analysis were oligohydramnios, polyhydramnions, [odds ratio (OR) = 1.6; 95% confidence interval (CI) 1.2-2.0; P = 001 and 1.5; 1.2-1.8; P < 0.01, respectively], suspected intra uterine growth restriction (IUGR, 3.2; 2.6-4.0; P < .001), gestational age, previous abortions and maternal age. These patients subsequently were more likely to deliver by cesarean section (CS, 72.9 vs. 12.1%, OR = 19.5; 95% CI 17.6-19.9; 14.9 vs. 1.1%; P < 0.001). Perinatal mortality among patients admitted due to second half bleeding was significantly higher as compared to patients without bleeding (P < .001). CONCLUSION: Bleeding upon admission during the second half of pregnancy is an independent risk factor for perinatal mortality. Careful surveillance, including fetal monitoring, is suggested in these cases in order to reduce the adverse perinatal outcome.     

Intrauterine growth restriction and oligohydramnios among high-risk patients

The purposes of this study were (1) to determine the prevalence of oligohydramnios (amniotic fluid index < 5.0 cm) among fetuses with intrauterine growth restriction (IUGR) and newborns identified as small for gestational age (SGA), and (2) among fetuses with IUGR, to determine the predictive accuracy of amniotic fluid index (AFI) < or = versus > 5.0 cm for adverse peripartum outcomes. This was a retrospective review of high-risk pregnancy that had reliable gestational age (GA) and needed weekly biophysical profile (BPP). Along with 95% confidence intervals (CIs), we calculated the likelihood ratios (LRs) and used guidelines promulgated by Evidence-Based Medicine Working Group. Among the 1859 singletons undergoing BPP, IUGR (estimated fetal weight < 10% for GA) was suspected in 22% (n = 410) and the prevalence of oligohydramnios was 6% (95% CI, 4 to 8%). SGA (birthweight < or = 10%) occurred among 28% (n = 517) of newborns and oligohydramnios was noted in 6% (95% CI, 4 to 8%). Among fetuses with IUGR, the LR of oligohydramnios to predict cesarean delivery for nonreassuring fetal heart tracing was 2.0 (range, 0.8 to 5.0); for newborns small for gestational age, 1.9 (range, 1.2 to 3.1), and for neonatal intensive care unit admission, 1.4 (range, 0.6 to 2.3) More than 90% of patients with IUGR or SGA have AFI > 5.0 cm, and oligohydramnios with IUGR is a poor predictor of peripartum complications.     

Cesarean delivery and subsequent pregnancies

OBJECTIVE: To assess possible effects of a cesarean delivery on outcome in subsequent pregnancies. METHODS: Using an historical cohort design, we analyzed 637,497 first and second births among women with two or more single births and 242,812 first, second, and third births among women with three or more single births registered in the population-based Medical Birth Registry of Norway between 1967 and 2003. RESULTS: Compared with a vaginal delivery at first birth, a cesarean delivery at first birth was followed, in a second pregnancy, by increased risks of preeclampsia (odds ratio [OR] 2.9 and corresponding 95% confidence interval [CI] 2.8-3.1), small for gestational age (OR 1.5; CI 1.4-1.5), placenta previa (OR 1.5; CI 1.3-1.8, placenta accreta (OR 1.9; CI 1.3-2.8), placental abruption (OR 2.0; CI 1.8-2.2), and uterine rupture (OR 37.4; CI 24.9-56.2). After excluding women with the actual complication at first birth, the corresponding ORs were, in general, lower: 1.7 (CI 1.6-1.8), 1.3 (CI 1.3-1.4), 1.4 (CI 1.2-1.7), 1.9 (CI 1.3-2.8), 1.7 (CI 1.6-1.9), and 37.2 (CI 24.7-55.9), respectively. Corresponding reduction in numbers of cesarean deliveries needed to prevent one case were 114, 56, 1,140, 3,706, 300, and 461. In third births, ORs after repeat cesarean delivery were similar to or lower than the ORs after one cesarean delivery; also here, the exclusion of women with the actual outcome in any of their previous pregnancies tended to reduce the ORs. CONCLUSION: Cesarean delivery was associated with an increased risk of complications in a subsequent pregnancy, but excess risks were reduced after excluding women with the actual complication in any of their previous births. To obtain less biased effects of cesarean delivery on subsequent pregnancies, it is important to account for obstetric history. LEVEL OF EVIDENCE: II.     

Risk factors for arrest of descent during the second stage of labor.

OBJECTIVE: To define obstetrical risk factors for arrest of descent during the second stage of labor and to determine perinatal outcome. STUDY DESIGN: All singleton, vertex, term deliveries with an unscarred uterus, between the years 1988 and 1999 were included. Univariable and multivariable analysis were performed to investigate independent risk factors associated with arrest of descent during the second stage of labor and the perinatal outcome. RESULTS: The study included 93266 deliveries, of these 1545 (1.7%) were complicated with arrest of descent during the second stage of labor. Using a multivariable analysis, the following obstetric risk factors were found to be significantly associated with arrest of descent: nulliparity (OR=7.8, 95% CI=6.9-8.7; P<0.001), birth weight >4 kg (OR=2.3, 95% CI=1.9-2.8; P<0.001), epidural analgesia (OR=1.8, 95% CI=1.6-2.0; P<0.001), hydramnios (OR=1.6, 95% CI=1.3-2.0; P<0.001), hypertensive disorders (OR=1.5, 95% CI=1.3-1.8; P<0.001), gestational diabetes A1 and A2 (OR=1.5, 95% CI=1.2-1.8; P<0.001), male gender (OR=1.4, 95% CI=1.2-1.5; P<0.001), premature rupture of membranes (PROM, OR=1.3, 95% CI=1.04-1.6; P=0.021), and induction of labor (OR=1.2, 95% CI=1.02-1.4; P=0.030). Deliveries complicated by arrest of descent resulted in cesarean section in 20.6%, vacuum extraction in 74.0%, and forceps delivery in 5.4%. Newborns delivered after arrest of descent during the second stage of labor had significantly higher rates of low Apgar scores (<7) at 1 and 5 min, as compared to the controls (12.7 vs. 2.1%, P<0.001; and 0.9 vs. 0.2%, P<0.001, respectively). Nevertheless, no significant differences were noted between the groups regarding perinatal mortality (0.38 vs. 0.44%; P=0.759). CONCLUSIONS: Major risk factors for arrest of descent during the second stage of labor were nulliparity, fetal macrosomia, epidural analgesia, hydramnios, hypertensive disorders and gestational diabetes mellitus. These risk factors should be carefully evaluated during pregnancy in order to actively manage high-risk pregnancies.     

Risk factors for wound infection following cesarean deliveries.

OBJECTIVE: To identify risk factors for early wound infection (diagnosed prior to discharge) following cesarean delivery. METHODS: A population-based study comparing women who have and have not developed a wound infection prior to discharge from Soroka University Medical Center, Ben Gurion University of the Negev, between 1988 and 2002. RESULTS: Of the 19,416 cesarean deliveries performed during the study period, 726 (3.7%) were followed by wound infection. Using a multivariable logistic regression model, the following risk factors were identified: obesity (odds ratio [OR] = 2.2; 95% confidence interval [CI], 1.6-3.1); hypertensive disorders (OR = 1.7; 95% CI, 1.4-2.1); premature rupture of membranes (OR = 1.5; 95% CI, 1.2-1.9); diabetes mellitus (OR = 1.4; 95% CI, 1.1-1.7); emergency cesarean delivery (OR = 1.3; 95% CI, 1.1-1.5); and twin delivery (OR = 1.6; 95% CI, 1.3-2.0). Combined obesity and diabetes (gestational and pregestational) increased the risk for wound infection 9.3-fold (95% CI, 4.5-19.2; P < .001). CONCLUSION: Independent risk factors for an early wound infection are obesity, diabetes, hypertension, premature rupture of membranes, emergency cesarean delivery, and twin delivery. Information regarding higher rates of wound infection should be provided to obese women undergoing cesarean delivery, especially when diabetes coexists.     

Pregnancy outcome of asthmatic patients: a population-based study.

OBJECTIVE: To investigate pregnancy outcome of asthmatic patients. METHODS: A retrospective population-based study comparing all singleton pregnancies in women with and without asthma was conducted. Patients lacking prenatal care (less than three visits in prenatal care facilities) were excluded from the study. Deliveries occurred during the years 1988-2002. Stratified analysis, using a multiple logistic regression model was performed to control for confounders. RESULTS: During the study period 139 168 singleton deliveries occurred, of which 1.4% in asthmatic patients (n = 963). Using a multivariate analysis, with backward elimination, the following complications were significantly associated with maternal asthma: diabetes mellitus (OR = 1.8, 95%CI 1.5-2.0, p < 0.001), fertility treatments (OR = 1.6, 95%CI 1.3-2.1, p < 0.001), intrauterine growth restriction (IUGR) (OR = 1.5, 95%CI 1.1-1.9, p = 0.004), hypertensive disorders (OR = 1.5, 95%CI 1.2-1.7, p < 0.001) and premature rupture of membranes (OR = 1.2, 95%CI 1.1-1.5, p = 0.013). Higher rates of cesarean deliveries were found among asthmatic patients as compared to the controls (17.1% vs. 11.4%, p < 0.001). This association persisted even after controlling for possible confounders such as failure to progress in labor, mal-presentations, IUGR, etc. No significant differences regarding low Apgar scores (less than 7) at 1 and 5 minutes were noted between the groups (3.9% vs. 4.4%, p = 0.268 and 0.4% vs. 0.6%, p = 0.187, respectively). Likewise, the perinatal mortality rate was similar among patients with and without asthma (1.3% vs. 1.3%, p = 0.798). CONCLUSION: Pregnant women with asthma are at an increased risk for adverse maternal outcome. This association persists after controlling for variables considered to co-exist with maternal asthma. However, perinatal outcome is favorable. Careful surveillance is required in pregnancies of asthmatic patients, for early detection of possible complications.     

Pneumonia during pregnancy: radiological characteristics,predisposing factors and pregnancy outcomes

To establish radiological characteristics of pneumonia during pregnancy and to investigate pregnancy outcomes in patients hospitalised due to pneumonia. Study design. A population-based study comparing all pregnancies of women with and without pneumonia between was conducted. The diagnosis of pneumonia was confirmed by chest radiograph. Multivariable logistic regression models were constructed in order to control for confounders. Results. During the study period, there were 181,765 deliveries, of which 160 were hospitalised due to pneumonia. The most common site of pneumonia was the left lower lobe (53.4%), followed by the right lower lobe (26.3%) and right middle lobe (8.3%); 9.8% were complicated with pleural effusion. Using a multivariable analysis, pneumonia was significantly associated with placental abruption (OR?=?4.2; 95% CI 1.9–9.1), intrauterine growth restriction (IUGR; OR?=?3.7; 95% CI 2.1–6.6), previous caesarean deliveries (CDs; OR?=?2.6; 95% CI 1.8–3.7) and severe preeclampsia (OR?=?2.6; 95% CI 1.2–5.7). Higher rates of low Apgar scores at 1 min (26.3% vs. 5.9%, <50.001) and 5 min (10.6% vs. 2.6%, p?<?0.001) were noted in the pneumonia group. No significant differences were noted between the groups regarding labour induction (23.8% vs. 27.9%, p?=?0.240), non-progressive labour second stage (2.5% vs. 1.6%, p?=?0.387) and post-partum haemorrhage (1.3% vs. 0.5%, p?=?0.224). Furthermore, patients with pneumonia were significantly associated with preterm delivery (PTD,537 weeks) (35.6% vs. 7.7%, p50.001) and perinatal mortality (7.5% vs. 1.3%, p50.001). Pneumonia was found as an independent risk factor for PTD (OR?=?5.4, 95% CI 3.8–7.7, p?<?0.001), in a multivariable model controlling for IUGR, placental abruption and preeclampsia Controlling for possible confounding variables such as IUGR, gestational age at delivery, placental abruption and maternal age, using another multivariable model with perinatal mortality as the outcome variable, pneumonia was not identified as an independent risk factor for perinatal mortality (weighted OR?=?0.9; 95% CI 0.4–1.9; p?=?0.718). Conclusion. Maternal pneumonia is associated with adverse perinatal outcomes and specifically it is an independent risk factor for PTD. Keywords: Pregnancy, pneumonia, outcomes.     

Umbilical cord prolapse and perinatal outcomes.

OBJECTIVES: To determine obstetric risk factors and perinatal outcomes of pregnancies complicated by umbilical cord prolapse. METHODS: A population-based study was performed comparing all deliveries complicated by cord prolapse to deliveries without this complication. Statistical analysis was performed using multiple logistic regression models. RESULTS: Prolapse of the umbilical cord complicated 0.4% (n=456) of all deliveries included in the study (n=121,227). Independent risk factors for cord prolapse identified by a backward, stepwise multivariate logistic regression model were: malpresentation (OR=5.1; 95% CI 4.1-6.3), hydramnios (OR=3.0; 95% CI 2.3-3.9), true knot of the umbilical cord (OR=3.0; 95% CI 1.8-5.1), preterm delivery (OR=2.1; 95% CI 1.6-2.8), induction of labor (OR=2.2; 95% CI 1.7-2.8), grandmultiparity (>five deliveries, OR=1.9; 95% CI 1.5-2.3), lack of prenatal care (OR=1.4; 95% CI 1.02-1.8), and male gender (OR=1.3; 95% CI 1.1-1.6). Newborns delivered after umbilical cord prolapse graded lower Apgar scores, less than 7, at 5 min (OR=11.9, 95% CI 7.9-17.9), and had longer hospitalizations (mean 5.4+/-3.5 days vs. 2.9+/-2.1 days; P<0.001). Moreover, higher rates of perinatal mortality were noted in the cord prolapse group vs. the control group (OR=6.4, 95% CI 4.5-9.0). Using a multiple logistic regression model controlling for possible confounders, such as preterm delivery, hydramnios, etc., umbilical cord prolapse was found to be an independent contributing factor to perinatal mortality. CONCLUSIONS: Prolapse of the umbilical cord is an independent risk factor for perinatal mortality.     

Precipitate labor: higher rates of maternal complications

OBJECTIVE: The study was aimed to identify risk factors and to elucidate pregnancy outcome following precipitate labor, i.e. expulsion of the fetus within less than 3 h of commencement of contractions. METHODS: A comparison of patients with and without precipitate labor, delivered during the years 1988-2002, was conducted. Patients who underwent cesarean deliveries were excluded from the analysis. A multiple logistic regression model, with backward elimination, was performed to investigate independent risk factors for precipitate labor. RESULTS: The number of vaginal deliveries that occurred during the study period was 137,171. Of these, 99 were precipitate. Independent risk factors for precipitate labor, using a backward, stepwise multivariate analysis were: placental abruption (odds ratio (OR) = 30.9, 95% confidence interval (CI) 15.9-60.4, P < 0.001); fertility treatments (OR = 3.9, 95% CI 1.7-9.0, P = 0.002); chronic hypertension (OR = 3.1, 95% CI 1.2-7.8, P = 0.015); intrauterine growth restriction (IUGR) (OR = 2.9, 95% CI 1.2-6.8, P = 0.014); prostaglandin E2 induction (OR = 1.9, 95% CI 1.1-3.5, P = 0.045); birth weight < 2,500 g (OR = 1.8, 95% CI 1.1-3.1, P = 0.020); and nulliparity (OR = 1.7, 95% CI 1.1-2.6, P = 0.014). No significant differences were noted between the groups regarding perinatal complications such as meconium stained amniotic fluid, perinatal mortality and low Apgar scores. However, there were higher rates of maternal complications in the precipitate labor group such as cervical tears and grade 3 perineal tears (18.2% versus 0.3%, P < 0.001; and 2.0% versus 0.1%, P < 0.001, respectively), post-partum hemorrhage (13.1% versus 0.4%, P < 0.001); retained placenta (2.0% versus 0.5%, P = 0.02); the need for revision of uterine cavity and packed-cells transfusions (34.3% versus 4.9%, P < 0.001; and 11.1% versus 1.1%, P < 0.001, respectively) and prolonged hospitalization (27.6% versus 19.2%, P = 0.035) as compared to the controls. CONCLUSION: Precipitate labor is associated with higher rates of maternal complications.     

Chronic hypertension and the risk for adverse pregnancy outcome after superimposed pre-eclampsia.

OBJECTIVE: To determine the risk factors and pregnancy outcome of patients with chronic hypertension during pregnancy after controlling for superimposed preeclampsia. METHOD: A comparison of all singleton term (>36 weeks) deliveries occurring between 1988 and 1999, with and without chronic hypertension, was performed. Stratified analyses, using the Mantel-Haenszel technique, and a multiple logistic regression model were performed to control for confounders. RESULTS: Chronic hypertension complicated 1.6% (n=1807) of all deliveries included in the study (n=113156). Using a multivariable analysis, the following factors were found to be independently associated with chronic hypertension: maternal age >40 years (OR=3.1; 95% CI 2.7-3.6), diabetes mellitus (OR=3.6; 95% CI 3.3-4.1), recurrent abortions (OR=1.5; 95% CI 1.3-1.8), infertility treatment (OR=2.9; 95% CI 2.3-3.7), and previous cesarean delivery (CD; OR=1.8 CI 1.6-2.0). After adjustment for superimposed preeclampsia, using the Mantel-Haenszel technique, pregnancies complicated with chronic hypertension had higher rates of CD (OR=2.7; 95% CI 2.4-3.0), intra uterine growth restriction (OR=1.7; 95% CI 1.3-2.2), perinatal mortality (OR=1.6; 95% CI 1.01-2.6) and post-partum hemorrhage (OR=2.2; 95% CI 1.4-3.7). CONCLUSION: Chronic hypertension is associated with adverse pregnancy outcome, regardless of superimposed preeclampsia.     

Chronic hypertension is an independent risk factor for preeclampsia and preterm delivery in women with rheumatologic diseases: a population-based study

OBJECTIVE: The objective was to determine the prevalence of maternal and perinatal complications among patients with rheumatologic diseases (RD) and to investigate the maternal risk factors for preeclampsia and preterm delivery among RD patients. STUDY DESIGN: A retrospective population-based cohort study was conducted. The study group comprised women with RD; the control group comprised patients without RD. The obstetric and neonatal outcomes of the groups were compared, and the data were obtained from a computerized database. RESULTS: During the study period, there were 179 deliveries by 125 women with RD. The prevalence of severe preeclampsia, chronic hypertension, pregestational diabetes, oligohydramnios, preterm deliveries and cesarean sections was significantly higher in the RD group than in the control group. Mean birth weight was significantly lower in the study group compared with the general population. Maternal RD was found to be an independent risk factor for preterm delivery and severe preeclampsia (OR 3.59; 95% CI: 2.52-5.11; OR 3.05; 95% CI: 1.44-6.45, respectively). The presence of chronic hypertension in patients with RD was found to be an independent risk factor for severe preeclampsia and preterm delivery (OR 12.2; 95% CI: 2.1-69.8; OR 3.8; 95% CI: 1.1-12.7, respectively). CONCLUSION: Chronic hypertension is an independent risk factor for preterm delivery and severe preeclampsia among RD patients.     

Cesarean delivery and peripartum hysterectomy

OBJECTIVE: To estimate the national incidence of peripartum hysterectomy and quantify the risk associated with cesarean deliveries and other factors. METHODS: A population-based, matched case-control study using the United Kingdom Obstetric Surveillance System, including 318 women in the United Kingdom who underwent peripartum hysterectomy between February 2005 and February 2006 and 614 matched control women. RESULTS: The incidence of peripartum hysterectomy was 4.1 cases per 10,000 births (95% confidence interval [CI] 3.6-4.5). Maternal mortality was 0.6% (95% CI 0-1.5%). Previous cesarean delivery (odds ratio [OR] 3.52, 95% CI 2.35-5.26), maternal age over 35 years (OR 2.42, 95% CI 1.66-3.58), parity of three or greater (OR 2.30, 95% CI 1.26-4.18), previous manual placental removal (OR 12.5, 95% CI 1.17-133.0), previous myomectomy (OR 14.0, 95% CI 1.31-149.3), and twin pregnancy (OR 6.30, 95% CI 1.73-23.0) were all risk factors for peripartum hysterectomy. The risk associated with previous cesarean delivery was higher with increasing numbers of previous cesarean deliveries (OR 2.14 with one previous delivery [95% CI 1.37-3.33], 18.6 with two or more [95% CI 7.67-45.4]). Women undergoing a first cesarean delivery in the current pregnancy were also at increased risk (OR 7.13, 95% CI 3.71-13.7). CONCLUSION: Peripartum hysterectomy is strongly associated with previous cesarean delivery, and the risk rises with increasing number of previous cesarean deliveries, maternal age over 35 years, and parity greater than 3. LEVEL OF EVIDENCE: II.     

Gender does matter in perinatal medicine

OBJECTIVE: To investigate complications and outcome of pregnancies with male and female fetuses. METHODS: A population-based study comparing all singleton deliveries between the years 1988 and 1999 was performed. We compared pregnancies with male vs. female fetuses. Patients with a previous cesarean section (CS) were excluded from the study. Statistical analyses with the Mantel-Haenszel technique and multiple logistic regression models were performed to control for confounders. RESULTS: During the study period there were 55,891 deliveries of male and 53,104 deliveries of female neonates. Patients carrying male fetuses had higher rates of gestational diabetes mellitus (OR = 1.1; 95% CI 1.01-1.12; p = 0.012), fetal macrosomia (OR = 2.0; 95% CI 1.8-2.1; p < 0.001), failure to progress during the first and second stages of labor (OR = 1.2; 95% CI 1.1-1.3; p < 0.001 and OR = 1.4; 95% CI 1.3-1.5; p < 0.001, respectively), cord prolapse (OR = 1.3; 95% CI 1.1-1.6; p = 0.014), nuchal cord (OR = 1.2; 95% CI 1.1-1.2; p < 0.001) and true umbilical cord knots (OR = 1.5; 95% CI 1.3-1.7; p < 0.001). Higher rates of CS were found among male compared with female neonates (8.7 vs. 7.9%; OR = 1.1; 95% CI 1.06-1.16; p < 0.001). Using three multivariate logistic regression models and controlling for birth weight and gestational age, male gender was significantly associated with non-reassuring fetal heart rate patterns (OR = 1.5; 95% CI 1.4-1.6; p < 0.001), low Apgar scores at 5 min (OR = 1.5; 95% CI 1.3-1.8; p < 0.001) and CS (OR = 1.2; 95%CI 1.2-1.3; p < 0.001). Controlling for possible confounders like gestational diabetes, cord prolapse, failed induction, nonprogressive labor, fetal macrosomia, nuchal cord and true umbilical cord knots using the Mantel-Haenszel technique did not change the significant association between male gender and CS. CONCLUSION: Male gender is an independent risk factor for adverse pregnancy outcome.     

Pregnancy outcomes for women with placenta previa in relation to the number of prior cesarean deliveries

OBJECTIVE: To estimate the association between the number of prior cesarean deliveries and pregnancy outcomes among women with placenta previa. METHODS: Women with a placenta previa and a singleton gestation were identified in a concurrently collected database of cesarean deliveries performed at 19 academic centers during a 4-year period. Maternal and perinatal outcomes were analyzed after stratifying by the number of cesarean deliveries before the index pregnancy. RESULTS: Of the 868 women in the analysis, 488 had no prior cesarean delivery, 252 had one prior cesarean delivery, 76 had two prior cesarean deliveries, and 52 had at least three prior cesarean deliveries. Multiple measures of maternal morbidity (eg, coagulopathy, hysterectomy, pulmonary edema) increased in frequency as the number of prior cesarean deliveries rose. Even one prior cesarean delivery was sufficient to increase the risk of an adverse maternal outcome (a composite of transfusion, hysterectomy, operative injury, coagulopathy, venous thromboembolism, pulmonary edema, or death) from 15% to 23%, which corresponded, in multivariable analysis, to an adjusted odds ratio of 1.9 (95% confidence interval 1.2-2.9). Conversely, gestational age at delivery and adverse perinatal outcome (a composite measure of respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3 or 4, seizures, or death) were unrelated to the number of prior cesarean deliveries. CONCLUSION: Among women with a placenta previa, an increasing number of prior cesarean deliveries is associated with increasing maternal, but not perinatal, morbidity. LEVEL OF EVIDENCE: II.     

Pregnancy outcome of patients with pruritic urticarial papules and plaques of pregnancy.

OBJECTIVE: The study was designed to investigate obstetric risk factors and pregnancy outcome of patients with pruritic urticarial papules and plaques of pregnancy (PUPPP). METHODS: A population-based study comparing all pregnancies of women with and without PUPPP was conducted. Deliveries occurred during the years 1988-2002 at the Soroka University Medical Center. A multivariable logistic regression model was constructed in order to find independent risk factors associated with PUPPP. RESULTS: During a 15-year period, 159 197 deliveries took place. PUPPP complicated 42 (0.03%) of all pregnancies. Using a multivariable analysis, the following conditions were significantly associated with PUPPP: multiple pregnancies (odds ratio (OR) = 4.9, 95% confidence interval (CI) 1.7-14.1), hypertensive disorders (OR = 2.2, 95% CI 1.1-4.7), and induction of labor (OR = 7.6, 95% CI 4.0-14.5). Higher rates of 5-minute Apgar scores lower than 7 (OR = 8.0, 95% CI 4.4-14.9) and of cesarean deliveries (OR = 2.9, 95% CI 1.5-5.6) were noted in the PUPPP as compared to the comparison group. While investigating other perinatal outcome parameters such as oligohydramnios, intrauterine growth restriction, meconium-stained amniotic fluid and perinatal mortality, no significant differences were observed between the groups. CONCLUSION: Pruritic urticarial papules and plaques of pregnancy is a condition significantly associated with multiple pregnancies, hypertensive disorders, and induction of labor. Perinatal outcome is comparable to pregnancies without PUPPP.     

Low maternal weight, failure to thrive in pregnancy, and adverse pregnancy outcomes

OBJECTIVE: The purpose of this study was to correlate low maternal pregravid weight, delivery weight, and poor gestational weight gain with perinatal outcomes. STUDY DESIGN: Maternal and perinatal data from January 1997 to June 2001 were obtained from a perinatal database at MetroHealth Medical Center. Low maternal weight (LMW) was defined as pregravid or delivery weight <100 pounds or body mass index (BMI) < or =19.8 kg/m(2). Low maternal weight gain was defined as <0.27 kg per week. Perinatal complication rates in these subjects were compared with those with weights of 100 to 200 pounds, normal BMI (>19.8, <26 kg/m(2)), and normal gestational weight gain (0.27-0.52 kg/wk). Chi-square and t tests were used where appropriate. P<.05 was significant. RESULTS: A percentage (2.6%) of 15,196 subjects began pregnancy weighing < or =100 pounds; 0.15% weighed <100 pounds at delivery and 13.2% had a pregravid BMI < or =19.8 kg/m(2). Pregravid LMW was highly correlated with ethnicity (Asians, 8.6%; Hispanics, 4.3%; Caucasians, 2.5%; African Americans, 1.9%; P<.001). Subjects with pregravid LMW were at increased risk for intrauterine growth restriction (IUGR) (relative risk [RR], 2.3, 95% CI, 1.3-4.05), and perineal tears (3rd-degree lacerations; RR, 1.8, 95% CI, 1.1-2.9), and low birth weight ([LBW] <2500 g; RR, 1.8, 95% CI, 1.1-2.9). They had a lower risk of cesarean section (RR, 0.72, 95% CI, 0.56-0.92) and preterm delivery (PTD) (RR, 1.1, 95% CI, 0.97-1.06). Pregravid BMI <19.8 kg/m(2) was associated with preterm labor (PTL) (RR, 1.22, 95% CI, 1.02-1.46), IUGR (RR, 1.67, 95% CI, 1.2-2.39), and LBW (<2500 g; RR, 1.13, 95% CI, 1.0-1.27) and was protective against cesarean delivery (RR, 0.8, 95% CI, 0.71-0.91). Delivery LMW was associated with LBW (<2500 g; RR, 2.81, 95% CI, 1.62-4.84), active-phase arrest (RR, 5.07, 95% CI, 1.85-13.9), PTL and PTD (RR, 2.5, 95% CI, 1.02-6.33, and RR, 2.45, 95% CI, 1.4-4.4, respectively), a lower gestational age at delivery (36.8 vs 38.3 wks, P<.05), and mediolateral episiotomy (RR, 9.6, 95% CI, 1.9-48.0). A percentage (0.8%) of subjects had BMI <19.8 kg/m(2) at delivery. Low delivery BMI was associated with birth weight <2500 g (RR, 1.74, 95% CI, 1.3-2.32), PTL (RR, 2.16, 95% CI, 1.45-3.19), and PTD (RR, 1.57, 95% CI, 1.18-2.11). Failure to thrive in pregnancy (weight gain <0.27 kg/wk) was associated with LBW (<1500 g; RR, 1.23, 95% CI, 1.03-1.45), <2500 g; RR, 1.22, 95% CI, 1.13-1.33), and PTL and PTD (RR, 1.2, 95% CI, 1.05-1.37, and RR, 1.11, 95% CI, 1.02-1.2, respectively). CONCLUSION: Low weight and BMI at conception or delivery, as well as poor weight gain during pregnancy, are associated with LBW, prematurity, and maternal delivery complications.