Effects of a single course of corticosteroids given more than 7 days before birth: a systematic review

OBJECTIVES: To determine the risk of fetal, neonatal and maternal mortality and morbidity for women and their infants who remained undelivered more than 7 days following a course of prenatal corticosteroids. DESIGN: Systematic review. POPULATION: Women who gave birth more than 7 days after a course of prenatal corticosteroids compared with women not administered corticosteroids. METHODS: Seven randomised controlled trials were identified which reported outcomes for women and their babies who remained undelivered more than 7 days after exposure to a single course of corticosteroids compared with a placebo/no treatment group. MAIN OUTCOME MEASURES: Fetal, neonatal and maternal mortality and morbidity. RESULTS: Seven trials involving 862 infants, 434 born to corticosteroid treated women and 428 to control women were included in this review. For corticosteroid treated infants there was no reduction in the risk of respiratory distress syndrome (relative risk (RR), 0.72; 95% confidence interval (CI), 0.49-1.07), or stillbirth (RR, 1.67; 95% CI, 0.86-3.25). However, there was a tripling in risk of death for liveborn corticosteroid treated infants (RR, 3.24; 95% CI, 1.32-7.96; P = 0.01), and a doubling in risk of perinatal mortality (RR, 2.13; 95% CI, 1.27-3.57; P < 0.01). Corticosteroid treated infants were born on average 5 days earlier than controls (95% CI, -9.15 to -0.85 days, P = 0.02). Their mothers were more likely to have chorioamnionitis (RR, 2.91; 95% CI, 1.25-6.74; P = 0.01). CONCLUSIONS: Infants exposed to corticosteroids more than 7 days before birth had no reduction in risk of respiratory distress syndrome but increased perinatal mortality.     

Reassessment of White's classification and Pedersen's prognostically bad signs of diabetic pregnancies in insulin-dependent diabetic pregnancies

The classification systems developed over 20 years ago by White and Pedersen identified diabetic pregnancies at increased risk for perinatal mortality. To assess whether these same criteria would currently be valid, 199 diabetic pregnancies with deliveries from 1977 to 1983 were reviewed. Perinatal mortality rates for White's Classes B gestational (n = 72), B (n = 27), C (n = 67), and D + F + R (n = 33) were 2.9%, 11.1%, 14.9%, and 21.1%, respectively (p less than 0.05). White's classes were also predictive of pulmonary morbidity (12.5%, 18.5%, 22.4%, and 42.4%, respectively). The presence of one or more of the prognostically bad signs of pregnancy (n = 76) increased the perinatal mortality rate to 17.1% versus 7.3% among insulin-dependent diabetic pregnancies without prognostically bad signs (p less than 0.05). The presence of any prognostically bad signs of pregnancy was also predictive of pulmonary morbidity in general (31.6% versus 16.3%, respectively) and hyaline membrane disease in particular (13.2% versus 4.1%, respectively). Thus with use of modern obstetric management and medical care of the pregnant diabetic patient, both White's classification and Pedersen's prognostically bad signs of pregnancy continue to be predictive of perinatal mortality.     

No benefit from conservative management in nulliparous women with premature rupture of the membranes (PROM) at term. A randomized study.

OBJECTIVE. To compare maternal and fetal outcome in pregnancies with premature rupture of the membranes (PROM) at term with either early induction of labor or conservative management awaiting spontaneous labor. DESIGN. A prospective randomized trial. SETTING. The University Hospital of Lund, Sweden. SUBJECTS. Altogether 369 women with singleton pregnancy, cephalic presentation, gestational duration 36-41 weeks, were randomized either to induction of labor (n = 139) or conservative management up to 3 days (n = 138). Those eligible but not participating in the study totalled 92. MAIN OBSTETRIC MEASURES. Obstetric intervention rate (cesarean section or instrumental delivery) and short-term neonatal morbidity. RESULTS. No difference was found in the rate of obstetric intervention between the induction of labor group and the group with conservative management (12.2 vs. 18.8%; chi 2 = 2.3, p greater than 0.05). A slightly increased rate of neonatal infections was seen in the latter group (0.7 vs. 4.3%; chi 2 = 3.2, p less than 0.05). CONCLUSIONS. We found no benefit from conservative management for up to 3 days in women with PROM at term, compared with immediate induction of labor. There was no difference in the number of obstetric interventions during labor. The neonatal infectious morbidity was slightly higher in conservatively managed cases.     

The perinatal and economic impact of prenatal care in a low-socioeconomic population

Reductions in publicly funded prenatal care programs in 1981 to 1984 resulted in an increase in unregistered patient deliveries from 7.8% to 14.9% of births at University of California San Diego Medical Center. To assess the economic and perinatal impact of the increasing number of deliveries of women without prenatal care, 100 consecutive patients with fewer than three prenatal visits were studied. Each "no care" patient was matched by age, parity, and week of delivery with a control patient who received care in a state-funded perinatal project (Comprehensive Perinatal Program). Maternal antenatal risk factors were equally distributed between the two groups when maternal age, parity, history of substance abuse, prior preterm delivery, hypertension, and abortion were compared. Maternal obstetric outcomes were similar, including cesarean section rate and incidence of postpartum fever and hemorrhage. However, neonates delivered of women receiving no care experienced significantly greater morbidity than the neonates of women in the Comprehensive Perinatal Program, including an increased incidence of premature rupture of the membranes and preterm delivery (13% versus 2%, p less than 0.05), low birth weight (21% versus 6% less than 2500 gm, p less than 0.002), and intensive care unit admissions (24% versus 10%, p less than 0.005). When the total inpatient hospital charges were tabulated for each mother-baby pair, the cost of perinatal care for the group receiving no care ($5168 per pair) was significantly higher than the cost for patients in the Comprehensive Perinatal Program ($2974 per pair, p less than 0.001) including an antenatal charge of $600 in the Comprehensive Perinatal Program. The excess cost for delivery of 400 women receiving no care per year in the study hospital was $877,600. These results suggest that extension of prenatal care programs to medically indigent women is likely to result in a net reduction in perinatal morbidity and health care expenditures.     

The impact of antenatal cocaine use on maternal characteristics and neonatal outcomes.

OBJECTIVE: To determine the risk factors and evaluate maternal and neonatal outcomes associated with antenatal cocaine use. METHODS: This was a retrospective case-control study of 200 cocaine-exposed maternal-neonatal pairs and 200 controls from 1991 to 2000. RESULTS: Cocaine-using mothers tended to be older, African American, multiparous and incarcerated and they utilized less prenatal care. However, 79% of Hispanics abusing cocaine were primarily English speaking. Cocaine use correlated with syphilis (36 vs. 1%, p = 0.000) and premature rupture of membranes (23 vs. 0%, p = 0.000), fetal demise (5 vs. 0%, p = 0.004), preterm delivery (40 vs. 6%, p = 0.000). Cocaine-exposed infants delivered earlier (36 vs. 39 weeks, p = 0.000), had lower birth weights (2660 vs. 3305 g, p = 0.000), more respiratory distress syndrome (14 vs. 4%, p = 0.001), congenital syphilis (12 vs. 1%, p = 0.000) and longer hospital stays (10 vs. 3 days, p = 0.000); 75% were placed in foster care or adoption and 37.5% had neonatal withdrawal syndrome. There was a stronger positive correlation between neonatal withdrawal and maternal urine toxicology (rho = 0.443, p = 0.000) than with neonatal urine screen (rho = 0.278, p = 0.003). CONCLUSION: Cocaine use in pregnancy is associated with acculturation, lack of prenatal care, and significant social and obstetric complications resulting in increased neonatal morbidity secondary to prematurity, congenital infection and withdrawal syndrome.     

The biologic and social consequences of perinatal cocaine use in an inner-city population: results of an anonymous cross-sectional study

Cocaine use among pregnant women and reports of its adverse perinatal consequences have increased substantially over the past 10 years. However, most researchers have studied patients registered at drug treatment centers or have relied on voluntary participation by patients, either of which introduces the possibility of selection bias. To determine the frequency and consequences of prenatal cocaine use among an unselected inner-city obstetric population, we collected urine samples from parturient women at a municipal hospital and anonymously tested these specimens for metabolites of cocaine, marijuana, opiates, and methadone. Urine specimens, with linked obstetric data sheets, were available from a study population of 1111 patients, and pediatric data sheets were available for 846 mother-infant pairs. Cocaine metabolites were found in 11.5% of the urine samples collected, whereas metabolites of marijuana, opiates, and methadone, respectively, were present in 1.1%, 1.2%, and 0.3% of the specimens. Cocaine users were more likely than nonusers to have had no prenatal care (51% vs 8.8%; p less than 0.0001), to be American-born rather than Caribbean-born (71% vs 33%; p less than 0.001), and to have a higher parity (1.83 vs 1.14; p less than 0.0001). Infants of cocaine users had a lower mean gestational age (-0.93 weeks; p less than 0.01), a lower mean birth weight (2560 +/- 788 vs 3151 +/- 699 gm; p less than 0.001), and an increased probability of having an Apgar score of less than 7 at 5 minutes (12.5% vs 3.2%; p less than 0.0001). Multiple linear regression analysis that isolated confounding variables such as the presence or absence of prenatal care, maternal age and parity, and the use of cigarettes and alcohol did not substantially affect the differences described above. The effect of cigarette smoking on reducing fetal size was cumulative. In conclusion, cocaine is the most commonly used illicit drug among parturients in this community and is strongly associated with underutilization of prenatal care services. Infants of cocaine users are more likely to be preterm and depressed at birth and to have a low birth weight. Cocaine use, through the above-noted effects, increases the need for prenatal care while simultaneously decreasing the likelihood that it will be obtained.     

Obstetric admissions to the intensive care unit.

OBJECTIVE: To determine whether obstetric admissions to the intensive care unit (ICU) are useful quality-assurance indicators. METHODS: We analyzed retrospectively obstetric ICU admissions at two tertiary care centers from 1991 to 1997. RESULTS: The 131 obstetric admissions represented 0.3% of all deliveries. The majority (78%) of women were admitted to the ICU postpartum. Obstetric hemorrhage (26%) and hypertension (21%) were the two most common reasons for admission. Together with cardiac disease, respiratory disorders, and infection, they accounted for more than 80% of all admissions. Preexisting medical conditions were present in 38% of all admissions. The median Acute Physiology and Chronic Health Evaluation II score was 8.5. The predicted mortality rate for the group was 10.0%, and the actual mortality rate was 2.3%. CONCLUSION: The most common precipitants of ICU admission were obstetric hemorrhage and uncontrolled hypertension. Improved management strategies for these problems may significantly reduce major maternal morbidity.     

Does exposure to magnesium sulfate in utero decrease the risk of necrotizing enterocolitis in premature infants?

BACKGROUND: The objective of this study is to assess whether antenatal exposure to magnesium sulfate may decrease the risk of necrotizing enterocolitis in preterm infants. METHODS: We have compared the rate of magnesium sulfate exposure before birth among 23 consecutive infants diagnosed with necrotizing enterocolitis with that of 46 controls matched by gestational age at delivery and gender. Relevant obstetric and neonatal variables were compared between the two groups using chi-square and Fisher's exact test for categorical data, and one-way analysis of variance for continuous variables, with a two-tailed p-value <0.05 considered significant. RESULTS: No significant differences were present between the two groups in mode of delivery (p=0.9), rate of Apgar score at five minutes below seven (p=0.4), prenatal exposure to indocin (p=0.5) or steroids (p=0.6), or neonatal administration of surfactant (p=0.1). Similar proportions of babies with necrotizing enterocolitis and controls were diagnosed with respiratory distress syndrome (p=0.5), intraventricular hemorrhage grades three or four (p=0.9), and sepsis (p=0.6). Babies with necrotizing enterocolitis had a significantly longer hospital stay (74.6+/-64.0 vs. 41.9+/-37.0 days, p=0.01) and intubation period (31.4+/-24.1 vs. 16.8+/-15.6 days, p=0.01) than controls. The rates of prenatal exposure to magnesium sulfate were similar in the necrotizing enterocolitis and control groups (30% vs. 39% respectively, p=0.4). Power analysis demonstrated that 385 babies would be required in each group to reach statistical significance (alpha=0.05, beta=80%). CONCLUSION: In this retrospective case-control study, maternal administration of magnesium sulfate prior to delivery does not appear to confer a significant protective effect for the neonatal occurrence of necrotizing enterocolitis.     

Who remains undelivered more than seven days after a single course of prenatal corticosteroids and gives birth at less than 34 weeks?

Minimal information exists as to how women who give birth more than seven days after initial corticosteroid treatment, who may benefit from repeat prenatal corticosteroids, differ from women who give birth within seven days, at < 34 weeks gestation. OBJECTIVES: To examine the differences, if any, between women who received a single course of prenatal corticosteroids and remained undelivered more than seven days later and women who gave birth within seven days of treatment, at < 34 weeks gestation. DESIGN: Retrospective cohort. SETTING: Women's and Children's Hospital, Adelaide. POPULATION: Women who gave birth at < 34 weeks gestation from 1 January 1994 to 31 December 1996. METHODS: Data were extracted from medical records and retrieved from the hospital's database. MAIN POTENTIAL PREDICTORS COLLECTED: Prenatal corticosteroid exposure, reason for risk of preterm birth, maternal demographics and previous and current obstetric history. RESULTS: Of the 506 women, 122 (24%) remained undelivered more than seven days following prenatal corticosteroid therapy Initial corticosteroid treatment was given on average 1.6 weeks earlier to women who remained undelivered more than seven days after treatment. Women who were given prenatal corticosteroids for placenta praevia (RR 6.03, 95% CI 2.67-13.61, p < 0.01) or cervical incompetence (RR 3.40, 95% CI 1.06-10.95, p = 0.04) were more likely to give birth more than seven days after corticosteroid treatment. CONCLUSIONS: Women who give birth very preterm, who remain undelivered more than seven days after prenatal corticosteroids, differ in the reasons for and timing of their first course from women who give birth within seven days.     

Randomized,prospective, double-blind comparison of abdominal and vaginal hysterectomy in women without uterovaginal prolapse

BACKGROUND: To determine under controlled conditions whether there are significant differences in the duration of hospitalization and recovery between abdominal and vaginal hysterectomy for indications other than uterovaginal prolapse. METHOD: In a two-center prospective, double-blind randomized trial, 36 women with dysfunctional uterine bleeding, uterine fibroids or pelvic pain scheduled for hysterectomy were randomized to abdominal or vaginal hysterectomy. The primary outcome measure was the duration of hospital stay. Secondary outcome measures included analgesic requirements and return to normal health and function. RESULTS: There were no significant differences in peri-operative patient or surgical characteristics. Vaginal hysterectomy was associated with a reduction in hospital stay compared to abdominal hysterectomy (median stay 3 days vs. 5 days, p = 0.01). In addition, patients undergoing vaginal hysterectomy had reduced analgesic requirements (mean 75.4 mg vs. 131.4 mg morphine equivalent, p = 0.002), shorter need for intravenous hydration (mean 25.3 h vs. 32.7 h, p = 0.05), and faster return of bowel action (median 3 days vs. 4 days, p = 0.002). They also returned to normal domestic activities (mean 4.6 weeks vs. 8.5 weeks, p = 0.01) and work (mean 7.0 weeks vs. 13.9 weeks, p = 0.005), and completed their recovery (mean 7.9 weeks vs. 16.9 weeks, p = 0.008) more quickly. CONCLUSIONS: Vaginal hysterectomy was associated with significant benefits in terms of reduced hospital stay and improved patient recovery. Vaginal hysterectomy should be the route of choice not only for women with genital tract prolapse but also those without.     

The Diabetes in Early Pregnancy Study: changes in cholesterol, triglycerides, body weight, and blood pressure. The National Institute of Child Health and Human Development--the Diabetes in Early Pregnancy Study.

This study examined changes in cholesterol, triglycerides, body weight, and blood pressure during pregnancy in 312 diabetic and 356 control women recruited within 21 days after conception. Cholesterol values rose in both groups but were significantly lower in diabetic women at each time point (166 vs 178 mg/dl at week 12, p = 0.0004). Triglyceride values also rose in both groups. Triglyceride levels did not differ between groups up to week 8 of gestation, but by weeks 10 to 12 they were significantly lower in diabetic women than in controls (75 vs 89 mg/dl at week 12, p = 0.0004). Although they were no heavier at entry, diabetic women gained significantly more weight between weeks 6 and 8 (p less than 0.001), resulting in a mean difference between groups of 1 kg. Systolic blood pressure increased steadily and significantly in the diabetic but not the control women (115.8 +/- 16.2 SD vs 109.3 +/- 11.8 mm Hg, p = 0.0006 at term). Diastolic blood pressure was higher in diabetic women on entry (70.7 vs 67.3 mm Hg, p = 0.0006) and throughout gestation. Significant correlations were found in the diabetic group between maternal blood pressure and lipids and infant birth weight. These newly found differences in cholesterol and triglyceride levels, weight gain, and blood pressure between type I diabetic and control women during gestation may have long-term cardiovascular implications.     

The impact of first-trimester screening on AMA patients' uptake of invasive testing

OBJECTIVE: Prenatal testing for AMA includes invasive procedures such as CVS and amniocentesis, which have risks. We sought to determine the effects of first-trimester screening (FTS) on referrals for genetic counseling and patients' decisions to pursue invasive testing after FTS was offered in 2002. METHODS: We compared AMA patients presenting for prenatal care who underwent early genetic counseling (<13 weeks' gestation) from 2001 to those from 2003. Charts were reviewed for maternal age, gestational age, past obstetric history, prior CVS or amniocentesis, abnormal ultrasound findings and decision to proceed with invasive testing. The two groups were compared using Student t-test and chi-square tests. RESULTS: In 2001, 552 AMA women enrolled in prenatal care; 68 presented for early genetic counseling. In 2003, 728 AMA women enrolled in prenatal care; 172 presented for early genetic counseling. More counseled women chose genetic testing in 2003 than in 2001 (95% vs 79%, p<0.01). More patients elected an invasive procedure in 2001 compared to 2003 (71% vs 26%, p<0.01). CONCLUSION: Availability of FTS results in more AMA women having early prenatal genetic counseling and choosing some form of genetic testing. Such women are less likely to choose invasive tests than those without access to FTS.     

High-density lipoprotein and homocysteine levels correlate inversely in preeclamptic women in northern Nigeria

BACKGROUND: Preeclampsia/eclampsia is one of the most common complications of pregnancy. It is a cause of high morbidity for both mother and fetus, especially in developing countries. In a recent survey conducted in Gombe, Nigeria, eclampsia was found to be a major cause of maternal mortality (24.2%), second only to obstetric hemorrhage (27.1%). Previous studies have produced contradictory findings regarding total homocysteine (tHcy) levels in women with preeclampsia/eclampsia and there is little information about the relationship between particular serum lipids and tHcy. The objective of this study in Gombe was to compare the levels of serum lipids and homocysteine in healthy pregnant women and women with preeclampsia/eclampsia in Nigeria. METHODS: The experimental subjects included 43 women with preeclampsia/eclampsia and 130 healthy pregnant women served as controls. The criteria for preeclampsia/eclampsia included the following: hypertension (blood pressure > 140/90 mmHg), total protein (> 190 mg/g creatinine), and edema. Blood sera obtained from patients and controls attending the prenatal clinics at the Specialist Hospital and the Federal Medical Center in Gombe were analyzed for tHcy, total cholesterol, triglycerides, high-density lipoprotein (HDL)-cholesterol, low-density lipoprotein (LDL)-cholesterol, antioxidant capacity, folate, and vitamin B-12. RESULTS: The mean tHcy concentration for the preeclamptic/eclamptic women was greater than that of the controls (10.1 vs. 8.4 micromol/l, respectively, p = 0.01). The mean concentrations of LDL-cholesterol and triacylglycerols were not different between the two groups. However, the mean HDL-cholesterol level was higher in the healthy pregnant women compared with the preeclamptic/eclamptic women (1.64 vs. 1.42 mmol/l, respectively, p = 0.02). The HDL-cholesterol concentration was correlated inversely with the tHcy concentration (p = 0.001, r = 0.51). Total homocysteine was not linked with either serum folate or vitamin B-12. CONCLUSIONS: These results show that preeclampsia/eclampsia is associated with increased tHcy levels and that HDL levels are depressed in Nigerian women with this hypertensive, pregnancy associated disorder.     

Effect of smoking on red cell oxygen transport and release in diabetic pregnancy

In order to investigate the effect of smoking on the red cell oxygen transport and release in pregnant diabetic women, 23 smokers and 23 non-smokers were studied in the third trimester. The two groups were comparable with regard to blood glucose regulation, as the median concentration of blood glucose and glycosylated hemoglobin (Hb A1c) did not differ. Red cell 2, 3-diphosphoglycerate (2, 3-DPG) levels were significantly lower in the smokers than in the non-smokers (16.5 vs 17.8 mumol/gHb, p less than 0.01). P50 of the oxyhemoglobin dissociation curve at actual pH and at pH 7.40 was also significantly lower in the smokers (25.9 vs 26.9 mmHg, p less than 0.01, and 26.5 vs 27.8 mmHg, p less than 0.01 respectively). Red cell 2, 3-DPG was significantly correlated with P50 at pH 7.40 (r = 0.73, p less than 0.001). Arterial oxygen saturation was reduced to the same degree in smokers and in non-smokers, as compared with healthy non-smoking pregnant women and no adaptive increase in the hemoglobin concentration occurred in the pregnant diabetic smokers. The study suggests that smoking in pregnant diabetic women impairs the adaptive increase in 2, 3-DPG associated with diabetes-induced hypoxia.     

The perinatal effects of delayed childbearing

OBJECTIVE: To determine if the rates of pregnancy complications, preterm birth, small for gestational age, perinatal mortality, and serious neonatal morbidity are higher among mothers aged 35-39 years or 40 years or older, compared with mothers 20-24 years. METHODS: We performed a population-based study of all women in Nova Scotia, Canada, who delivered a singleton fetus between 1988 and 2002 (N = 157,445). Family income of women who delivered between 1988 and 1995 was obtained through a confidential linkage with tax records (n = 76,300). The primary outcome was perinatal death (excluding congenital anomalies) or serious neonatal morbidity. Analysis was based on logistic models. RESULTS: Older women were more likely to be married, affluent, weigh 70 kg or more, attend prenatal classes, and have a bad obstetric history but less likely to be nulliparous and to smoke. They were more likely to have hypertension, diabetes mellitus, placental abruption, or placenta previa. Preterm birth and small-for-gestational age rates were also higher; compared with women aged 20-24 years, adjusted rate ratios for preterm birth among women aged 35-39 years and 40 years or older were 1.61 (95% confidence interval [CI] 1.42-1.82; P < .001) and 1.80 (95% CI 1.37-2.36; P < .001), respectively. Adjusted rate ratios for perinatal mortality/morbidity were 1.46 (95% CI 1.11-1.92; P = .007) among women 35-39 years and 1.95 (95% CI 1.13-3.35; P = .02) among women 40 years or older. Perinatal mortality rates were low at all ages, especially in recent years. CONCLUSION: Older maternal age is associated with relatively higher risks of perinatal mortality/morbidity, although the absolute rate of such outcomes is low.     

Early and late postnatal identification of isolated lenticulostriate vasculopathy in preterm infants: associated findings.

OBJECTIVES: To determine the incidence, possible etiologies, and neurodevelopmental outcome of premature infants (<35 weeks) with isolated lenticulostriate vasculopathy (LSV). STUDY DESIGN: In a retrospective case-control design, we reviewed the medical records of all premature infants who were admitted to our neonatal intensive care unit between 1996 and 2000. RESULTS: The prevalence of LSV was 4.6% (21 of 453). Patients with late LSV (detected after 10 days of age) had less exposure than controls to prenatal steroids [42.8% (6 of 14) vs. 92.8% (13 of 14), respectively; p<0.01], and prenatal antibiotics [42.8% (6 of 14) vs. 85.7% (12 of 14), respectively; p=0.01]. Fifty-seven percent (8 of 14) of patients with late LSV had a low Apgar score vs. 14.2% (2 of 14) of the control group (p=0.01). Patients with LSV also had more muscle tone abnormalities than controls at 6 months of age [33.3% (5 of 15) vs. 5.2% (1 of 19), respectively; p=0.03]. CONCLUSION: Patients with late LSV have less exposure to antenatal steroids and antibiotics, lower Apgar scores, and abnormal muscle tone at 6 months of age.     

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.     

Evaluation of a telemedicine program managing high-risk pregnant women with pre-existing diabetes in Arkansas's Medicaid program

ObjectiveWe aim to evaluate the effects of the telemedicine program, High-Risk Pregnancy Program at University of Arkansas for Medical Sciences (UAMS), on health services utilization and medical expenditures among pregnant women with pre-existing diabetes and their newborns.Research design and methodsThe study sample was selected from the Arkansas Medicaid claims linked to infant birth/death certificates and UAMS telemedicine records from 2013 through 2016. We used propensity score matching based on participants’ characteristics to create three groups - UAMS telemedicine care, UAMS in-person care, and non-UAMS prenatal care. We compared inpatient and outpatient care services, medication use and caesarean section rates, severe maternal morbidity, infant mortality and preterm birth rates and medical expenditures.ResultsThe UAMS telemedicine group had fewer inpatient admissions (1.18 vs 1.31; 95% CI: -0.27, 0.00), lower insulin use rates (41.86% vs 59.88%; 95% CI: -29.00%, -7.05%) and lower maternal care expenditures ($7,846 vs $10,644; 95% CI: -$4,089, -$1,507) compared with the UAMS in-person care group. Women receiving UAMS telemedicine had more prenatal care visits (10.45 vs 8.57; 95% CI: -2.96, -0.81), higher insulin use rates (41.86% vs 26.74%: 95% CI: 4.63%, 25.60%) and similar maternal care expenditures ($7,846 vs $7,051), compared with those receiving non-UAMS in-person care. Caesarean section, severe maternal morbidity, and infant mortality rates were similar across the three groups.ConclusionUAMS telemedicine was associated with improved utilization of prenatal care among pregnant women with pre-existing diabetes. Telemedicine services did not differ from usual in-person services in clinical outcomes and medical expenditures.     

La edad materna como factor de riesgo obstétrico. Resultados perinatales en gestantes de edad avanzada

Objective

To compare perinatal outcomes in women aged 35 years or over with those in a control group aged less than 35 years.

Design

Historical cohort study.

Setting

Valladolid (Spain).

Methods

Univariate analysis was performed with estimation of relative risks (RR). Variables related to epidemiology, pregnancy course and perinatal outcomes were analyzed.

Results

A total of 1,455 deliveries were analyzed, of which 355 involved women aged 35 years or over (24.39%). Older women more frequently showed pregnancy-associated disorders (29.2 vs 15.8%, p < 0.001): gestational diabetes (6.2%, p < 0.0029), first-trimester metrorrhagia (5.6%, p < 0.01), and risk of preterm birth (3.9%, P < 0.007); pregnancy-induced hypertension was also more frequent in this group but this difference was not statistically significant. Induction of labor was more frequently required in the older group (RR = 1.42; 95% CI:1.08-1.87). Cesarean section was required in 47% of older nulliparous women (RR = 1.63; 95% CI: 1.24-2.15). The overall perinatal mortality rate in older patients was 16.5‰, compared with 2.77‰ in the control group. Maternal morbidity was higher in the group of older patients (RR 5.98; 95% CI 1.35-26.54) and mainly consisted of hemorrhagic complications.

Conclusions

Advanced maternal age is associated with a higher frequency of pregnancy-related disorders and a greater incidence of medically-induced delivery and cesarean sections, especially in primiparous mothers. Age therefore influences maternal and fetal morbidity and mortality. Consequently, these women constitute an obstetric risk population requiring special attention which, given the number of older pregnant women, goes beyond the scope of health provisions in our environment.     

Perinatal outcomes in severe preeclampsia-eclampsia with and without HELLP syndrome

OBJECTIVE: Our purpose was to find out and compare perinatal outcomes in pregnancies complicated by severe preeclampsia-eclampsia with and without HELLP syndrome. METHODS: Clinical and laboratory findings, and perinatal-neonatal outcomes of all pregnants with severe preeclampsia, eclampsia and HELLP have been prospectively recorded. Results were compared by means of Student's t test, chi2 analysis and Fisher's exact test as appropriate. RESULTS: Among 367 consecutive severe preeclampsia, 106 (29%) had HELLP syndrome, 261 (71%) had severe preeclampsia and eclampsia. Mean gestational age and birth weight at delivery in severe preeclampsia without HELLP syndrome and in HELLP syndrome were 34.1 +/- 6.1 vs. 33.0 +/- 5.8 weeks (p = 0.119) and 1,886 +/- 764 vs. 1,724 +/- 776 g (p = 0.063), respectively. Comparing overall fetal mortality (4.6 vs. 10.3%, p = 0.009) and perinatal mortality (8.0% vs. 16.8%, p = 0.026) in severe preeclampsia-eclampsia and HELLP syndrome, respectively, there were statistically significant differences. But when analyses were performed according to gestational age before and after 32nd gestational week, the difference of perinatal mortality between the two groups was non-significant (p = 0.644 and p = 0.250), suggesting borderline difference. The most common contributing factor for fetal death after 32nd week was due to abruptio placenta without prenatal follow-up. Neonatal morbidity and neonatal mortality (4.8 vs. 6.3%, p = 0.905) in severe preeclampsia-eclampsia and HELLP syndrome respectively were similar and the difference was statistically nonsignificant. CONCLUSIONS: Perinatal mortality and neonatal morbidity-mortality according to gestational age before and after the 32nd week were similar in HELLP syndrome compared with severe preeclampsia-eclampsia without HELLP but overall fetal mortality was higher in HELLP syndrome with no regular prenatal care.