Maternal and neonatal outcome after failed ventouse delivery: Comparison of forceps versus cesarean section

Objectives.?To compare the immediate maternal and neonatal morbidity in women delivered by forceps or cesarean section after failed ventouse delivery.

Methods.?Case notes of 400 consecutive successful ventouse deliveries compared with 342 failed ventouse deliveries, where delivery was subsequently achieved with either forceps (N = 247) or cesarean section (N = 95), which took place between October 1999 and May 2003, were reviewed.

Results.?Failed ventouse delivery was associated with an increased chance for fetal malposition (OR 3.7, 95% CI 2.6 – 5.3) and postpartum hemorrhage (OR 3.5, 95% CI 1.8 – 6.8). Compared to forceps after failed ventouse, cesarean section was associated with a higher prevalence of postpartum hemorrhage (OR 7.8, 95% CI 3.6 – 16.9) and fewer third degree perineal tears (p < 0.05). There were no significant differences between cesarean section and forceps delivery after failed ventouse for neonatal morbidity.

Conclusions.?Failure of ventouse delivery is 3 – 4 times more likely with a fetal malposition and is associated with an increased risk of postpartum hemorrhage. While cesarean section increases the postpartum hemorrhage rate, forceps delivery is associated with increased likelihood of third degree perineal tears. The neonatal morbidity was comparable regardless of whether forceps or cesarean was used after failed ventouse.     

Risk factors for intrauterine fetal death (1988–2009)

Objective.?To determine risk factors for intrauterine fetal death (IUFD).

Study design.?A retrospective population-based study, of all singleton deliveries between the years 1988–2009 was conducted. Intrapartum deaths, postpartum death, and multiple gestations were excluded. A multiple logistic regression model was used to determine independent risk factors.

Results.?During the study period, out of 228,239 singleton births, 1694 IUFD cases were recorded (7.4 per 1000 births). The following independent risk factors were identified in the logistic regression executed: Oligohydramnios (OR 2.6, 95% CI 2.1–3.2, p-value?<?0.001), polyhydramnios (OR 1.8, 95% CI 1.4–2.2, p-value?<?0.001), previous adverse perinatal outcome (OR 1.7, 95% CI 1.5–2.1, p-value?<?0.001), congenital malformations (OR 2.0, 95% CI 1.8–2.3, p-value?<?0.001), true knot of cord (OR 3.7, 95% CI 2.8–4.9, p-value?<?0.001), meconium stained amniotic fluid (OR 2.7, 95% CI 2.3–3.0, p-value<0.001), placental abruption (OR 2.9, 95% CI 2.4–3.5, p-value?<?0.001), advanced maternal age (OR 1.03, 95% CI 1.02–1.04, p-value?<?0.001), and hypertensive disorders (OR 1.24, 95% CI 1.0–1.4, p-value?=?0.026). Jewish ethnicity (versus Bedouin – OR 0.64, 95% CI 0.57–0.72, p-value?<?0.001), gestational diabetes (OR 0.7, 95% CI 0.5–0.8, p-value?=?0.001), previous cesarean section (OR 0.8, 95% CI 0.7–0.97, p-value?=?0.019), and recurrent abortions (OR 0.8, 95% CI 0.6–0.9, p-value?=?0.011) were negatively associated with IUFD.

Conclusion.?Several independent risk factors were identified, suggesting a possible cause of death. Other pathologic conditions that facilitate tighter pregnancy surveillance and active management were found protective, pointing the benefit of such management approaches in high-risk pregnancies.     

Is the risk of obstetric anal sphincter injuries increased in vaginal twin deliveries?

Objective: Vaginal twin deliveries have a higher rate of intrapartum interventions. We aimed to determine whether these characteristics are associated with an increased rate of obstetric anal sphincter injuries compared with singleton.

Study design: Retrospective study of all twin pregnancies undergoing vaginal delivery trial was conducted from January 2000–September 2014. Sphincter injury rate compared with all concurrent singleton vaginal deliveries. Multivariable analysis was used to determine twin delivery association with sphincter injuries while adjusting for confounders.

Results: About 717 eligible twin deliveries. Outcome was compared with 33?886 singleton deliveries. Twin pregnancies characterized by a higher rate of nulliparity (54.8% versus 49.5%, p?=?0.005), labor induction (42.7% versus 29.1%, p?<?0.001), and instrumental deliveries (27.5% versus 16.7%, p?<?0.001), lower gestational (34.6?±?3.3 versus 38.8?±?2.3, p?<?0.001), and lower birth weight. Total breech extraction was performed in 29.0% (208/717) of twin deliveries. Overall obstetric sphincter injury rate was significantly lower in the twins group (2.8% versus 4.4%, p?=?0.03, OR?=?0.6, 95% CI 0.4–0.9), due to lower rate of 3rd degree tears in twins versus singletons (2.2% versus 4.0%, p?=?0.02), rate of 4th degree tears similar among the groups (0.6% versus 0.4%, p?=?0.5). In multivariable analysis, sphincter injuries were associated with nulliparity (OR?=?3.9, 95% CI 3.4–4.5), forceps (OR?=?6.8, 95% CI 5.8–7.8), vacuum (OR?=?2.9, 95% CI 2.5–3.3), earlier gestational age (OR?=?0.2, 95% CI 0.1–0.3), episiotomy (OR?=?0.8, 95% CI 0.7–0.9), and birth weight over 3500?g (OR?=?1.8, 95% CI 1.6–2.0). However, the association between twins (versus singletons) deliveries and sphincter injuries was lost after adjustment for delivery gestational age (OR?=?0.7, 95% CI 0.4–1.2).

Conclusion: Despite a higher rate of intrapartum interventions, the rate of sphincter injuries is lower in twins versus singleton deliveries, mainly due to a lower gestational age at delivery.     

Once episiotomy,always episiotomy?

Objective

To investigate the association between episiotomy and perineal damage in the subsequent delivery.

Study design

A retrospective cohort study was conducted, comparing outcome of subsequent singleton deliveries of women with and without episiotomy in their first (index) delivery. Deliveries occurred between the years 1991–2015 in a tertiary medical center. Traumatic vaginal tears, multiple pregnancies, and cesarean deliveries (CD) in the index pregnancy were excluded from the analysis. Multiple logistic regression models were used to control for confounders.

Results

During the study period, 43,066 women met the inclusion criteria; of them, 50.4% (n?=?21,711) had subsequent delivery after episiotomy and 49.6% (n?=?21,355) had subsequent delivery without episiotomy in the index pregnancy. Patients with episiotomy in the index birth higher rates of subsequent episiotomy (17.5 vs. 3.1%; P?<?0.001; OR?1.9; 95% CI). In addition, the rates of the first and second degree perineal tears as well as the third and fourth degree perineal tears were significantly higher in patients following episiotomy (33.6 vs. 17.8%; P?<?0.001, and 0.2 vs. 0.1%; P?=?0.002, respectively). Nevertheless, there was no significant difference at the rates of CD and instrumental deliveries, between the groups. While adjusting for maternal age, ethnicity, birth weight, and vacuum delivery—the previous episiotomy was noted as an independent risk factor for recurrent episiotomy in the subsequent delivery (adjusted OR?6.7; 95% CI 6.2–7.3, P?<?0.001). The results remained significant for term (adjusted OR?6.8; 95% CI 6.2–7.4, P?<?0.001) as well as preterm deliveries (adjusted OR?4.5; 95% CI 3.3–6.3, P?<?0.001) in two different models.

Conclusion

Episiotomy is an independent risk factor for recurrent episiotomy in the subsequent delivery.

     

Intravenous carbetocin versus intravenous oxytocin for preventing atonic postpartum hemorrhage after normal vaginal delivery in high-risk singleton pregnancies: a triple-blind randomized controlled trial

Purpose

To compare the effectiveness of intravenous carbetocin to that of intravenous oxytocin for prevention of atonic postpartum hemorrhage (PPH) after vaginal delivery in high-risk singleton pregnancies.

Methods

This triple-blind randomized controlled trial included singleton pregnant women who delivered at Siriraj Hospital between August 2016 and January 2017 and who were 20 years or older, had a gestational age of at least 34 weeks, had a vaginal delivery, and had at least one risk factor for atonic postpartum hemorrhage. Immediately after vaginal delivery, participants were randomly assigned to receive either 5 U of oxytocin or 100 mcg of carbetocin intravenously. Postpartum blood loss was measured objectively in mL using a postpartum drape with a calibrated bag.

Results

A total of 174 and 176 participants constituted the oxytocin and carbetocin groups, respectively. The baseline characteristics were comparable between the groups. The carbetocin group had less postpartum blood loss (146.7?±?90.4 vs. 195.1?±?146.2 mL; p?<?0.01), a lower incidence of atonic PPH (0 vs. 6.3%; p?<?0.01), less usage of additional uterotonic drugs (9.1 vs. 27.6%; p?<?0.01), and a lower incidence of postpartum anemia (Hb?≤?10 g/dL) (9.1 vs. 18.4%; p?<?0.05) than the oxytocin group. No significant differences regarding side effects were evident between the groups.

Conclusions

Intravenous carbetocin is more effective than intravenous oxytocin for the prevention of atonic PPH among singleton pregnancies with at least one risk factor for PPH.

Clinical trial registration

TCTR20160715004.

     

Peripartum cesarean hysterectomy: critical analysis of risk factors and trends over the years

Objective.?To investigate time trends and risk factors for peripartum cesarean hysterectomy.

Methods.?A population-based study comparing all deliveries that were complicated with peripartum hysterectomy to deliveries without this complication was conducted. Deliveries occurred during the years 1988–2007 at a tertiary medical center. A multiple logistic regression model was constructed to find independent risk factors associated with peripartum hysterectomy.

Results.?Emergency peripartum cesarean hysterectomy complicated 0.06% (n?=?125) of all deliveries in the study period (n?=?211,815). The incidence of peripartum hysterectomy increased over time (1988–1994, 0.04%; 1995–2000, 0.05%; 2001–2007, 0.095%). Independent risk factors for emergency peripratum hysterectomy from a backward, stepwise, multivariable logistic regression model were: uterine rupture (OR?=?487; 95% CI 257.8–919.8, p?<?0.001), placenta previa (OR?=?66.4; 95% CI 39.8–111, p?<?0.001), postpartum hemorrhage (PPH) (OR?=?40.8; 95% CI 22.4–74.6, p?<?0.001), cervical tears (OR?=?22.3; 95% CI 10.4–48.1, p?<?0.001), second trimester bleeding (OR?=?6; 95% CI 1.8–20, p?=?0.003), previous cesarean delivery (OR?=?5.4; 95% CI 3.5–8.4, p?<?0.001), placenta accreta (OR?=?4.7; 95% CI 1.9–11.7, p?=?0.001), and grand multiparity (above five deliveries, OR?=?4.1; 95% CI 2.5–6.6, p?<?0.001). Newborns of these women had lower Apgar scores (<7) at 1 and 5?min (32.7% vs.4.4%; p?<?0.001, and 10.5% vs. 0.6%; p?<?0.001, respectively), and higher rates of perinatal mortality (18.4% vs. 1.4%; p?<?0.001) as compared to the comparison group.

Conclusion.?Significant risk factors for peripartum hysterectomy are uterine rupture, placenta previa, PPH, cervical tears, previous cesarean delivery, placenta accreta, and grand multiparity. Since the incidence rates are increasing over time, careful surveillance is warranted. Cesarean deliveries in patients with placenta previa-accreta, specifically those performed in women with a previous cesarean delivery, should involve specially trained obstetricians, following informed consent regarding the possibility of peripartum hysterectomy.     

Carbetocin versus oxytocin for the prevention of postpartum hemorrhage: A meta-analysis of randomized controlled trials in cesarean deliveries

Objective

Postpartum hemorrhage remains the leading cause of maternal mortality in developing countries and a significant proportion of these cases are attributable to uterine atony. In contrast to the advances made in the treatment of postpartum hemorrhage, there has been few novel prophylactic agents. This study was undertaken to analyze the effectiveness of carbetocin compared to oxytocin for the prevention of postpartum hemorrhage, in the context of cesarean deliveries.

Risk factors for neonatal brachial plexus paralysis

Purpose

The study was aimed to identify risk factors for neonatal brachial plexus paralysis.

Methods

A retrospective case?Ccontrol study was designed. A comparison was performed between cases of brachial plexus paralysis, with all consecutive deliveries during the same 5 months period, without brachial plexus paralysis. Statistical analysis was performed using the SPSS package.

Results

The prevalence of brachial plexus paralysis was 1.62/1,000 (9/5,525) vaginal births. Independent risk factors for brachial plexus paralysis were shoulder dystocia (OR?=?525; 95% CI 51?C4,977, P?P?4,000?g; OR?=?16.3; 95% CI 3.7?C70.2, P?P?P?=?0.032).

Conclusions

In our population, shoulder dystocia, macrosomia, labor dystocia, vacuum delivery and vaginal breech deliveries were significant risk factors for neonatal brachial plexus paralysis, while maternal characteristics such as obesity and diabetes were not. Despite our growing knowledge concerning the risk factors associated with brachial plexus paralysis, unfortunately, this condition cannot be predicted or prevented.     

The differences in placental pathology and neonatal outcome in singleton vs. twin gestation complicated by small for gestational age

Objective

We aimed to compare placental histopathology and neonatal outcome between dichorionic diamniotic (DCDA) twins and singleton pregnancies complicated by small for gestational age (SGA).

Methods

Medical files and placental pathology reports from all deliveries between 2008 and 2017 of SGA neonates, (birthweight?<?10th percentile), were reviewed. Comparison was made between singleton pregnancies complicated with SGA (singletons SGA group) and DCDA twin pregnancies (Twins SGA group), in which only one of the neonates was SGA. Placental diameters were compared between the groups. Placental lesions were classified into maternal and fetal vascular malperfusion lesions (MVM and FVM), maternal (MIR) and fetal (FIR) inflammatory responses, and chronic villitis. Neonatal outcome parameters included composite of early neonatal complications.

Results

The twins SGA group (n?=?66) was characterized by a higher maternal age (p?=?0.011), lower gestational age at delivery (34.9?±?3.1 vs. 37.7?±?2.6 weeks, p?<?0.001), and a higher rate of preeclampsia (p?=?0.010), compared to the singletons SGA group (n?=?500). Adverse composite neonatal outcome was more common in the twins SGA group (p?<?0.001). Placental villous lesions related to MVM (p?<?0.001) and composite MVM lesions (p?=?0.04) were more common in the singletons SGA group. On multivariate logistic regression analysis, the singletons SGA group was independently associated with placental villous lesions (aOR 3.6, 95% CI 1.9–7.0, p?<?0.001) and placental MVM lesions (aOR 2.44, 95% CI 1.29–4.61, p?=?0.006).

Conclusion

Placentas from SGA singleton pregnancies have more MVM lesions as compared to placentas from SGA twin pregnancies, suggesting different mechanisms involved in abnormal fetal growth in singleton and twin gestations.

     

The effect of placental removal method on perioperative hemorrhage at cesarean delivery; a randomized clinical trial

Purpose

The aim of this prospective randomized clinical study is to compare whether the removal methods of placenta during cesarean section have an impact on perioperative hemorrhage.

Methods

One hundred women with singleton term pregnancies undergoing elective cesarean section through lower segment transverse incision under general anesthesia were included in this study. They were randomly allocated to two groups according to the type of removal of the placenta from the uterus after childbirth; manually or spontaneously. The main outcome measures were change in hemoglobin levels after cesarean section. The secondary outcomes were operative time, required transfusions and postcesarean endometritis.

Results

Fifty patients were randomized to the manual removal group and 50 to the spontaneous group. The demographic characteristics of the two groups were similar. There were no difference in terms of change in hemoglobin levels after cesarean section between two groups (1.6 ± 1.0 and 1.5 ± 1.0, respectively; P = 0.711). In addition, none of the patients required blood transfusion and showed postpartum infections.

Conclusion

There is not an association between the method of removal of the placenta and postpartum blood loss in cesarean section deliveries.     

Association of smoking with wound complications after cesarean delivery

Objective: To determine whether smoking is an independent risk factor for wound dehiscence after cesarean delivery. Methods: In this case–control study, medical records were reviewed for all patients with wound dehiscence after cesarean delivery during a 7-month period. Wound dehiscence was defined as separation of wound edges requiring treatment. Three control patients without such complications were randomly selected for each case patient. Univariate associations were assessed using t test or Fisher’s exact test; univariate odds ratios (OR) and 95% confidence intervals (CI) were calculated with logistic regression. Multivariate associations were assessed with logistic regression on variables with a univariate association significant at p?≤?0.10. Results: Of 597 cesarean deliveries, 30 cases (5 %) with wound dehiscence were identified. As individual variables, smoking (46.7 vs. 21.1%, p?<?0.01, cases vs. controls), histological chorioamnionitis (27.6 vs. 6.7%, p?<?0.01) and preoperative hematocrit (34.0?±?3.2 vs. 35.4?±?3.4, p?<?0.05) were significantly associated with wound complications. In a multivariate logistic regression model, only smoking (OR 5.32; 95% CI 1.77–15.97, p?<?0.01) and histological chorioamnionitis (OR 5.62; 95% CI 1.43–22.11, p?<?0.01) were independently associated with wound dehiscence. Conclusions: Smoking and histological chorioamnionitis are independently associated with wound dehiscence after cesarean delivery.     

Puerperal morbidity following repeat cesarean delivery in twin pregnancies

Objective

To evaluate the puerperal complications following twin deliveries.

Study design

We conducted a population-based analysis of puerperal delivery-related complications of twins born in Slovenia for comparing three groups of births (vaginal, elective and emergent cesarean).

Results

A total of 1,001 elective, 1,109 emergent cesarean sections, and 2,204 vaginal twin births were evaluated. No differences were found between the complications after emergent and elective cesareans. Uterine atony was more frequent after vaginal births (OR 1.8–2.0, 95 % CI 1.1–1.2, 2.9–3.3). Vaginal births had a higher frequency of endometritis compared with elective cesarean (OR 4.1, 95 % CI 1.2, 13.6). Conversely, vaginal deliveries were less frequently associated with anemia, hematoma formation, and need for blood transfusion as compared to both modes of cesarean deliveries.

Conclusion

No solid data exist to show a clear advantage or disadvantage in terms of puerperal complications of an elective cesarean over vaginal birth for twins.     

Episiotomy: the final cut?

Objective

To investigate whether episiotomy prevents 3rd or 4th degree perineal tears in critical conditions such as shoulder dystocia, instrumental deliveries (vacuum or forceps), persistent occiput-posterior position, fetal macrosomia (>4,000?g), and non-reassuring fetal heart rate (NRFHR) patterns.

Methods

A retrospective study comparing 3rd and 4th degree perineal tears during vaginal deliveries with or without episiotomy, in selected critical conditions was performed. Multiple gestations, preterm deliveries (<37?weeks’ gestation) and cesarean deliveries were excluded from the analysis. Stratified analysis (using the Mantel–Haenszel technique) was used to obtain the weighted odds ratio (OR), while controlling for these variables.

Results

During the study period, there were 168,077 singleton vaginal deliveries. Of those, 188 (0.1?%) had 3rd or 4th degree perineal tears. Vaginal deliveries with episiotomy had statistically significant higher rates of 3rd or 4th degree perineal tears than those without episiotomy (0.2 vs. 0.1?%; P?<?0.001). The association between episiotomy and severe perineal tears remained significant even in the critical conditions. Stratified analysis revealed that the adjusted ORs for 3rd or 4th degree perineal tears in these critical conditions (Macrosomia OR?=?2.3; instrumental deliveries OR?=?1.8; NRFHR patterns OR?=?2.1; occipito-posterior position OR?=?2.3; and shoulder dystocia OR?=?2.3) were similar to the crude OR (OR?=?2.3).

Conclusions

Mediolateral episiotomy is an independent risk factor for 3rd or 4th degree perineal tears, even in critical conditions such as shoulder dystocia, instrumental deliveries, occiput-posterior position, fetal macrosomia, and NRFHR. Prophylactic use of episiotomy in these conditions does not seem beneficial if performed to prevent 3rd or 4th degree perineal tears.     

Models for the prediction of successful induction of labor based on pre-induction sonographic measurement of cervical length

Objective.?To examine the effect of pre-induction cervical length, parity, gestational age at induction, maternal age and body mass index (BMI) on the possibility of successful delivery in women undergoing induction of labor.

Methods.?In 822 singleton pregnancies, induction of labor was carried out at 35 to 42^?+?6 weeks of gestation. The cervical length was measured by transvaginal sonography before induction. The effect of cervical length, parity, gestational age, maternal age and BMI on the interval between induction and vaginal delivery within 24?hours was investigated using Cox's proportional hazard model. The likelihood of vaginal delivery within 24?hours and risk for cesarean section overall and for failure to progress was investigated using logistic regression analysis.

Results.?Successful vaginal delivery within 24?hours of induction occurred in 530 (64.5%) of the 822 women. Cesarean sections were performed in 161 (19.6%) cases, 70 for fetal distress and 91 for failure to progress. Cox's proportional hazard model indicated that significant prediction of the induction-to-delivery interval was provided by the pre-induction cervical length (HR?=?0.89, 95 % CI 0.88–0.90, p?<?0.0001), parity (HR?=?2.39, 95% CI 1.98–2.88, p?<?0.0001), gestational age (HR?=?1.13, 95% CI 1.07–1.2, p?= <?0.0001) and birth weight percentile (HR?=?0.995, 95% CI 0.99?– 0.995, p?=?0.001), but not by maternal age or BMI. Logistic regression analysis indicated that significant prediction of the likelihood of vaginal delivery within 24?hours was provided by pre-induction cervical length (OR?=?0.86, 95% CI 0.84–0.88, p?<?0.0001), parity (OR?=?3.59, 95% CI 2.47–5.22, p?<?0.0001) and gestational age (OR =?1.19, 95% CI 1.07–1.32, p?= <?0.0001) but not by BMI or maternal age. The risk of cesarean section overall was significantly associated with all the variables under consideration, i.e., pre-induction cervical length (OR?=?1.09, 95% CI 1.06–1.11, p?<?0.0001), parity (OR?=?0.25, 95% CI 0.17–0.38, p?<?0.0001), BMI (OR?=?1.85, 95% CI 1.24–2.74, p?=?0.0024), gestational age (OR?=?0.88, 95% CI 0.78–0.98, p?=?0.0215) and maternal age (OR?=?1.04, 95% CI 1.01–1.07, p?=?0.0192). The risk of cesarean section for failure to progress was also significantly associated with pre-induction cervical length (OR?=?1.11, 95% CI 1.07–1.14, p?<?0.0001), parity (OR?=?0.26, 95% CI 0.15–0.43, p?<?0.0001), gestational age (OR?=?0.83, 95% CI 0.73–0.96, p?=?0.0097) and BMI (OR?=?2.07, 95% CI 1.27–3.37, p?=?0.0036).

Conclusion.?In women undergoing induction of labor, pre-induction cervical length, parity, gestational age at induction, maternal age and BMI have a significant effect on the interval between induction and delivery within 24?hours, likelihood of vaginal delivery within 24?hours and the risk of cesarean section.     

Outcomes of pregnancies complicated by hyperemesis gravidarum

Objectives

To evaluate maternal and fetal outcomes among women with hyperemesis gravidarum (HG).

Methods

In a university hospital and a research and training hospital, a retrospective cohort study was conducted among women with singleton deliveries between 2003 and 2011. Maternal outcomes evaluated included gestational diabetes, pregnancy-induced hypertension, cesarean delivery. Neonatal outcomes also determined were 5-min Apgar score of less than 7, low birth weight, small for gestational age (SGA), preterm delivery, fetal sex, and stillbirth.

Results

There were no statistical differences in the mean of age, parity, the number of artificial pregnancy, and smoking between two groups. Infants from HG pregnancies manifested similar birth weight (3,121.5?±?595.4 vs. 3,164?±?664.5?g) and gestational age (38.1?±?2.3 vs. 38.1?±?2.6?weeks), relative to infants from the control group (p?=?0.67 and 0.91, respectively). In addition, no statistical significant differences were found in the rates of SGA birth, preterm birth, gestational diabetes, pregnancy-induced hypertension, and adverse fetal outcome between two groups (p?>?0.05). Cesarean delivery rates were similar in two groups (31.9% in hyperemesis group vs. 27% in control group, p?=?0.49). Comparing the gender of the newborn baby and Apgar scores less than 7 at 5?min, there were no statistically significant differences between two groups (p?=?0.16 and 0.42, respectively).

Conclusion

Hyperemesis gravidarum is not associated with adverse pregnancy outcomes.     

Pregnancy outcomes in liver transplant patients,a population-based study

Objective: To determine the incidence of pregnancy in liver transplant (LT) patients in a large population-based cohort and to determine the maternal and fetal risks associated with these pregnancies.

Methods: We conducted an age-matched cohort study using the US Healthcare and Utilization project–Nationwide Inpatient Sample from 2003–2011. We used unconditional logistic regression, adjusted for baseline characteristics, to estimate the likelihood of common obstetric complications in the LT group compared with age-matched nontransplant patients.

Results: There were 7?288?712 deliveries and an estimated incidence of 2.1 LTs/100?000 deliveries over the nine-year study period. LT patients had higher rates of maternal complications including hypertensive disorders (OR 6.5, 95% CI: 4.4–9.5), gestational diabetes (OR 1.9, 95% CI: 1.0–3.5), anemia (OR 3.2, 95% CI: 2.1–4.9), thrombocytopenia (OR 27.5, 95% CI: 12.7–59.8) and genitourinary tract infections (OR 4.2, 95% CI: 1.8–9.8). Deliveries among women with LT had higher risks of cesarean section (OR 2.9, 95% CI: 2.0–4.1), postpartum hemorrhage (OR 3.2, 95% CI: 1.7–6.2) and blood transfusion (OR 18.7, 95% CI: 8.5–41.0). Fetal complications in LT patients included preterm delivery (OR 4.7, 95% CI: 3.2–7.0), intrauterine growth restriction (OR 4.1, 95% CI: 2.1–7.7) and congenital anomalies (OR 6.0, 95% CI: 1.1–32.0).

Conclusion: Although pregnancies in LT recipients are feasible, they are associated with a high rate of maternal and fetal morbidities. Close antenatal surveillance is recommended.     

Impact of Resident Overnight Duty Hour Changes on Obstetrical Outcomes: A Population-Based Cohort Study

Objective

To determine whether obstetrical patient outcomes have changed following the introduction of restricted resident work hours.

Outcomes of subsequent pregnancies after conservative treatment for placenta accreta

Objective

To estimate the association between conservative treatment for placenta accreta and subsequent pregnancy outcomes.

Methods

In a retrospective study, data were analyzed on women who received conservative treatment for placenta accreta (removal of the placenta with uterine preservation) at a tertiary hospital in Jerusalem, Israel, between 1990 and 2000. Data were collected on subsequent pregnancies and neonatal outcomes until 2010, and compared with those from a matched control group of women who did not have placenta accreta.

Results

A total of 134 women were included in both groups. Placenta accreta occurred in 62 (22.8%) of 272 subsequent deliveries in the study group for which data were available and 5 (1.9%) of 266 in the control group (relative risk [RR] 12.13; 95% confidence interval [CI] 4.95–29.69; P < 0.001). Early postpartum hemorrhage occurred in 23 (8.6%) of 268 deliveries in the study group and 7 (2.6%) of 268 in the control group (RR 3.29; 95% CI 1.43–7.53; P < 0.001). The odds ratio for recurrent placenta accreta in subsequent deliveries in the study group was 15.41 (95% CI 6.09–39.03; P < 0.001).

Conclusion

Although subsequent pregnancies after conservative treatment for placenta accreta were mostly successful, the risk of recurrent placenta accreta and postpartum hemorrhage is high in future deliveries.