Perinatal outcomes in patients with gestational diabetes mellitus by race/ethnicity

Objective.?To determine if racial/ethnic differences exist in perinatal outcomes in women with gestational diabetes mellitus (GDM).

Methods.?This is a retrospective cohort study of singleton pregnancies with GDM cared for by the Sweet Success: California Diabetes and Pregnancy Program (CDAPP) between 2001 and 2004 at inpatient obstetric and neonatal services in California. There were a total of 26,411 women with gestational diabetes who were subgrouped by four races/ethnicities: Caucasian, African-American, Latina, and Asian. The chi-squared test was used to compare the dichotomous outcomes and p?<?0.05 was used to indicate statistical significance. Multivariable logistic regression analyses were performed to control for potential confounders. Perinatal outcomes, including severity of GDM, cesarean delivery (CD), birthweight, preterm birth, intrauterine fetal demise (IUFD) and neonatal intensive care unit (NICU) admission were compared.

Results.?Compared to Caucasians, African-Americans had higher odds of primary CD [aOR?=?1.29, 95% CI (1.05–1.59)] while lower odds were seen in Latinas [aOR?=?0.84, 95% CI (0.75–0.94)] and Asians [aOR?=?0.86, 95% CI (0.77–0.96)]. Asians had lower odds [aOR?=?0.58 (95% CI 0.48–0.70)] of birthweight >4000?g. African-Americans had highest odds of IUFD [aOR?=?5.93 95% CI (1.73–20.29)]. There were no differences in NICU admission.

Conclusion.?Perinatal outcomes in women diagnosed with GDM differ by racial/ethnic group. Such variation can be used to individually counsel women with GDM.     

Pregnancy outcome in women aged 40 years or more

Objective: The study aimed to analyze the pregnancy outcome of women aged 40 years or more. Methods: A matched retrospective cohort study comparing women aged 40 years or more with a control group aged 20 to 30 years is described. Multivariate logistic regression models were fitted for the prediction of preterm birth and cesarean delivery. Results: Pregnancy-induced hypertension, preeclampsia and placenta previa were similar in both groups, but a higher rate of gestational diabetes was found in elderly patients (odds ratio [OR] 3.820, 95% confidence interval [CI] = 1.400–10.400; p < 0.0001). Preterm delivery was significantly more frequent in elderly women (OR 1.847, 95% CI = 1.123–3.037; p = 0.020). Gestational diabetes and pregnancy-induced hypertension were strongly associated with preterm delivery and advanced maternal age was not an independent risk factor for preterm delivery. The cesarean delivery rate was significantly higher in the study group (OR 3.234, 95% CI = 2.266–4.617; p < 0.0001). The variables most influencing the cesarean delivery rate were maternal age, analgesia, parity, premature rupture of the membranes and gestational hypertension. No significant differences were detected in neonatal birth weight and Apgar score. Conclusions: Patients aged 40 years or more have been demonstrated to carry a favorable pregnancy and neonatal outcome, similar to younger patients. The risk of cesarean delivery was higher in patients with advanced maternal age, in nulliparous and in women with a previous cesarean section. The risk of preterm delivery was not related to age but it was strongly associated with gestational diabetes and pregnancy-induced hypertension.     

Sleep disturbances during pregnancy are associated with cesarean delivery and preterm birth

Objective: The purpose of this study was to examine the associations of sleep disturbances during pregnancy with cesarean delivery and preterm birth.

Methods: In this prospective study, 688 healthy women with singleton pregnancy were selected from three hospitals in Chengdu, China 2013–2014. Self-report questionnaires, including the sleep quantity and quality as well as exercise habits in a recent month were administered at 12–16, 24–28, and 32–36 weeks’ gestation. Data on type of delivery, gestational age, and the neonates’ weight were recorded after delivery. After controlling the potential confounders, a serial of multi-factor logistic regression models were performed to evaluate whether sleep quality and quantity were associated with cesarean delivery and preterm birth.

Results: There were 382 (55.5%) women who had cesarean deliveries and 32 (4.7%) who delivered preterm. Women with poor sleep quality during the first (OR: 1.87, 95% CI [1.02–3.43]), second (5.19 [2.25–11.97]), and third trimester (1.82 [1.18–2.80]) were at high risk of cesarean delivery. Women with poor sleep quality during the second (5.35 [2.10–13.63]) and third trimester (3.01 [1.26–7.19]) as well as short sleep time (<7?h) during the third trimester (4.67 [1.24–17.50]) were at high risk of preterm birth.

Conclusions: Sleep disturbances are associated with an increased risk of cesarean delivery and preterm birth throughout pregnancy. Obstetric care providers should advise women with childbearing age to practice healthy sleep hygiene measures.     

Symphysiolysis as an independent risk factor for cesarean delivery

Objectives.?To investigate whether symphysiolysis during pregnancy is a risk factor for cesarean delivery (CD).

Methods. A retrospective population-based study comparing all singleton pregnancies of women with and without symphysiolysis was conducted. Deliveries occurred between the years 2000 and 2007. Multiple logistic regression models were used to control for confounders.

Results.?Out of 80,898 patients, 0.2% (n?=?154) were diagnosed with symphysiolysis during pregnancy. Patients with symphysiolysis were significantly older as compared to the comparison group. These patients had higher rates of mild pre-eclampsia, gestational diabetes mellitus (GDM) and labor induction as compared to patients without symphysiolysis. Higher rates of CD were noted in pregnancies complicated by symphysiolysis [22.1% vs. 15.9%; Odds ratio (OR)?=?1.5, 95% confidence interval (CI) 1.02–2.2; P?=?0.036]. Using multiple logistic regression model, with symphysiolysis as the outcome variable, controlling for labor induction, mild pre-eclampsia and GDM, symphysiolysis was noted as an independent risk factor for CD (weighted OR?=?1.7, 95% CI 1.1–2.5; P?=?0.009). Perinatal outcomes such as low Apgar scores (<7) at 1 and 5?min and perinatal mortality were comparable between the groups.

Conclusions.?Symphysiolysis is an independent risk factor for CD.     

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.     

Risk factors associated with respiratory disorders in late preterm infants

Objective: Late preterm infants are still high risk for respiratory problems. The aim of this study was to identify risk factors associated with respiratory problems in Japanese late preterm infants.

Methods: In this retrospective multicenter study, we included singleton late preterm deliveries at 34+^0/7–36+^6/7 weeks of gestation. We excluded cases with congenital anomalies. We defined neonatal respiratory disorders (NRD) as the combination of the need for mechanical ventilation or the use of nasal continuous positive airway pressure. We examined the perinatal risk factors associated with NRD.

Results: We included 683 late preterm infants. We found that 13.7%, 6.8% and 2.6% of the infants with NRD were born at 34, 35 and 36 weeks of gestation, respectively. In a multivariate logistic regression analysis adjusting for confounders, the gestational age (GA) at birth (adjusted odds ratio 0.40 per week [95% confidence interval, 0.25–0.61]), cesarean birth (4.18 [2.11–8.84]), and a low Apgar score (33.3 [9.93–121.3]) were independent risk factors associated with NRD.

Conclusions: An earlier GA, cesarean delivery, and a low Apgar score are independent risk factors associated with NRD in singleton late preterm infants. Patients with late preterm deliveries exhibiting these risk factors should be managed in the intensive delivery setting.     

Does dystocia during labor pose a risk factor for another non-progressive labor during the subsequent delivery?

Objective: To establish whether failure to progress during labor poses a risk factor for another non-progressive labor (NPL) during the subsequent delivery.

Methods: A retrospective cohort study including singleton pregnancies that failed to progress during the previous labor and resulted in a cesarean section (CS) was conducted. Parturients were classified into three groups for both previous and subsequent labors: CS due to NPL stage I, stage II and an elective CS as a comparison group.

Results: Of 202?462 deliveries, 10?654 women met the inclusion criteria: 3068 women were operated due to NPL stage I and 1218 due to NPL stage II. The comparison group included 6368 women. Using a multivariable logistic regression models, NPL stage I during the previous delivery was found as an independent risk factor for another NPL stage I in the subsequent labor (adjusted odds ratio [OR]?=?2.9; 95% confidence interval [CI]?=?2.4–3.7; p?p?=?0.033; adjusted OR?=?5.3; 95% CI?=?3.7–7.5; p?Conclusion: A previous CS due to a NPL is an independent risk factor for another NPL in the subsequent pregnancy and for recurrent cesarean delivery.     

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

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

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

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

Please exit safely: maternal and twin pair neonatal outcomes according to delivery mode when twin A is vertex*

Objective: To investigate maternal and infant outcomes associated with delivery mode for twins with a cephalic presenting twin.

Methods: Linked birth certificate and ICD hospital discharge data were analyzed retrospectively for 5573 mothers and their respective twin pairs born live at 34–42 weeks’ gestation, with twin A vertex, in Washington State from 1997–2007. Relative risks (RR) and 95% confidence intervals of adverse maternal and twin pair outcomes were calculated for vaginal delivery or cesarean during labor in comparison to cesarean without labor.

Results: Vaginal delivery or cesarean during labor was associated with significantly elevated rates of maternal hemorrhage (RR?=?2.8 [2.2,3.7]), infection (RR?=?2.2 [1.5,3.3]), twin pair birth injury (RR?=?2.6 [1.2,5.4]) and low 5-min Apgar scores (RR?=?1.4 [1.1,1.8]) and with significantly lower rates of ventilation among preterm twin pairs only (RR?=?0.8 [0.7,0.9]). The lowest rate of combined poor short-term outcomes occurred in mothers and twin pairs delivered by cesarean without labor (23%) and the highest rates occurred in those with operative vaginal or cesarean during labor (39% and 34%, respectively). Among women in labor, 35% of nulliparas achieved spontaneous vaginal delivery of both twins compared to 63% of non-nulliparas.

Conclusion: For nulliparous women who carry twins to term, planned cesarean may improve outcomes.     

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.     

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.     

Term induction of labor and risk of cesarean delivery by parity

Abstract

Objective: To evaluate the risk of cesarean delivery among both nulliparous and multiparous women undergoing a term induction of labor compared to women that present in spontaneous labor at term.

Methods: We performed a retrospective cohort study of term (≥37 weeks) singleton pregnancies between 2005 and 2010 comparing women that had an induction to those that presented in spontaneous labor. Multiparity was defined as a prior delivery after 20 weeks’ gestation. Chi-square was used to compare categorical variables. Multivariable logistic regression was used to control for confounders. Analyses were stratified by parity.

Results: 863 women were included in the analysis. There were 605 inductions (cesarean rate 23%) and 257 spontaneous labor (cesarean rate 7%), OR 3.4, 95% CI [2.1–5.4]. Stratified by parity, nulliparas undergoing induction had an increased cesarean rate compared to spontaneous labor (27% versus 11%, OR 3.13, 95% CI [1.76–5.57]) as did multiparas (13% versus 3%, OR 4.04, 95% CI [1.36–11.94]). This increased risk for cesarean after induction remained in both nulliparous and multiparous women even after controlling for confounders (aOR 2.90, 95% CI [1.60–5.25] and aOR 3.47, 95% CI [1.12–10.67], respectively). Neither starting cervical exam nor indication for induction altered this increased risk.

Conclusions: The increased risk of cesarean in women undergoing an induction is present regardless of parity and indication for induction. This should be taken into account when counseling women regarding risks of induction, regardless of parity. Future studies should focus on other clinical characteristics of induction that may mitigate this risk.     

Non-medical factors affecting antenatal preferences for delivery route and actual delivery mode of women in southwestern Iran

Objective: Assessment of the contribution of non-medical factors to mode of delivery and birth preference in Iranian pregnant women in southwestern Iran.

Study design: This cohort study used data from a structured questionnaire completed in early pregnancy and information about the subsequent delivery obtained through personal contact. Women were recruited by random sampling from antenatal clinics when scheduling visits over the course of 5 weeks from December 2012 to February 2013 and were followed-up 1 month after birth. Of the 2199 women recruited, 99.63% were eligible for the study.

Results: Of the 748 women who expressed a desire to deliver their babies by cesarean section (CS) in early pregnancy, 87% had an elective cesarean section. The logistic regression analyses showed that normative beliefs (odds ratio [OR] 1.792, 95% confidence interval (1) 1.073–2.993), control beliefs (OR: 0.272, 95% CI: 0.162–0.459), and evaluation of outcomes (OR: 0.431, 95% CI: 0.268–0.692) favored the preference for cesarean section. The desire for delivery by elective cesarean section was associated with normative beliefs (OR: 1.138; 95% CI: 1.001–1.294), control beliefs (OR: 0.804; 95% CI: 0.698–0.927), and expectations about maternity care (OR: 0.772; 95% CI: 0.683–0.873), medical influences (OR: 1.150; 95% CI: 1.023–1.291), evaluation of outcome (OR: 0.789; 95% CI: 0.696–0.894), age, preference for cesarean section (OR: 5.445; 95% CI: 3.928–7.546), spouse educational level, and number of live births.

Conclusions: A woman’s preference for delivery by cesarean section influenced their subsequent mode of delivery. Asking women in early pregnancy about their preferred mode of delivery provides the opportunity to extend their supports which might reduce the rate of elective cesarean section. This decision is affected by age, spouse educational level, number of live births, and preconceived maternal attitudes about delivery.     

Obstetric and neonatal outcome in patients with anxiety disorders

Abstract

Objective: To investigate whether a diagnosis of anxiety disorder is a risk factor for adverse obstetric and neonatal outcome.

Methods: A retrospective population-based study was conducted comparing obstetric and neonatal complications in patients with and without a diagnosis of anxiety. Multivariable analysis was performed to control for confounders.

Results: During the study period 256?312 singleton deliveries have occurred, out of which 224 (0.09%) were in patients with a diagnosis of an anxiety disorder. Patients with anxiety disorders were older (32.17?±?5.1 versus 28.56?±?5.9), were more likely to be smokers (7.1% versus 1.1%) and had a higher rate of preterm deliveries (PTD; 15.2% versus 7.9%), as compared with the comparison group. Using a multiple logistic regression model, anxiety disorders were independently associated with advanced maternal age (OR 1.087; 95% CI 1.06–1.11; p?=?0.001), smoking (OR 4.51; 95% CI 2.6–7.29; p?=?0.001) and preterm labor (OR 1.92; 95% CI 1.32-–2.8; p?=?0.001). In addition, having a diagnosis of an anxiety disorder was found to be an independent risk factor for cesarean section (adjusted OR 2.5; 95% CI 1.82–3.46; p?<?0.001), using another multivariable model. No association was noted between anxiety disorders and adverse neonatal outcomes including small for gestational age, low Apgar scores and perinatal mortality.

Conclusion: Anxiety disorders are independent risk factors for spontaneous preterm delivery and cesarean section, but in our population it is not associated with adverse perinatal outcome.     

Does the presence of polycystic ovary syndrome increase the risk of obstetrical complications in women with gestational diabetes?

Objective.?To determine whether women with both polycystic ovary syndrome (PCOS) and gestational diabetes mellitus (GDM) have an increased risk of obstetric complications compared with women with GDM alone.

Methods.?A retrospective cohort study of maternal/fetal outcomes in women with GDM and PCOS was compared with women with GDM alone. Outcomes were compared using Fisher's exact test for categorical variables and t-test for continuous variables. Logistic regression models allowed for the calculation of odds ratios and 95% confidence intervals (CIs) for each outcome, adjusted for confounding.

Results.?One hundred seventy one women were included in the study. Significantly more women with both GDM and PCOS had pregnancy-induced hypertension/preeclampsia (15.9% vs. 3.9%, p?=?0.019, OR?=?4.62, 95% CI?=?1.38–15.41). Multiple logistic regression revealed that this increase persisted after controlling for body mass index (p?=?0.028, OR?=?4.43, 95% CI?=?1.17–16.72) and parity (p?=?0.050, OR?=?3.45, 95% CI?=?1.00–11.92). Women with GDM and PCOS tended to have more preterm deliveries (25.0% vs. 11.8%, p?=?0.063). More infants of women with GDM and PCOS required phototherapy treatment for hyperbilirubinemia (25.0% vs. 7.9%, p?=?0.0066, OR?=?3.90, 95% CI?=?1.52–9.98). Logistic regression revealed that this association persisted after controlling for preterm delivery (OR?=?3.18, 95% CI?=?1.14–8.82, p?=?0.026).

Conclusions.?Mothers with both disorders should be monitored more carefully and counseled regarding their increased risk of both maternal and fetal complications.     

The mutual effect of pregestational body mass index,maternal hyperglycemia and gestational weight gain on adverse pregnancy outcomes

Objective: To investigate the mutual effect of obesity, gestational diabetes (GDM) and gestational weight gain (GWG) on adverse pregnancy outcomes.

Methods: Charts of patients who delivered in our hospital between June 2001 and June 2006 singleton, live births >24 weeks gestation were reviewed. Univariate and multivariate logistic regression were used to assess pregnancy outcomes defined as large for gestational age (LGA), primary cesarean section (PCS) and a composite outcome of LGA and/or PCS.

Results: A total of 8595 women were included. Frequency of composite outcome increased with increasing body mass index (BMI), increasing hyperglycemia and above-recommended GWG. In the multivariate logistic regression analysis compared to women with normal BMI, odds ratio (OR) for composite outcome was 1.23 (95% confidence interval [CI] 1.06–1.44) in overweight women, OR?=?1.86 (1.51–2.31) in obese women and in severe obesity OR?=?2.97 (2.15–4.11).

Compared to normoglycemic women, odds for composite outcome in women with abnormal glucose challenge test OR?=?1.46 (1.20–1.79), impaired glucose tolerance OR?=?1.65 (1.14–2.4) and GDM OR?=?1.56 (1.16–2.10). Women with GWG above recommended had OR?=?1.58, (1.37–1.81) for composite outcome.

Conclusions: Higher pregestational BMI, maternal hyperglycemia and above-recommended GWG independently contribute to adverse pregnancy outcomes. Furthermore, there is mutual effect between these three factors and adverse outcomes. Appropriate pregestational weight and adequate GWG might reduce risk of adverse pregnancy outcomes.     

Effect of exercise during pregnancy to prevent gestational diabetes mellitus: a systematic review and meta-analysis

Introduction: Exercise showed some potential in preventing gestational diabetes mellitus. However, the results remained controversial. We conducted a systematic review and meta-analysis to evaluate the impact of exercise during pregnancy on gestational diabetes mellitus.

Methods: PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the influence of exercise during pregnancy on gestational diabetes mellitus were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcome was the incidence of gestational diabetes mellitus. Meta-analysis was performed using random-effect model.

Results: Six RCTs involving 2164 patients were included in the meta-analysis. Compared with control intervention, exercise intervention was associated with significantly decreased incidence of gestational diabetes mellitus (Std. mean difference?=?0.59; 95%CI?=?0.39–.88; p?=?.01), but had no effect on gestational age at birth (Std. mean difference?=??0.03; 95%CI?=??0.12 to 0.07; p?=?.60), the number of preterm birth (OR?=?0.85; 95%CI?=?0.43–1.66; p?=?.63), glucose 2-h post-OGTT (Std. mean difference?=??1.02; 95%CI?=??2.75 to 0.71; p?=?.25), birth weight (Std. mean difference?=??0.13; 95%CI?=??0.26 to 0.01; p?=?.06), and Apgar score less than 7 (OR?=?.78; 95%CI?=?0.21–2.91; p?=?.71).

Conclusions: Compared to control intervention, exercise intervention could significantly decrease the risk of gestational diabetes mellitus, but showed no impact on gestational age at birth, preterm birth, glucose 2-h post-OGTT, birth weight, and Apgar score less than 7.     

Ethnic disparity in the success of vaginal birth after cesarean delivery

Objective.?To estimate whether maternal race/ethnicity is independently associated with successful vaginal birth after cesarean delivery (VBAC).

Study design.?A retrospective cohort study from January 1, 1997 to July 30, 2002 of women with singleton pregnancies and a previous cesarean delivery. The odds ratio (OR) for successful VBAC as a function of ethnicity was corrected for age >35 years, parity, weight gain, diabetes mellitus, hospital site, prenatal care provider, gestational age, induction, labor augmentation, epidural analgesia, and birth weight >4000 g.

Results.?Among 54 146 births, 8030 (14.8%) occurred in women with previous cesarean deliveries. The trials of labor rates were similar among Caucasian (46.6%), Hispanic (45.4%), and African American (46.0%) women. However, there was a significant difference among ethnic groups for VBAC success rates (79.3% vs. 79.3% vs. 70.0%, respectively). When compared to Caucasian women, the adjusted OR for VBAC success was 0.37 (95% confidence interval (CI) 0.27–0.50) for African American women and 0.63 (95% CI 0.51–0.79) for Hispanic women.

Conclusion.?African American and Hispanic women are significantly less likely than Caucasian women to achieve successful VBAC.     

Pregnancy outcome of patients following deep venous thrombosis

Objective. To investigate pregnancy outcome of patients with a history of deep vein thrombosis (DVT).

Methods. A population-based study comparing all pregnancies of patients with and without a history of DVT was conducted. Deliveries occurred during the years 1988–2007 at a tertiary Medical Center. Stratified analyses were performed using multivariable logistic regression models and the Mantel-Haenszel technique.

Results. During the study there were 212,086 deliveries, of which 122 (0.06%) occurred in patients with a history of DVT. Using a multivariate analysis, with backward elimination, the following conditions were significantly associated with DVT: advanced maternal age (OR, 1.1; 95% CI, 1.02–1.1; p = 0.004), chronic hypertension (OR, 2.9; 95% CI, 1.4–6.0; p = 0.005) and previous caesarean delivery (OR, 2.8; 95% CI, 1.9–4.1; p < 0.001). Patients with a history of DVT were more likely to have caesarean deliveries (OR, 2.6; 95% CI, 1.8–3.8; p < 0.001) than non-DVT patients. After controlling for possible confounders, such as maternal age, hypertensive disorders, pregestational diabetes and multiple gestations, by using another multivariate analysis with preterm delivery (<37 weeks' gestation) as the outcome variable, DVT was found to be an independent risk factor for preterm birth (OR, 1.8; 95% CI, 1.1–2.9; p = 0.033). This association remained significant after controlling for labor induction, using the Mantel-Haenszel technique (OR, 1.8; 95% CI, 1.1–3.0; p = 0.011). No significant differences were noted between the groups regarding perinatal outcomes such as low Apgar scores, congenital malformations or perinatal mortality.

Conclusions. A history of DVT is an independent risk factor for spontaneous preterm delivery. Nevertheless, in our population it is not associated with adverse perinatal outcome.     

Vaginismus as an independent risk factor for cesarean delivery

Objective. The present study was aimed to investigate pregnancy outcome of patients with vaginismus, and specifically the relationship between vaginismus and cesarean delivery.

Methods. A population based study comparing all pregnancies in patients with and without vaginismus was conducted. Patients lacking prenatal care were excluded from the analysis. Deliveries occurred during the years 1988–2007. A multivariate logistic regression model, with backward elimination, was constructed to find independent risk factors associated with vaginismus.

Results. During the study period there were 192,954 deliveries, of which 118 occurred in patients with vaginismus. Patients with vaginismus tended to be younger (26.04±4.89 vs. 28.61±5.83; p < 0.001) and delivered smaller children (3024.2±517 g vs. 3160.9±576 g; p = 0.01) when compared with patients without vaginismus. Patients with vaginismus had higher rates of infertility treatments (5.9%vs. 2.7%, odds ratio [OR] 2.3; 95% confidence interval [CI] 1.1–4.9; p = 0.04) and labor induction (37.3%vs. 27.4%, OR 1.6; 95% CI 1.1–2.3; p = 0.02), vacuum extraction (9.3%vs. 2.8%, OR 3.6, 95% CI 1.9–6.7; p < 0.001), and cesarean delivery (39.0%vs. 14.5%, OR 3.8; 95% CI 2.6–5.5; p < 0.001) when compared with the comparison group. Even after controlling for possible confounders associated with cesarean delivery such as previous cesarean delivery, pathological presentations, and fetal distress, vaginismus remained as an independent risk factor for cesarean delivery (OR 7.1; 95% CI 4.5–11.1; p < 0.001).

Conclusion. Vaginismus is an independent risk factor for cesarean delivery.