Is fetal gender associated with adverse perinatal outcome in intrauterine growth restriction (IUGR)?

OBJECTIVE: The purpose of this study was to determine if there is a difference in perinatal outcome by gender among growth-restricted fetuses. STUDY DESIGN: This was a retrospective cohort study of intrauterine growth restriction (IUGR) singleton pregnancies over a 5-year period. Clinical outcomes compared by gender included preterm delivery, perinatal mortality (PNM), respiratory distress syndrome (RDS), grade 3 or 4 intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and periventricular leukomalacia (PVL). Statistical analysis included bivariate and multivariable techniques. RESULTS: Seven hundred and twenty-seven singleton pregnancies with IUGR were identified. Three hundred and forty-six (47.6%) were males. Birth weight was similar between the groups. After adjusting for maternal demographics, medical history, gestational age, mode of delivery, and antenatal corticosteroids, adverse perinatal outcomes were similar between the groups. Severity of outcomes was also similar between males and females (P = .66). CONCLUSION: Male fetuses with IUGR have similar outcomes when compared with female IUGR fetuses. Gender does not play a role in perinatal outcome in the setting of fetal growth restriction

A population-based study of race-specific risk for placental abruption

<p>Abstract</p> <p>Background</p> <p>Efforts to elucidate risk factors for placental abruption are imperative due to the severity of complications it produces for both mother and fetus, and its contribution to preterm birth. Ethnicity-based differences in risk of placental abruption and preterm birth have been reported. We tested the hypotheses that race, after adjusting for other factors, is associated with the risk of placental abruption at specific gestational ages, and that there is a greater contribution of placental abruption to the increased risk of preterm birth in Black mothers, compared to White mothers.</p> <p>Methods</p> <p>We conducted a population-based cohort study using the Missouri Department of Health's maternally-linked database of all births in Missouri (1989–1997) to assess racial effects on placental abruption and the contribution of placental abruption to preterm birth, at different gestational age categories (n = 664,303).</p> <p>Results</p> <p>Among 108,806 births to Black mothers and 555,497 births to White mothers, 1.02% (95% CI 0.96–1.08) of Black births were complicated by placental abruption, compared to 0.71% (95% CI 0.69–0.73) of White births (aOR 1.32, 95% CI 1.22–1.43). The magnitude of risk of placental abruption for Black mothers, compared to White mothers, increased with younger gestational age categories. The risk of placental abruption resulting in term and extreme preterm births (< 28 weeks) was higher for Black mothers (aOR 1.15, 95% CI 1.02–1.29 and aOR 1.98, 95% CI 1.58–2.48, respectively). Compared to White women delivering in the same gestational age category, there were a significantly higher proportion of placental abruption in Black mothers who delivered at term, and a significantly lower proportion of placental abruption in Black mothers who delivered in all preterm categories (p < 0.05).</p> <p>Conclusion</p> <p>Black women have an increased risk of placental abruption compared to White women, even when controlling for known coexisting risk factors. This risk increase is greatest at the earliest preterm gestational ages when outcomes are the poorest. The relative contribution of placental abruption to term births was greater in Black women, whereas the relative contribution of placental abruption to preterm birth was greater in White women.</p

Should all pregnant diabetic women undergo a fetal echocardiography? A cost-effectiveness analysis comparing four screening strategies.

OBJECTIVE: To determine if a policy of universal fetal echocardiography for all pregnant diabetic women is cost-effective as a screening tool for congenital heart defects. STUDY DESIGN: Using a decision-analysis model, we compared the cost-effectiveness of four screening strategies: (1) none--no ultrasound is performed; (2) selective fetal echocardiography after abnormal detailed anatomic survey; (3) fetal echocardiography for only high hemoglobin A1C, and (4) universal fetal echocardiography for all diabetics. The sensitivity and specificity for each strategy were derived by literature search. The analysis was from a societal perspective using a willingness-to-pay threshold (50,000 dollars) and a theoretic cohort of 40,000 pregnant diabetics. Costs included costs of tests and the costs of complications and of raising a child with a cardiac defect. Outcomes were reported as cost per quality-adjusted life years (QALY) gained for each congenital heart defect prevented by each strategy and the number of congenital heart defects detected. One-way, multiway and probabilistic sensitivity analyses were performed. RESULTS: Compared with the other strategies, selective fetal echocardiography after abnormal detailed anatomic survey costs less per QALY gained for cardiac defect screening. Although universal fetal echocardiography was associated with a higher detection rate for cardiac defects, it was more costly. The sensitivity analyses revealed a robust model over a wide range of values. CONCLUSION: Under the baseline assumptions, selective fetal echocardiography after an abnormal detailed anatomic survey is more cost-effective compared with universal fetal echocardiography as a screening strategy for cardiac defects in pregnant diabetics

What antepartum fetal test should guide the timing of delivery of the preterm growth-restricted fetus? A decision-analysis.

OBJECTIVE: The purpose of this study was to use a decision-analytic approach to explore the best strategy for the timing of the delivery of preterm intrauterine growth-restricted fetuses. STUDY DESIGN: We constructed a decision-analysis model that compared 4 antenatal fetal testing strategies The fetal/neonatal states that were compared included live in utero pregnancy; fetal death; neonatal death; disabled neonate, and healthy neonate. Probability estimates for these states and sensitivity and specificity for Doppler velocimetry and biophysical profile were derived from literature review. Sensitivity analyses were performed on the baseline assumptions. RESULTS: Under the baseline assumptions, biophysical profile was the best test to guide decisions on delivery. Sensitivity analyses revealed the model to be sensitive only to the specificity of a biophysical profile \u3c82%. CONCLUSION: Compared with the other options, biophysical profile was the best strategy to guide physicians on the timing of the delivery of the preterm growth-restricted fetus

Thromboprophylaxis after cesarean delivery: a decision analysis.

OBJECTIVE: To compare 4 strategies for managing patients after cesarean delivery. METHODS: Using decision analysis, we compared universal subcutaneous (SC) heparin prophylaxis, heparin prophylaxis only for patients with a genetic thrombophilia, use of pneumatic compression stockings (PCS), and no thromboprophylaxis. Outcomes included heparin-induced thrombocytopenia (HIT), HIT-related thrombosis, major maternal bleeding, and venous thromboembolism (VTE). RESULTS: Use of PCS was the strategy with the lowest number of adverse events. With heparin prophylaxis, 13 cases of HIT-induced thrombosis and hemorrhage would occur per VTE prevented. When heparin prophylaxis is administered only to thrombophilia-positive women, 1.2 cases of HIT-induced thrombosis and bleeding would occur per VTE prevented. In sensitivity analyses, the model was stable across virtually all variable ranges. CONCLUSION: Use of PCS after cesarean delivery is the strategy with the lowest number of adverse events. Universal prophylaxis with SC heparin is associated with an excess risk of HIT-induced thrombosis and bleeding per VTE prevented compared with PCS use. Until future studies are completed, postcesarean thromboprophylaxis with PCS should be used if the clinician elects to provide prophylaxis

The effect of prematurity on vaginal birth after cesarean delivery: success and maternal morbidity.

OBJECTIVE: We sought to compare vaginal birth after cesarean (VBAC) success and uterine rupture rates between preterm and term gestations in women with a history of one prior cesarean delivery. Our hypothesis was that preterm women undergoing VBAC were more likely to be successful and have a lower rate of complications than term women undergoing VBAC. METHODS: We reviewed medical records of women with a history of a cesarean delivery who either attempted a VBAC or underwent a repeat cesarean delivery from 1995 through 2000 in 17 community and university hospitals. We collected information on demographics, medical and obstetric history, complications, and outcome of the index pregnancy. The primary analysis was limited to women with singleton gestations and one prior cesarean delivery. Statistical analysis consisted of bivariate and multivariable techniques. RESULTS: Among the 20,156 patients with one prior cesarean delivery, 12,463 (61%) attempted a VBAC. Mean gestational ages for the term and preterm women were 39.2 weeks and 33.9 weeks of gestation, respectively. The VBAC success rates for the term and preterm groups were 74% and 82%, respectively (P \u3c .001). Multivariable analysis showed that the VBAC success was higher (adjusted odds ratio 1.54, 95% confidence interval 1.27-1.86) in preterm gestations. A decreased risk of rupture among preterm gestations was suggested in these results (adjusted odds ratio 0.28, 95% confidence interval 0.07-1.17; P = .08). CONCLUSION: Preterm patients undergoing a VBAC have higher success rates when compared with term patients undergoing a VBAC. Preterm patients undergoing VBAC may have lower uterine rupture rates

Safety and efficacy of vaginal birth after cesarean attempts at or beyond 40 weeks of gestation.

OBJECTIVE: To compare rates of vaginal birth after cesarean (VBAC) failure and major complications in women attempting VBAC before and after the estimated date of delivery (EDD) METHODS: This was a 5-year retrospective cohort study in 17 university and community hospitals of women with at least 1 prior cesarean delivery. Women who attempted VBAC before the EDD were compared with those at or beyond 40 weeks of gestation. Logistic regression analyses were performed to assess the relationship between delivery beyond the EDD and VBAC failure or complication rate. RESULTS: A total of 11,587 women in the cohort attempted VBAC. Women past 40 weeks of gestation were more likely to have a failed VBAC. After controlling for confounders, the increased risk of a failed VBAC beyond 40 weeks remained significant (31.3% compared with 22.2%, odds ratio 1.36, 95% confidence interval 1.24-1.50). The risk of uterine rupture (1.1% compared with 1.0%) or overall morbidity (2.7% compared with 2.1%) was not significantly increased in the women attempting VBAC beyond the EDD. When the cohort was defined as 41 weeks or more of gestation, the risk of a failed VBAC was again significantly increased (35.4% compared with 24.3%, odds ratio 1.35, 95% confidence interval 1.20-1.53), but the risk of uterine rupture or overall morbidity was not increased. CONCLUSION: Women beyond 40 weeks of gestation can safely attempt VBAC, although the risk of VBAC failure is increased