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

Vaginal birth after caesarean section versus elective repeat caesarean section: assessment of maternal downstream health outcomes.

OBJECTIVE: To compare the maternal implications of strategies of vaginal birth after caesarean section (VBAC) attempt versus elective repeat caesarean section in women with one previous lower segment caesarean section. DESIGN: Decision model. POPULATION: Women with one prior low transverse caesarean section who are eligible for trial of labour. METHODS: Two decision models were built: the first one applying to women planning only one more pregnancy, the second one applying to women planning two more pregnancies. Probability estimates for VBAC success rate and risks of uterine rupture, placenta praevia, placenta accreta and hysterectomy were extracted from the available literature. MAIN OUTCOME MEASURES: Hysterectomy for uterine rupture, placenta accreta or other indications. RESULTS: In the first model VBAC attempt led to a higher hysterectomy rate (267/100,000) compared with repeat caesarean section (187/100,000). However, in the second model a policy of elective repeat caesarean section led to higher cumulative hysterectomy rate: 1465/100,000 versus 907/100,000 for VBAC. The first model was robust to all but one variable in sensitivity analyses. The second model was robust to all variables in sensitivity analyses. CONCLUSIONS: These results indicate that long term reproductive consequences of multiple caesarean sections should be considered when making policy decisions regarding the risk-benefit ratio of VBAC

Legal Aspects of Obstetric Sonography.

PIP:The combination of rapid innovation and high risk obstetric sonography has resulted in increased potential for litigation: 80% of suits in sonography are obstetric-related. These suits come under the category of tort law, where damages are sought to compensate those whose interests have been harmed. To win a claim the plaintiff must prove that a legal duty has been breached, that damages have been incurred, and that the breach was the legal as well as the actual cause of the damage. Although it is not possible to claim that the radiologist caused the damage, damages to a living being, the fetus, are being awarded for several types of claims. Wrongful pregnancy claims are being awarded costs of the pregnancy and childbirth in cases of failed sterilization or abortion. Wrongful birth suits arise from negligent genetic counseling when the infant is born defective, and the anomalies are diagnosable but overlooked. Wrongful life suits, brought by the defective individual, are controversial for their large monetary awards, as well as the ethical question whether impaired life is better than no life at all. Only 4 states recognize these claims. Wrongful death suits are applicable where therapy under sonographic guidance causes death of the fetus. Agency law applies where an error is committed by a technologist in a radiologist\u27s employ. It is recommended that the radiologist follow American College of Radiology guidelines for fetal surveys; obtain follow-up or a 2nd opinion in case of an abnormality; keep written notes of normal fetal structures; keep abreast of local case law and legislation; rescan patients after the technologist\u27s exam; and document and report promptly all normal and abnormal findings

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

Mild pyelectasis: evaluating the relationship between gestational age and renal pelvic anterior-posterior diameter.

OBJECTIVE: To determine the relationship between gestational age and renal pelvic anterior-posterior diameter and the feasibility of developing gestational age-specific thresholds for the diagnosis of mild pyelectasis. METHODS: Cross-sectional study of 420 singleton fetuses between 16 and 39 weeks\u27 gestation. The mean renal AP diameter as a function of gestational age was determined using fractional polynomial regression models and centile plots were generated. Assessment of goodness of fit for each regression model was performed. RESULTS: There was a positive correlation between gestational age and renal pelvic AP diameter (Pearson\u27s Correlation Coefficient 0.65). Using the derived mean and standard deviations of renal AP diameter, gestational-age specific 95% reference levels were generated. The sensitivity, specificity, positive, and negative predictive values of using the gestational age-specific cutoffs for predicting persistent postnatal renal anomaly were 80%; 99%; 29%; and 99% respectively. CONCLUSION: There is a positive correlation between gestational age and renal pelvic AP diameters. Reliable gestational age-specific renal AP thresholds for diagnosis of pyelectasis are provided