To estimate the risk of short-term complications in neonates born between 34 and 36 weeks by week of gestation.
This is a retrospective cohort study.
Deliveries in 2005 in the United States of America.
Singleton live births between 34 and 40 weeks gestational age.
Gestational age was subgrouped into 34, 35, 36 and 37–40 completed weeks. Statistical comparisons were performed using chi-square test and multivariable logistic regression models, with 37–40 weeks gestational age designated as referent.
Main Outcome Measures
Perinatal morbidities, including 5-minute Apgar scores, hyaline membrane disease, neonatal sepsis/antibiotics use, and admission to the intensive care unit.
There were 175,112 neonates born between 34 and 36 weeks in 2005. Compared to neonates born between 37 and 40 weeks, neonates born at 34 weeks had higher odds of 5-minute Apgar<7 (adjusted odds ratio [aOR]=5.51, 95% CI [5.16–5.88]), hyaline membranes disease (aOR=10.2 [9.44–10.9]), mechanical ventilation use >6 hours (aOR=9.78 [8.99–10.6]) and antibiotics use (aOR=9.00 [8.43–9.60]). Neonates born at 35 weeks were similarly at risk of morbidity, with higher odds of 5-minute Apgar <7 (aOR 3.42 [3.23–3.63], surfactant use (aOR 3.74 [3.21–4.22], ventilation use >6 hours (aOR 5.53 [5.11–5.99] and NICU admission (aOR 11.3 [11.0–11.7). Further, neonates born at 36 weeks remain at higher risk of morbidity compared to deliveries at 37–40 weeks.
While the risk of undesirable neonatal outcomes decreases with increasing gestational age, the risk of neonatal complications in late preterm births remains higher compared to infants delivered at 37–40 weeks gestation.
late preterm births; perinatal outcomes
To examine the association between active phase arrest and perinatal outcomes.
This was a retrospective cohort study of women with term, singleton, cephalic gestations diagnosed with active phase arrest of labor, defined as no cervical change for two hours despite adequate uterine contractions. Women with active phase arrest who underwent a cesarean delivery were compared to those who delivered vaginally and women who delivered vaginally with active phase arrest were compared to those without active phase arrest. The association between active phase arrest, mode of delivery, and perinatal outcomes was evaluated using univariable and multivariable logistic regression models.
We identified 1,014 women with active phase arrest: 33% (335) went on to deliver vaginally and the rest were delivered by cesarean. Cesarean delivery was associated with an increased risk of chorioamnionitis (aOR 3.37, 95% CI [2.21–5.15]), endomyometritis (aOR 48.41, [6.61–354]), postpartum hemorrhage (aOR 5.18, [3.42–7.85]), and severe postpartum hemorrhage (aOR 14.97, [1.77–126]). There were no differences in adverse neonatal outcomes. Among women who delivered vaginally, women with active phase arrest had significantly increased odds of chorioamnionitis (aOR 2.70, [1.22–2.36]]), and shoulder dystocia (aOR 2.37, [1.33–4.25]). However, there were no differences in the serious sequelae associated with these outcomes, including neonatal sepsis and Erb’s palsy.
Efforts to achieve vaginal delivery in the setting of active phase arrest may reduce the maternal risks associated with cesarean delivery without additional risk to the neonate
To examine perinatal outcomes in women with gestational diabetes mellitus treated with glyburide compared to insulin injections.
This is a retrospective cohort study of women diagnosed with gestational diabetes mellitus (GDM) who required pharmaceutical therapy and were enrolled in the Sweet Success California Diabetes and Pregnancy Program between 2001 and 2004, a California state-wide program. Women managed with glyburide were compared to women treated with insulin injections. Perinatal outcomes were compared using chi-square test and multivariable logistic regression models; statistical significance was indicated by p < 0.05 and 95% confidence intervals (CI).
Among the 10,682 women with GDM who required medical therapy and met study criteria, 2073 (19.4%) received glyburide and 8609 (80.6%) received subcutaneous insulin injections. Compared to insulin therapy and controlling for confounders, oral hypoglycemic treatment was associated with increased risk of birthweight >4000 g (aOR = 1.29; 95% CI [1.03–1.64]), and admission to the intensive care nursery (aOR = 1.46 [1.07–2.00]).
Neonates born to women with gestational diabetes managed on glyburide, and were more likely to be macrosomic and to be admitted to the intensive care unit compared to those treated with insulin injections. These findings should be examined in a large, prospective trial.
Gestational diabetes mellitus; treatment; perinatal outcomes
This study investigated the cost-effectiveness of treating mild gestational diabetes mellitus (GDM).
A decision analytic model was built to compare treating vs not treating mild GDM. The primary outcome was the incremental cost per quality-adjusted life year (QALY). All probabilities, costs, and benefits were derived from the literature. Base case, sensitivity analyses, and a Monte Carlo simulation were performed.
Treating mild GDM was more expensive, more effective, and cost-effective at $20,412 per QALY. Treatment remained cost-effective when the incremental cost to treat GDM was less than $3555 or if treatment met at least 49% of its reported efficacy at the baseline cost to treat of $1786.
Treating mild GDM is cost-effective in terms of improving maternal and neonatal outcomes including decreased rates of preeclampsia, cesarean sections, macrosomia, shoulder dystocia, permanent and transient brachial plexus injury, neonatal hypoglycemia, neonatal hyperbilirubinemia, and neonatal intensive care unit admissions.
cost-effectiveness; decision analysis; gestational; diabetes mellitus
VBAC; Pregnancy; Pregnancy complications; Cesarean section; Evidence review
To examine the effect of first trimester obstetric ultrasound (OBUS) on the measurement of the effect of complications ascribed to postterm pregnancies.
We conducted a retrospective cohort study of all term, singleton pregnancies delivered at our institution who had an OBUS at ≤24 weeks of gestation. Those women who underwent an OBUS at ≤12 weeks of gestation (OBUS12) were compared to those who had an OBUS at 13–24 weeks of gestation (OBUS13–24). The primary outcome measures were the rates of postterm pregnancies greater than 41 or 42 weeks’ gestation. Secondary outcomes were the differences between the postterm and term gestations in maternal and neonatal outcomes.
In the OBUS12 group, the rate of postterm pregnancy ≥42 weeks was lower (2.7%) as compared to the OBUS13–24 group (3.7%, p=0.022). With regards to reaching 41 weeks of gestation, the OBUS12 group was again lower (18.2%) as compared to the OBUS13–24 group (22.1%, p<0.001). There were also fewer postterm inductions at ≥42 weeks in the OBUS12 group (1.8%) as compared to the OBUS13–24 group (2.6%, p=0.017). When comparing perinatal outcomes between those women who reached 41 weeks of gestation and those prior to 41 weeks of gestation, the OBUS12 group demonstrated greater differences between these two groups.
Our findings suggest that earlier obstetric ultrasound, which leads to better pregnancy dating, reduces the rate of estimated postterm pregnancies. This may, in turn, reduce unnecessary intervention and lead to better identification of postterm pregnancies at greater risk of complications.
pregnancy dating; ultrasound; complications of pregnancy; post-term; post-dates
The objective of the study was to evaluate the efficacy of an educational intervention at increasing the rates of postpartum (PP) follow-up for women with gestational diabetes mellitus (GDM).
A retrospective cohort study of all patients with GDM delivering during 2002–2009 was conducted. The primary outcome was obtaining PP diabetes testing. The 2002–2006 cohort was advised to obtain PP testing by their providers. The 2007–2009 cohort received educational counseling at the 37–38 week visit by a nurse educator. Univariate and multivariable statistical tests were utilized.
The PP testing frequency was 53% for the 2007–2009 cohort, compared with 33% for the 2002–2006 cohort (P <.001). When stratified by race/ethnicity, increased rates of testing were seen in whites (28% to 53%, P <.001), Latinas (15% to 50%, P <.001), and Asians (43% to 59%, P = .005). There was a nonsignificant decrease in the African American follow-up, 28% to 17% (P =.414).
GDM precedes the development of type 2 diabetes. Antepartum education counseling increases postpartum diabetes testing. More efforts are needed to obtain universal screening.
gestational diabetes mellitus; postpartum screening
We sought to examine associations between gestational weight gain according to the 2009 Institute of Medicine (IOM) guidelines and perinatal outcomes in overweight/obese women with type 2 diabetes mellitus (T2DM).
This is a retrospective cohort study of 2310 women with T2DM enrolled in the California Diabetes and Pregnancy Program. Gestational weight gain was categorized by 2009 IOM guidelines. Perinatal outcomes were assessed using the χ2 test and multivariable logistic regression analysis.
With excessive gestational weight gain, the odds of having large-for-gestational age (adjusted odds ratio [aOR], 2.00; 95% confidence interval [CI], 1.33–3.00) or macrosomic (aOR, 2.59; 95% CI, 1.56 – 4.30) neonates and cesarean delivery (aOR, 1.47; 95% CI, 1.03–2.10) was higher. Women with excessive gestational weight gain per week had increased odds of preterm delivery (aOR, 1.57; 95% CI, 1.11–2.20).
In overweight or obese women with T2DM, gestational weight gain greater than the revised IOM guidelines was associated with higher odds of perinatal morbidity, suggesting these guidelines are applicable to a diabetic population.
gestational weight gain; perinatal outcomes; type 2 diabetes mellitus
Examine the effect of prepregnancy weight and maternal gestational weight gain on postterm delivery rates.
This was a retrospective cohort study of term, singleton births (N=375,003). We performed multivariable analyses of the association between postterm pregnancy and both prepregnancy body mass index (BMI) and maternal weight gain.
Prolonged or postterm delivery (41 or 42 weeks) was increasingly common with increasing prepregnancy weight (p<0.001) and increasing maternal weight gain (p<0.001). Underweight women were 10% less likely to deliver postterm than normal weight women who gain within the recommendations (aOR 0.90 (95% CI 0.83, 0.97)). Overweight women who gain within or above recommendations were also at increased risk of a 41 week delivery. Finally, obese women were at increased risk of a 41 week delivery with increasing risk with increasing weight (below, within, and above recommendations aOR 1.19, 1.21, and 1.27, respectively).
Elevated prepregnancy weight and weight gain both increase the risk of a postterm delivery. While most women do not receive preconceptional care, restricting weight gain to the within the recommended range can reduce the risk of postterm pregnancy in normal, overweight, and obese women.
postterm; prepregnancy weight; prolonged delivery; gestational weight gain
We sought to estimate when rates of maternal pregnancy complications increase beyond 37 weeks of gestation.
We designed a retrospective cohort study of all low-risk women delivered beyond 37 weeks gestational age from 1995 to 1999 within a mature managed care organization. Rates of mode of delivery and maternal complications of labor and delivery were examined by gestational age with both bivariate and multivariable analyses.
We found that among the 119,254 women who delivered at 37 completed weeks and beyond that the rates of operative vaginal delivery (OR 1.15, 95% CI 1.09, 1.22), 3rd or 4th degree perineal laceration (OR 1.15, 95% CI 1.06, 1.24), and chorioamnionitis (OR 1.32, 95% CI 1.21, 1.44) all increased at 40 weeks as compared to 39 weeks of gestation (p<0.001), and rates of postpartum hemorrhage (OR 1.21, 95% CI (1.10, 1.32), endomyometritis (OR 1.46, 95% CI 1.14, 1.87) and primary cesarean delivery (1.28, 95% CI 1.20, 1.36) increased at 41 weeks of gestation (p< 0.001). The cesarean indications of nonreassuring fetal heart rate (OR 1.81, 95% CI 1.49, 2.19) and cephalo-pelvic disproportion (OR 1.64, 95% CI 1.40, 1.94) increased at 40 weeks of gestation (p<0.001)
We found that the risk of maternal peripartum complications increase as pregnancy progresses beyond 40 weeks of gestation. Management of pregnancies that progress past their EDC should include counseling regarding the risks of increasing gestational age.
Rates of operative delivery, postpartum hemorrhage, chorioamnionitis, perineal lacerations, and endomyometritis all increase beyond 40 weeks of gestation.
complications of pregnancy; postterm; post-dates; cesarean delivery
To determine the effect of maternal super-obesity (BMI ≥50 kg/m2) compared to morbid obesity (BMI 40–49.9 kg/m2) or obesity (BMI 30–39.9 kg/m2) on perinatal outcomes.
Retrospective cohort study of birth records linked to hospital discharge data for all live born singleton term infants born to obese Missouri residents from 2000–2006. We excluded major congenital anomalies and women with diabetes or chronic hypertension.
There were 64,272 births meeting study criteria, including 1,185 (1.8%) super-obese mothers. Super-obese women were significantly more likely than obese women to have preeclampsia (aRR 1.7, 95% CI 1.4, 2.1), macrosomia (aRR 1.8, 95% CI 1.3, 2.5), and cesarean delivery (aRR 1.8, 95% CI 1.5, 2.1). Almost half (49.1%) of all super-obese women delivered via cesarean, and 33.8% of super-obese nulliparous women underwent scheduled primary cesarean.
Women with a BMI ≥50 kg/m2 are at significantly increased risk for perinatal complications compared to obese women of lower BMI.
pregnancy outcomes; super-obesity
The American Academy of Pediatrics recommends exclusive breastfeeding until 6 months- of-age. The authors examined prevalence and risk factors for use of infant formulas, water, and teas at 4–6 weeks in Latino infants in the San Francisco Bay Area, a group at high risk for future obesity. They recruited a cohort of pregnant Latina women (N = 201). Infant dietary recall and postpartum depressive symptoms were assessed at 4–6 weeks. The authors found that 105 women (53.1%) were feeding infant formulas and 48 (25.4%) were supplementing with tea or water. Of those providing water or tea, 60.0% were providing daily supplementation. In multivariate analyses, risk for infant supplementation with water or tea was associated with postpartum depressive symptoms (relative risk, 1.8; 95% confidence interval, 1.1–3.0), cesarean delivery (relative risk, 1.9; 95% confidence interval, 1.3–2.9), and infant formula use (relative risk, 1.3; 95% confidence interval, 1.1–1.6). Early supplementation with water or teas and infant formulas should be discouraged in Latinos, given the high frequency observed in this population. J Hum Lact. 27(2):122–130.
perinatal depression; breastfeeding; infant feeding; complementary feeding; risk factors
To estimate which strategy is the most cost-effective for prevention of preterm birth and associated morbidity.
We used decision-analytic and cost-effectiveness analyses to estimate which of 4 strategies was superior based on quality-adjusted life-years (QALYs), cost in US dollars ($), and number of preterm births prevented.
Universal sonographic screening for cervical length and treatment with vaginal progesterone was the most cost-effective strategy and dominant over 3 alternatives: cervical length screening for women at increased risk for preterm birth and treatment with vaginal progesterone; risk-based treatment with 17 α-hydroxyprogesterone Caproate (17-OHP-C) without screening; no screening or treatment. Universal screening represented savings of $1,339 ($8,325 vs. $9,664) when compared to treatment with 17-OHP-C, and led to a reduction of 95,920 preterm births annually in the US.
Universal sonographic screening for short cervical length and treatment with vaginal progesterone appears cost-effective and yields the greatest reduction in preterm birth prior to 34 weeks.
Wide disparities in obstetrical outcomes exist between women of different race/ethnicities. The prevalence of preterm birth, fetal growth restriction, fetal demise, maternal mortality and inadequate receipt of prenatal care all vary by maternal race/ethnicity. These disparities have their roots in maternal health behaviors, genetics, the physical and social environments, and access to and quality of health care. Elimination of the health inequities due to sociocultural differences or access to or quality of health care will require a multidisciplinary approach. We aim to describe these obstetrical disparities, with an eye towards potential etiologies, thereby improving our ability to target appropriate solutions.
disparities; maternal mortality; obstetrical care; preterm birth; race/ethnicity
Latino children are at increased risk for mirconutrient deficiencies and problems of overweight and obesity. Exposures in pregnancy and early postpartum may impact future growth trajectories.
To evaluate the relationship between prenatal and postnatal maternal depressive symptoms experienced in pregnancy and infant growth from birth to 2 years of age in a cohort of Latino infants.
We recruited pregnant Latina mothers at two San Francisco hospitals and followed their healthy infants to 24 months of age. At 6, 12 and 24 months of age, infants were weighed and measured. Maternal depressive symptoms were assessed prenatally and at 4-6 weeks postpartum. Women who had high depressive symptoms at both time periods were defined as having chronic depression. Logistic mixed models were applied to compare growth curves and risk for overweight and underweight based on exposure to maternal depression.
We followed 181 infants to 24 months. At 12 and 24 months, respectively, 27.4% and 40.5% were overweight, and 5.6% and 2.2% were underweight. Exposure to chronic maternal depression was associated with underweight (OR = 12.12, 95%CI 1.86-78.78) and with reduced weight gain in the first 2 years of life (Coef = -0.48, 95% CI -0.94—0.01) compared with unexposed infants or infants exposed to episodic depression (depression at one time point). Exposure to chronic depression was also associated with reduced risk for overweight in the first 2 years of life (OR 0.28, 95%CI 0.03-0.92).
Exposure to chronic maternal depression in the pre- and postnatal period was associated with reduced weight gain in the first two years of life and greater risk for failure to thrive, in comparison with unexposed infants or those exposed episodically. The infants of mothers with chronic depression may need additional nutritional monitoring and intervention.
The objective of this article is to determine whether racial/ethnic disparities exist in screening for group B streptococcus (GBS) colonization among pregnant women. A retrospective cohort study of deliveries at a single institution was conducted. The primary outcome was the availability of GBS culture data at the time of delivery; the primary predictor was maternal race/ethnicity. Analyses were stratified by the time periods before and after the CDC recommendations for universal screening for GBS. Among 16,333 deliveries, 60.4% of the population was screened for GBS but screening rates varied markedly by year of delivery. Black women had a lower odds of having available GBS data (AOR 0.81 [0.69, 0.95]) but this disparity was limited to the period of time before universal screening was recommended. Prior to the recommendation for universal screening for GBS, racial/ethnic disparities existed in rates of screening among pregnant women delivering at term. These differences were reduced after 2002, suggesting that uniform policies regarding obstetrical care may be effective in eliminating disparities in obstetrical care and outcomes.
GBS screening; Disparities; Quality of care
To determine the concordance of patient recall compared to chart abstraction for distant intrapartum variables and to evaluate predictors of concordance.
A random sample from a population-representative cohort of 2,109 ethnically diverse women aged 40–74 years. Intrapartum variables reported by participants were compared to data abstracted from labor and delivery records from up to 53 years prior. Outcomes were assessed for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of patient recall compared to chart abstraction. Logistic regression was used to determine predictors of concordance of patient recall.
401 births among 178 women were analyzed. Mean length of time between birth and recall was 29.6 years. Recall of cesarean delivery had the highest concordance (sensitivity=0.98, specificity=1.00, PPV=1.00, NPV=0.99), followed by birth weight ≥4000gm (sensitivity=0.86, specificity=0.91, PPV=0.53, NPV=.98) Use of oxytocin and laceration requiring repair had the lowest concordance (sensitivity=0.43, specificity=0.75, PPV=0.54, NPV=0.91; sensitivity=0.37, specificity=0.68, PPV=0.34, NPV=0.81 respectively). No variables consistently predicted concordance or discordance of recall.
The concordance of patient recall to chart abstraction for intrapartum variables varies widely. Knowledge of the level of concordance expected for specific variables may be helpful to clinicians who often must rely on patient recall, rather then medical records, for intrapartum histories, and for researchers seeking to identify intrapartum risk factors based on patient recall.
To determine if exposure of nulliparous women to a high rate of preventive labor induction was associated with improvement in birth health.
A risk-scoring system was used to guide the frequent use of preventive labor induction in 100 nulliparous women. The birth outcomes of this group were compared to those of 352 nulliparous women who received usual care. Cesarean delivery was the primary study outcome. The Adverse Outcome Index and the rate of uncomplicated vaginal delivery were used to measure overall birth health.
The exposed group experienced a higher labor induction rate (48% vs. 23.6%, p = <0.001), a lower cesarean rate (9% vs. 25.8%, aOR 0.36 p=0.02), and better composite birth outcomes.
Exposure of nulliparous women to a high preventive induction rate was significantly associated with improvement in birth health. Prospective randomized trials are needed to further explore the utility of risk-guided preventive labor induction.
Nulliparous; Birth outcomes; Cesarean delivery; Adverse outcome index; Preventive labor induction
To compare birth outcomes resulting from the active management of risk in pregnancy at term (AMOR-IPAT) to those resulting from standard management.
Randomized clinical trial with 270 women of mixed parity. AMOR-IPAT used preventive labor induction to ensure delivery before the end of an estimated optimal time of delivery. Rates of four adverse obstetric events, and two composite measures, were used to evaluate birth outcomes.
The AMOR-IPAT-exposed group had a similar cesarean delivery rate (10.3% vs. 14.9%, p=0.25), but a lower NICU admission rate (1.5% vs. 6.7%, p = 0.03), a higher uncomplicated vaginal birth rate (73.5% vs. 62.8%, p=0.046), and a lower mean Adverse Outcome Index score (1.4 vs. 8.6, p=0.03).
AMOR-IPAT exposure improved the pattern of birth outcomes. Larger randomized clinical trials are needed to further explore the impact of AMOR-IPAT on birth outcomes and to determine the best methods of preventive labor induction.
Adverse Outcome Index; Cesarean delivery; Neonatal Intensive Care Unit admission; Preventive labor induction; Uncomplicated Vaginal Delivery
Pregnancy in chronic dialysis patients is unusual and associated with many complications. Infants are often born both prematurely and small for gestational age. We report a case of a 36-year-old diabetic hemodialysis patient G4P3 who had prolonged hyperemesis gravidarum, for whom intradialytic parenteral nutrition (IDPN) was started at week 14 and continued throughout her pregnancy. She delivered a 3.5-kg baby girl at the 36th week of gestation by cesarean section. We discuss the use of IDPN as adjunct therapy for pregnant dialysis patients.
Pregnancy; Intradialytic parenteral nutrition; Fetal outcomes
This study was conducted to assess the potential impact of an unintended pregnancy on women’s quality of life.
We asked 192 non-pregnant women to report how they would feel if they learned they were pregnant using a visual analog scale (VAS), time-tradeoff (TTO), standard gamble (SG), and willingness-to-pay (WTP) metric.
Women’s anticipated responses to an unintended pregnancy varied widely. Using a VAS, 8% reported pregnancy would make them feel like they were dying. To avoid pregnancy, 28% were willing to trade time from the end of their life (TTO), 16% of women were willing to accept an immediate risk of death (SG), and 60% of women were willing to pay some amount of money (WTP). On average, women reported using the VAS, TTO, and SG metrics, that an unintended pregnancy would create a health utility state (where 0 represents death and 1 represents perfect health) of 0.487, 0.992, and 0.997, respectively.
The anticipated effects of pregnancy on women’s quality of life should be integrated into cost-effectiveness analyses of family planning services.
Utility; QALY (Quality-adjusted life years); Decision Analysis; Cost effectiveness; unintended pregnancy
To assess an instant results protocol for first trimester combined screening (FTCS).
Retrospective analysis of patients having FTCS between 11/1/03 - 10/31/05. We evaluated the feasibility of patient self-collection and mail-in of blood samples prior to nuchal translucency ultrasound. Primary outcome was success with providing in office, immediate screening results following the ultrasound. Predictor variables included age, ethnicity, insurance, and provider. Chi-square analysis was performed.
2310 women completed FTCS, and 60.6% received instant results. When the biochemistry sample was collected at home, 80% received instant results. Age ≥35 predicted instant results (p=0.001), while ethnicity, insurance, and referring provider did not. Comparing the prior 24 months, clinic volume increased by 18%. Diagnostic procedure volume was unchanged, although CVS increased by 12% (p=0.02) and amniocentesis decreased by 6% (p=0.049).
Patients were able to obtain instant results in 60.6% of cases, which appeared to increase the utilization of CVS.
first trimester combined screening; nuchal translucency; Down syndrome screening; prenatal diagnosis
Perinatal outcomes differ by week of gestational age. However, it appears that how measures to examine these outcomes vary among various studies. The current paper explores how perinatal complications are reported and how they might differ when different denominators, numerators, and comparison groups are utilized.
One issue that can clearly affect absolute rates and trends is how groups of women are categorized by their gestational age. Since most perinatal outcomes can only occur in women and neonates who have delivered, using the number of pregnancies delivered (PD) as the denominator of outcomes is appropriate. However, for an outcome such as antepartum stillbirth, all women who are pregnant at a particular gestational age are at risk. Thus, the denominator should include all ongoing pregnancies (OP). When gestational age is used by week this means using both deliveries during a particular week plus those women who deliver beyond the particular week of gestation in the denominator. Researchers should be careful to make sure they are utilizing the appropriate measure of perinatal complications so they do not report findings that would be misleading to clinicians, patients, and policy makers.