Outcomes of Triplets reduced to Twins versus non-reduced Triplet Pregnancies.

INTRODUCTION: This study examined the outcomes of triplet pregnancies selectively reduced to twin pregnancies, compared with non-reduced triplet pregnancies using a standardized approach. MATERIAL AND METHODS: This study is an observational retrospective study of all women who presented to the Fetal Diagnostic Center between 1999-2009, had triplet pregnancies in the first trimester, received prenatal care and delivered at Abington Memorial Hospital. Data analysis was performed with SPPS version 15 for Windows using analysis of variance and Fisher's Exact test. RESULTS: 132 triplet pregnancies were identified. In the reduced group (n = 30) compared to the non-reduced triplet group (n = 102) average gestational age of delivery was longer 34.6 weeks versus 31.2 weeks gestation (P = <0.0005) and days in hospital were less 9.0 versus 26.7 days (P = .001). There was a significantly lower incidence of gestational diabetes and preterm labor in reduced pregnancies. Rate of loss, defined as delivery less than 24 weeks, were similar [3.3% versus 4.9%]. DISCUSSION: Women electing to reduce a triplet pregnancy to twins have higher gestational ages at delivery, lower rates of gestational diabetes and preterm labor, and spent fewer days in hospital than non-reduced triplet pregnancies.

The impact of length of second stage of labor on shoulder dystocia outcomes: a retrospective cohort study.

OBJECTIVE: To compare obstetrical and neonatal outcomes of vaginal deliveries complicated by shoulder dystocia, according to the length of second stage of labor. METHODS: We conducted a retrospective cohort study of 177 shoulder dystocia cases that were divided into three categories according to second stage duration (1-20, 21-59, 60-180 min, respectively). The three categories were compared in terms of obstetric characteristics and neonatal outcomes. Statistical analysis utilized the χ2-test and analysis of variance where appropriate. The odds ratios of brachial plexus injury and having a 5-min APGAR score <7 across the second stage duration categories were calculated using logistic regression models that adjusted for potential confounders. RESULTS: The incidence of brachial plexus injury was 5.4% (1st category), 4.4% (2nd category) and 26.9% (3rd category); P<0.01. The higher incidence of brachial plexus injury in the group where second stage lasted >1 h was confirmed by logistic regression, with and without adjusting for confounders. CONCLUSIONS: The incidence of brachial plexus injury increases with the length of second stage, even after controlling for confounders.

Improved overall delivery documentation following implementation of a standardized shoulder dystocia delivery form.

OBJECTIVE: Our objective was to evaluate whether using a standardized shoulder dystocia delivery form improved documentation. A standardized delivery form was added to our institution's obstetrical record in August 2003. METHODS: A retrospective cohort study was conducted comparing 100 vaginal deliveries complicated by shoulder dystocia before, and 81 after implementation of the standardized delivery form. The two groups were compared in terms of obstetric characteristics, neonatal outcomes and documentation components. RESULTS: Charts that included the standardized delivery form were more likely to contain documentation of estimated fetal weight (82.7% vs. 39.0% without the form, P<0.001) and head-to-shoulder delivery interval (76.5% vs. 15.0% without the form, P<0.001). Both groups were statistically similar in terms of documenting estimated blood loss and fetal weight, umbilical cord pH, type and order of maneuvers utilized to relieve the shoulder dystocia, and second stage duration. CONCLUSIONS: Inclusion of a standardized form in the delivery record improves the rate of documentation of both shoulder dystocia-specific and general delivery components.

Risk factors associated with retained placenta after cesarean delivery.

OBJECTIVES: Retained placenta after cesarean delivery (RPAC) is a rare phenomenon that has not been previously studied in detail. The objective of our study was to identify potential risk factors that predispose to the development of this obstetrical complication. METHODS: We performed a retrospective case-control study comparing 20 cases of RPAC with 40 matched controls, using logistic regression models to test likely risk factors. RESULTS: RPAC occurred in 0.16% of cesarean deliveries in our population. The crude odds ratio (OR) of RPAC was increased in patients who had preterm delivery (PTD) (OR=9.06, 95% CI: 2.04-40.29), conceived with artificial reproductive technology (ART) (OR=5.03, 95% CI: 1.24-20.40), and carried multiples (OR=18.89, 95% CI: 2.29-151.23). Conversely, for each week of gestation the odds of RPAC decreased by 0.57 (95% CI: 0.40-0.82). CONCLUSIONS: Earlier gestational age, PTD, use of ART and multiples are associated with increased OR of RPAC.

Da Vinci-assisted abdominal cerclage.

OBJECTIVE: To report the first placement of an abdominal cervicoisthmic cerclage using the da Vinci robot. DESIGN: Case report. SETTING: Tertiary-care hospital. PATIENT(S): A 39-year-old female with a history of cervical insufficiency who required a cerclage and was not a candidate for transvaginal cerclage placement. INTERVENTION(S): Abdominal cervicoisthmic cerclage placement using the da Vinci robot. MAIN OUTCOME MEASURE(S): Ability to safely and successfully place an abdominal cerclage using the da Vinci robot. RESULT(S): Abdominal cerclage was successfully placed using the da Vinci robot. The patient had minimal blood loss and was discharged to home on the same day as surgery. CONCLUSION(S): Da Vinci robot-assisted abdominal cerclage placement is an innovative application of robotic surgery and may alter the standard of care for women who require this surgery.

Fetal serum beta2-microglobulin before and after bladder shunting: a 2-step approach to evaluate fetuses with lower urinary tract obstruction.

PURPOSE: The evaluation of renal function in fetuses with lower urinary tract obstruction by analysis of electrolytes and beta2-microglobulin in fetal urine has limitations. We measured fetal serum beta2-microglobulin before and after bladder shunting to evaluate renal function. MATERIALS AND METHODS: A total of 12 fetuses with lower urinary tract obstruction underwent vesicoamniotic shunting. In addition to the standard evaluation of urinary electrolytes and beta2-microglobulin, fetal renal status was assessed by pre-shunt and post-shunt fetal serum beta2-microglobulin. RESULTS: At 2 to 4 weeks after shunting 2 of the 12 fetuses had persistent oligohydramnios, demonstrated increased values of serum beta2-microglobulin and were confirmed to have renal dysplasia. In the remaining 10 fetuses there was reaccumulation of amniotic fluid for a minimum of 4 weeks after shunting. Serum beta2-microglobulin values increased after shunting in 4 fetuses, all of which developed renal failure, whereas serum beta2-microglobulin did not change or was decreased after shunting in 6, of which 4 had normal renal function at latest followup. CONCLUSIONS: Urinary electrolytes, urinary beta2-microglobulin and pre-shunt serum beta2-microglobulin, whether increased or normal, failed to be predictive of potential response to prenatal intervention. Serial samples of fetal blood may provide distinction between patients who do and do not respond to prenatal treatment of lower urinary tract obstruction.