Negative pressure wound therapy system in extremely obese women after cesarean delivery compared with standard dressing.

Objective: Data regarding the use of the negative pressure wound therapy (NPWT) system in extremely obese women (body mass index [BMI] ≥ 50 kg/m2) undergoing cesarean delivery are limited. We sought to examine the rate of wound complications in extremely obese women according to postcesarean dressings (NPWT [PICO, Smith & Nephew, St. Peterburg, FL] versus standard dressings).Study design: This was a retrospective cohort study of all extremely obese women (BMI ≥ 50 kg/m2) at 23 weeks' gestation or greater who underwent cesarean delivery at an academic teaching hospital in Washington, DC, between January 2009 and September 2017. During this period, a PICO Single Use NPWT system was used at our institution. Women who missed a postpartum follow-up were excluded. Since 2014, Medstar Washington Hospital Center recommended the use of a PICO Single Use NPWT system for extremely obese women at the time of delivery. However, the ultimate decision to use the NPWT was made by attending physicians, considering the cost of the device and the risk of wound complication. Our primary outcome was a composite of cellulitis, hematoma/seroma, and wound dehiscence. Coarsened exact matching with k-to-k solution was performed using BMI, rupture of membranes, and labor.Results: Of 179 extremely obese women, 73 (40.8%) and 106 (59.2%) received NPWT and standard dressings, respectively; 61 women who received NPWT were matched to 61 women who received standard dressings. The rates of the primary outcome in the unmatched cohort were similar between women who received NPWT and those who received standard dressings (20.6 versus 16.0%; p = .44). The rates of primary outcome remained similar between women who received NPWT and those who received standard dressings after matching (18.0 versus 18.0%; p = 1.00).Conclusion: In extremely obese women undergoing cesarean delivery, prophylactic PICO NPWT was not associated with a decreased risk of the primary outcome compared with standard dressings. A large prospective randomized controlled trial would be useful to answer if NPWT is beneficial for extremely obese women.

Externally Validated Prediction Model of Vaginal Delivery After Preterm Induction With Unfavorable Cervix.

OBJECTIVE: To create and externally validate a predictive model to calculate the likelihood of vaginal delivery after preterm induction with unfavorable cervix. METHODS: This was a retrospective cohort study of women with a singleton gestation from a single academic institution who underwent an induction of labor at less than 37 weeks of gestation from January 2009 to June 2018. Women with contraindications for vaginal delivery were excluded. Analyses were limited to women with unfavorable cervix (both simplified Bishop score [dilation, station, and effacement: range 0-9] less than 6 and cervical dilation less than 3 cm). A stepwise logistic regression analysis was used to identify the factors associated with vaginal delivery by considering maternal characteristics and comorbidities as well as fetal conditions. The final model was validated using an external data set of the Consortium on Safe Labor after applying the same inclusion and exclusion criteria. We compared the area under the curve (AUC) of our predictive model and the simplified Bishop score. RESULTS: Of the 835 women, 563 (67%) had vaginal delivery. Factors associated with vaginal delivery included later gestational age at delivery, higher parity, more favorable simplified Bishop score, and preterm prelabor rupture of membranes. Factors including older maternal age, non-Hispanic Black race, higher body mass index, and abruption were associated with decreased likelihood of vaginal delivery. In the external validation cohort, 1,899 women were analyzed, of whom 1,417 (75%) had vaginal delivery. The AUCs of simplified Bishop score and the final model were 0.65 (95% CI 0.59-0.66) and 0.73 (95% CI 0.72-0.79), respectively, for the external validation cohort. The online calculator was created and is available at www.medstarapps.org/obstetricriskcalculator/ and in the Obstetric Risk Calculator mobile application in the Apple App Store and Google Play Store. CONCLUSION: Our externally validated model was efficient in predicting vaginal delivery after preterm induction with unfavorable cervix.

A Survey of Women and Their Providers Regarding Gestational Weight Gain.

Background: Inappropriate gestational weight gain (GWG) is prevalent in the United States. About 20% of women gain below Institute of Medicine (IOM) recommendations; more than 50% gain above. GWG outside of recommendations is linked to poor birth outcomes and health issues for mother and baby. Counseling by health care providers is important to encourage appropriate GWG. Methods: Assess patient recall of counseling regarding GWG, provider knowledge, and opinions about IOM GWG guidance, and GWG outcomes in a subset of women. Cross-sectional, with questionnaires distributed by 8 medical centers across the United States to patients. Questionnaires were distributed to providers and data on maternal body mass index (BMI) and GWG collected at seven sites. Results: A total of 1,157 women returned questionnaires (1,820 maximum possible). A majority at all sites reported a provider discussed their expected GWG with them. Close to half reported that a provider had discussed potential harms from inappropriate GWG. Most of the women (71.2%) considered their obstetrician to be a helpful resource for GWG advice. Most providers (87.5%) reported they were aware of IOM guidelines. As many providers disagreed (18.8%) as agreed (20.8%) that they were successful helping their patients attain appropriate GWG (58.3% were neutral). Physician self-reported confidence was associated with whether they believed they could help their patients avoid excessive GWG. The most common outcome was GWG above recommendations (51.4%). Overweight and obese women were more likely to gain above recommendations. Providers underestimated the proportion of their patients that gained below IOM recommendations (8.5% vs. 18.6%). Conclusions: Providers are aware of the dangers of excessive GWG and a majority of patients report receiving counseling. Providers appear more cognizant of excessive GWG and underestimate inadequate GWG. Most women are not achieving an appropriate GWG, with overweight and obese women especially likely to gain above recommendations.

Third trimester ultrasound for fetal macrosomia: optimal timing and institutional specific accuracy.

PURPOSE: To determine the performance of third trimester ultrasound in women with suspected fetal macrosomia. MATERIALS AND METHODS: We performed a retrospective cohort study of fetal ultrasounds from January 2004 to December 2014 with estimated fetal weight (EFW) between 4000 and 5000 g. We determined accuracy of birth weight prediction for ultrasound performed at less than and greater than 38 weeks, accounting for diabetic status and time between ultrasound and delivery. RESULTS: There were 405 ultrasounds evaluated. One hundred and twelve (27.7%) were performed at less than 38 weeks, 293 (72.3%) at greater than 38 weeks, and 91 (22.5%) were performed in diabetics. Sonographic identification of EFW over 4000 g at less than 38 weeks was associated with higher correlation between EFW and birth weight than ultrasound performed after 38 weeks (71.5 versus 259.4 g, p < .024). EFW to birth weight correlation was within 1.7% of birth weight for ultrasound performed less than 38 weeks and within 6.5% of birth weight for ultrasound performed at greater than 38 weeks. CONCLUSIONS: Identification of EFW with ultrasound performed less than 38 weeks has greater reliability of predicting fetal macrosomia at birth than measurements performed later in gestation. EFW to birth weight correlation was more accurate than previous reports.

Differences in prenatal aneuploidy screening among African-American women with hemoglobin S variants.

OBJECTIVE: It has been shown that hemoglobinopathies increase the risk of pregnancy complications and placental dysfunction. This could alter the placental analytes examined during prenatal aneuploidy screening. Our objective was to determine whether there is a difference in maternal serum screening results for women with hemoglobin S variants (AS, SS, SC, S/beta thalassemia) compared with women with normal hemoglobin (AA). STUDY DESIGN: This is a retrospective cohort study in African-American women receiving aneuploidy screening at MedStar Washington Hospital Center from 2008 to 2015. We evaluated 79 women with hemoglobin S variants (69 AS and 10 sickle cell disease (SCD)) and 79 controls. Descriptive statistics (means, medians, and frequencies) were calculated for each group. For the continuous variables, differences in the averages between the two groups were tested using the t test or Wilcoxon rank sum test. Differences in the averages between three or more groups were tested using the analysis of variance test or the Kruskal-Wallis test. RESULTS: Demographics were similar between cases and controls. The overall screen positive rate for Down syndrome among patients with sickle cell trait (AS) was 3% (2/69). For patients with SCD, the overall screen positive rate was 10% (1/10). None of the women in the control population (AA) has a positive Down syndrome screening result (0/79). CONCLUSION: As expected, the screen positive rate in patients with hemoglobin S variants was higher than controls, however, patients with sickle cell trait do not appear to be at an increased risk for false-positive results with serum aneuploidy screening compared with the general population. We did, however, find an increased risk of false-positive quad screen results in patients with sickle cell disease.

Maternal Iodine Exposure: A Case of Fetal Goiter and Neonatal Hearing Loss.

A 27-year-old gravid 1 at 27 weeks 6 days with a history of hypothyroidism had an ultrasound that demonstrated a 3.9 × 3.2 × 3.3-cm well-circumscribed anterior neck mass, an extended fetal head, and polyhydramnios. Further characterization by magnetic resonance imaging (MRI) showed a fetal goiter. During her evaluation for the underlying cause of the fetal goiter, the patient revealed she was taking nutritional iodine supplements for treatment of her hypothyroidism. She was ingesting 62.5 times the recommended amount of daily iodine in pregnancy. The excessive iodine consumption caused suppression of the fetal thyroid hormone production, resulting in hypothyroidism and goiter formation. After the iodine supplement was discontinued, the fetal goiter decreased in size. At delivery, the airway was not compromised. The infant was found to have reversible hypothyroidism and bilateral hearing loss postnatally. This case illustrates the importance of examining for iatrogenic causes for fetal anomalies, especially in unregulated nutritional supplements.

Maternal and fetal capillary malformation-arteriovenous malformation (CM-AVM) due to a novel RASA1 mutation presenting with prenatal non-immune hydrops fetalis.

RASA1 mutations have been shown to cause capillary malformation-arteriovenous malformation (CM-AVM). We describe a patient with CM-AVM and a fetus who presented with non-immune hydrops fetalis during the pregnancy. Sequencing revealed a novel RASA1 mutation in the RASGAP domain that results in a loss of function of p120-RasGap. This report expands our current genetic and clinical understanding of CM-AVM in pregnancy.

Early Second Trimester Weight Gain in Obese Women Predicts Excessive Gestational Weight Gain in Pregnancy.

OBJECTIVE: To assess gestational weight gain (GWG) in obese women to determine an inflection point that identifies women at risk for excessive weight gain. STUDY DESIGN: This is an observational prospective cohort study of pregnancies managed through the UC San Diego Maternal Weight and Wellness Program from 2011 to 2014. The primary outcome was total gestational weight gain. GWG was categorized as inadequate (<11 pounds), adequate (11-20 pounds), and excessive (>20 pounds) based on Institute of Medicine (IOM) recommendations. Other outcomes were GWG by trimester and postpartum weight retention. Bivariate and multivariate analyses were used to assess factors associated with GWG. RESULTS: Ninety-five patients had a mean prepregnancy body mass index (BMI) of 41.9 ± 8.9 kg/m(2) and a net weight gain of 21.9 ± 19 pounds. First trimester GWG was -0.3 ± 4.9 pounds, second trimester was 10.4 ± 10.8 pounds, and third trimester was 11.4 ± 8.5 pounds for all participants. Women who exceeded IOM recommendations accelerated weight gain at 12-14 weeks and gained a majority of weight during the second trimester. Weight gain of more than two pounds at 12-14 weeks had a 96 % positive predictive value (95 % CI 79-99) for excessive GWG. Postpartum women with excessive GWG retained more weight than those with inadequate GWG (10.7 ± 15.6 pounds compared with -13.6 ± 10.9 pounds, P < 0.001). On multiple linear regression GWG by trimester was predictive of total GWG with second and third trimester GWG having the greatest effect on total GWG. Prepregnancy BMI and gestational diabetes were not predictors of total GWG. CONCLUSIONS: Obese women at risk for excessive GWG may be identified as early as 12-14 weeks and gain most weight during the second trimester. GWG less than 11 pounds resulted in significant postpartum weight loss among obese women.

Enoxaparin dosing after cesarean delivery in morbidly obese women.

OBJECTIVE: To compare the adequacy of venous thromboembolism prophylaxis based on anti-Xa concentrations between weight-based enoxaparin dosing and body mass index (BMI)-stratified dosing in morbidly obese women after cesarean delivery. METHODS: A prospective sequential cohort study of women with BMIs of 40 or greater who underwent cesarean delivery was conducted. Participants received either weight-based or BMI-stratified enoxaparin dosing to prevent venous thromboembolism formation. The weight-based regimen was 0.5 mg/kg of enoxaparin every 12 hours. In the BMI-stratified regimen, women with BMIs of 40-59.9 received 40 mg enoxaparin every 12 hours and women with BMIs of 60 or greater received 60 mg every 12 hours. The primary outcome was an anti-Xa concentration in the adequate thromboprophylaxis range (0.2-0.6 international units/mL). Secondary outcomes included enoxaparin dosage, timing of dosing and anti-Xa concentration, estimated surgical blood loss, postoperative changes in hemoglobin and platelets, wound hematoma, and adverse reactions to enoxaparin. Univariate analysis was used to compare dosing regimens. RESULTS: Forty-two morbidly obese women received weight-based enoxaparin, and 43 received BMI-stratified dosing. Anti-Xa concentrations were significantly higher in the weight-based group compared with the BMI-stratified group (0.29±0.08 international units/mL compared with 0.17±0.07 international units/mL, P<.001). Thirty-six participants (86%) on weight-based dosing had anti-Xa concentrations within the prophylactic range compared with 11 (26%) on BMI-stratified dosing (P<.001). No participant had an anti-Xa concentration of 0.6 international units/mL or greater, the therapeutic threshold for venous thromboembolism prophylaxis. CONCLUSION: In morbidly obese women after cesarean delivery, weight-based dosing of enoxaparin for venous thromboembolism prophylaxis is significantly more effective than BMI-stratified dosing in achieving adequate anti-Xa concentrations. LEVEL OF EVIDENCE: II.

Multi-institutional practice patterns and outcomes in uncomplicated gastroschisis: a report from the University of California Fetal Consortium (UCfC).

BACKGROUND/PURPOSE: Gastroschisis is a resource-intensive birth defect without consensus regarding optimal surgical and medical management. We sought to determine best-practice guidelines by examining differences in multi-institutional practices and outcomes. METHODS: Site-specific practice patterns were queried, and infant-maternal chart review was retrospectively performed for gastroschisis infants treated at 5 UCfC institutions (2007-2012). The primary outcome was length of stay. Univariate analysis was done to assess variation practices and outcomes by site. Multivariate models were constructed with site as an instrumental variable and with sites grouped by silo practice pattern adjusting for confounding factors. RESULTS: Of 191 gastroschisis infants, 164 infants were uncomplicated. Among uncomplicated patients, there were no deaths and only one case of necrotizing enterocolitis. Bivariate analysis revealed significant differences in practices and outcomes by site. Despite wide variations in practice patterns, there were no major differences in outcome among sites or by silo practice, after adjusting for confounding factors. CONCLUSIONS: Wide variability exists in institutional practice patterns for infants with gastroschisis, but poor outcomes were not associated with expeditious silo or primary closure, avoidance of routine paralysis, or limited central line and antibiotic durations. Development of clinical pathways incorporating these practices may help standardize care and reduce health care costs.

Factors associated with gastroschisis outcomes.

OBJECTIVE: To identify perinatal variables associated with adverse outcomes in neonates prenatally diagnosed with gastroschisis. METHODS: A retrospective review was conducted of all inborn pregnancies complicated by gastroschisis within the five institutions of the University of California Fetal Consortium from 2007 to 2012. The primary outcome was a composite adverse neonatal outcome comprising death, reoperation, gastrostomy, and necrotizing enterocolitis. Variables collected included antenatal ultrasound findings, maternal smoking or drug use, gestational age at delivery, preterm labor, elective delivery, mode of delivery, and birth weight. Univariate and multivariate analysis was used to assess factors associated with adverse outcomes. We also evaluated the association of preterm delivery with neonatal outcomes such as total parenteral nutrition cholestasis and length of stay. RESULTS: There were 191 neonates born with gastroschisis in University of California Fetal Consortium institutions at a mean gestational age of 36 3/7±1.8 weeks. Within the cohort, 27 (14%) had one or more major adverse outcomes, including three deaths (1.6%). Early gestational age at delivery was the only variable identified as a significant predictor of adverse outcomes on both univariate and multivariate analysis (odds ratio 1.4, 95% confidence interval 1.1-1.8 for each earlier week of gestation). Total parenteral nutrition cholestasis was significantly more common in neonates delivered at less than 37 weeks of gestation (38/115 [33%] compared with 11/76 [15%]; P<.001). CONCLUSION: In this contemporary cohort, earlier gestational age at delivery is associated with adverse neonatal outcomes in neonates with gastroschisis. Other variables, such as antenatal ultrasound findings and mode of delivery, did not predict adverse neonatal outcomes.

The clinical approach to obesity in pregnancy.

Over one third of reproductive age women are obese, and this marked prevalence is impacting pregnancy. Obese women face many challenges from preconception to postpartum. They are at increased risk for both maternal and fetal complications including gestational diabetes, hypertension, preeclampsia, congenital anomalies, stillbirth, fetal macrosomia, cesarean delivery, venous thromboembolism, wound complications, breast-feeding difficulty, postpartum depression, postpartum weight retention, and neonatal death. This discussion is designed to help clinicians understand how obesity affects pregnancy, how to counsel patients regarding gestational weight gain, and how to implement management strategies during pregnancy to optimize health outcomes for these patients.

Late-first-trimester cesarean section scar ectopic pregnancy with placenta increta: a case report.

BACKGROUND: Cesarean section scar pregnancy is a rare ectopic pregnancy that is difficult to manage due to high risk of uterine rupture and maternal hemorrhage-a risk that increases with gestational age. CASE: A 21-year-old, gravida 3 para 2 woman was diagnosed at 13.5 weeks' gestation by pelvic ultrasound and magnetic resonance imaging with a cesarean scar ectopic pregnancy and placenta increta. Surgical removal of the pregnancy via exploratory laparatomy with intraoperative use of vasopressin minimized initial blood loss. However, extraction of the placenta increta resulted in uncontrolled bleeding, requiring a supracervical hysterectomy. CONCLUSION: This is the first case report, to our knowledge, of a late-first-trimester cesarean section scar ectopic pregnancy with placenta increta. Early identification of the ectopic pregnancy may allow for more conservative, nonsurgical management. However, with a more advanced gestational age and placenta increta, surgical management is most appropriate to minimize associated maternal risks. A transverse wedge resection of the implantation site, uterine artery embolization, uterine artery ligation, endovascular balloon catheters, or uterine artery tourniquet may help decrease bleeding during surgical extraction of the pregnancy and placenta increta, and also may prevent a hysterectomy.

Development of a culturally specific assessment tool for pelvic organ prolapse in a Mayan population.

INTRODUCTION: Pelvic organ prolapse is a common condition that can significantly affect a woman's life, including her sexual, urinary, and social functioning. In Guatemala, anecdotal evidence suggests that the daily activities of Mayan women contribute to and worsen the degree of pelvic organ prolapse. The objective of this research was to develop a culturally specific assessment tool to better evaluate how pelvic organ prolapse affects the daily activities of Mayan women in rural Guatemala. METHODS: A survey was created entitled a Culturally Specific Assessment Tool for Pelvic Organ Prolapse (CSAT-POP). The survey was administered to a 19 Mayan women with various degrees of pelvic organ prolapse in Montellano, Guatemala. Participants were asked using a Likert scale about how their pelvic organ prolapse affected their ability to perform 7 culturally specific activities of daily living. The survey was administered through an on-site interpreter who translated the CSAT-POP into Spanish and Quiché. RESULTS: Nineteen women were assessed using the CSAT-POP. Their mean age was 49.2 ± 28 years, and the median parity was 6.8 children (range 1-11). Three culturally specific activities: performing vigorous activities, gathering wood, and carrying water, were identified as the activities most impacted by pelvic organ prolapse. Of the participants, 15-20% were unable to perform these activities on a daily basis. However, preparing food, washing clothes, and caring for children were the activities reported by women with pelvic organ prolapse which required the least amount of assistance. CONCLUSIONS: The CSAT-POP identified several activities specific to the rural Mayan community in Guatemala which are difficult to perform with pelvic organ prolapse. By using culturally specific activities of daily living, the CSAT-POP allowed for more relevant assessment, identification, and treatment of women with pelvic organ prolapse in Guatemala.