Postpartum remote home blood pressure monitoring: the new frontier.

There has been an alarming and substantial increase in hypertensive disorders of pregnancy, which are a significant driver of maternal morbidity and mortality. The postpartum period is an especially high-risk time, with >50% of pregnancy-related deaths and significant morbidity occurring during this period. The American College of Obstetricians and Gynecologists suggests inpatient or equivalent monitoring of blood pressures in patients with hypertensive disorders of pregnancy for the immediate 72 hours postpartum and again within 7 to 10 days postpartum. Hypertensive disorders of pregnancy significantly contribute to healthcare costs through increasing admission lengths, rates of readmissions, the number of medications given, and laboratory studies ordered, and through the immeasurable impact on the patient and society. Telemedicine is an essential option for patients with barriers to accessing care, particularly those in remote areas with difficulty accessing subspecialty care, transportation, childcare, or job security. The implementation of these programs also has potential to mitigate racial inequities given that patients of color are disproportionately affected by the morbidity and mortality of hypertensive disorders of pregnancy. Remote blood pressure monitoring programs are generally acceptable, with high levels of satisfaction in the obstetrical population without posing an undue burden of care. Studies have reported different, but encouraging, measures of feasibility, including rates of recruitment, consent, engagement, adherence, and retention in their programs. Considering these factors, the widespread adoption of postpartum blood pressure monitoring programs holds promise to improve the identification and care of this at-risk population. These immediate clinical effects are significant and can reduce short-term hypertension-related morbidity and even mortality, with the potential for long-term benefit with culturally competent, well-reimbursed, and widespread use of these programs. This clinical opinion aims to show that remote monitoring of postpartum hypertensive disorders of pregnancy is a reliable and effective alternative to current follow-up care models that achieves improved blood pressure control and diminishes racial disparities in care while simultaneously being acceptable to providers and patients and cost-saving to hospital systems.

Simplifying the prediction of vaginal birth after cesarean delivery: role of the cervical exam.

OBJECTIVE: Predicting likelihood of vaginal birth after cesarean (VBAC) is a cornerstone in counseling patients considering a trial of labor after cesarean (TOLAC). Yet, the simplified Bishop score (SBS), a score comprised cervical dilation, station, and effacement assessment used to predict successful vaginal delivery, has not been applied to the TOLAC population. We evaluated the relationship between admission SBS and likelihood of successful VBAC. We also determined the predictive characteristics of SBS, compared to cervical dilation alone, for successful VBAC. METHODS: This is a secondary analysis of a prospective cohort study of patients with a singleton gestation, ≥37 0/7 weeks gestation, and prior cesarean admitted to Labor & Delivery between 2010 and 2014. The primary outcome of successful VBAC was compared between those with a favorable (score >5) and unfavorable (score ≤5) admission SBS. Secondary outcomes were select maternal and neonatal outcomes. Adjusted risk ratios were estimated using multivariable logistic regression analyses. Receiver-operating characteristic curves compared predictive capabilities of cervical dilation alone to SBS for successful VBAC. RESULTS: Of the 656 patients who underwent a TOLAC during the study period, 421 (64%) had a successful VBAC. 203 (31%) and 453 (69%) had a favorable and an unfavorable admission SBS, respectively. After adjusting for body mass index and prior vaginal delivery, patients with a favorable admission SBS had a 30% greater likelihood of successful VBAC compared to those with an unfavorable SBS (aRR 1.30, 95% CI 1.16-1.40). Admission cervical dilation alone performed similarly to SBS as a predictor of successful VBAC, with a receiver-operator characteristic curve area under the curve (AUC) of 0.68 (95% CI 0.64-0.72) versus an AUC 0.66 (95% CI 0.62-0.70), respectively (p = .07). There were no differences in adverse maternal or neonatal outcomes between those with an unfavorable and favorable SBS. CONCLUSIONS: A favorable admission SBS is associated with an increased likelihood of VBAC. Although both admission SBS and cervical dilation alone are only modest predictors of VBAC, admission cervical dilation performs overall similarly to current models for VBAC prediction and is an objective, reproducible, and generalizable measure. Our study highlights the value of waiting until end of pregnancy (rather than the first prenatal visit) to conclude patient counseling on the decision to TOLAC in order to consider admission cervical assessment, particularly cervical dilation.

Risk of Maternal Morbidity with Increasing Number of Cesareans.

OBJECTIVE: To estimate the risk of perioperative morbidity with increasing number of cesareans. STUDY DESIGN: We conducted a retrospective cohort study from 2004 to 2010. Patients delivered by cesarean were included. Outcome measures were a composite organ injury (bowel or bladder), hysterectomy, hemorrhage requiring transfusion, severe morbidity, or surgical site complications. The Cochran-Armitage's test of trend was used to assess increasing incidence of each morbidity with number of prior cesareans. Multivariable logistic regression was used to estimate adjusted risks for each morbidity with increasing number of cesareans compared with primary cesarean. RESULTS: Of the 15,872 women in the cohort, 5,144 had cesarean delivery: 3,113 primary, 1,310 one prior, 510 two prior, and 211 three or more prior cesareans. There was a significant increase in organ injury, hysterectomy, and surgical site complications with increasing number of cesareans. In multivariable analysis, the risk of organ injury and hysterectomy was increased compared with primary cesarean after two prior cesareans, and after three or more cesareans for hemorrhage requiring transfusion and surgical site complications. CONCLUSION: The risks of organ injury and hysterectomy are increased after two or more prior cesareans, and risks of hemorrhage and surgical site complications are increased after three or more cesareans.

Early Second-Trimester Fetal Growth Restriction and Adverse Perinatal Outcomes.

OBJECTIVE: To estimate the risk of adverse perinatal outcomes among women with isolated fetal growth restriction from 17 to 22 weeks of gestation. METHODS: This was a retrospective cohort study of all singleton, nonanomalous pregnancies undergoing ultrasonography to assess fetal anatomy between 17 and 22 weeks of gestation at a single center from 2010 to 2014. After excluding patients with fetal structural malformations, chromosomal abnormalities, or identified infectious etiologies, we compared perinatal outcomes between pregnancies with and without fetal growth restriction, defined as estimated fetal weight less than the 10th percentile for gestational age. Our primary outcome was small for gestational age (SGA) at birth, defined as birth weight less than the 10th percentile. Secondary outcomes included preterm delivery at less than 37 and less than 28 weeks of gestation, preeclampsia, abruption, stillbirth, neonatal death, neonatal intensive care unit admission, intraventricular hemorrhage, need for respiratory support, and necrotizing enterocolitis. RESULTS: Of 12,783 eligible patients, 355 (2.8%) had early second-trimester fetal growth restriction. Risk factors for growth restriction were African American race and tobacco use. Early second-trimester growth restriction was associated with a more than fivefold increase in risk of SGA at birth (36.9% compared with 9.1%, adjusted odds ratio [OR] 5.5, 95% CI 4.3-7.0), stillbirth (2.5% compared with 0.4%, OR 6.2, 95% CI 2.7-12.8), and neonatal death (1.4% compared with 0.3%, OR 5.2, 95% CI 1.6-13.5). Rates of indicated preterm birth at less than 37 weeks of gestation (7.3% compared with 3.3%, OR 2.3, 95% CI 1.5-3.5) and less than 28 weeks of gestation (2.5% compared with 0.2%, OR 10.8, 95% CI 4.5-23.4), neonatal need for respiratory support (16.9% compared with 7.8%, adjusted OR 1.6, 95% CI 1.1-2.2), and necrotizing enterocolitis (1.4% compared with 0.2%, OR 7.7, 95% CI 2.3-20.9) were also significantly higher for those with growth restriction. Rates of preeclampsia, abruption, and other neonatal outcomes were not significantly different. CONCLUSION: Although fetal growth restriction in the early second trimester occurred in less than 3% of our cohort and most of those with isolated growth restriction did not have adverse outcomes, it is a strong risk factor for SGA, stillbirth, neonatal death, and indicated preterm birth.

Impact of evidence-based interventions on wound complications after cesarean delivery.

BACKGROUND: A number of evidence-based interventions have been proposed to reduce post-cesarean delivery wound complications. Examples of such interventions include appropriate timing of preoperative antibiotics, appropriate choice of skin antisepsis, closure of the subcutaneous layer if subcutaneous depth is ≥2 cm, and subcuticular skin closure with suture rather than staples. However, the collective impact of these measures is unclear. OBJECTIVE: We sought to estimate the impact of a group of evidence-based surgical measures (prophylactic antibiotics administered before skin incision, chlorhexidine-alcohol for skin antisepsis, closure of subcutaneous layer, and subcuticular skin closure with suture) on wound complications after cesarean delivery and to estimate residual risk factors for wound complications. STUDY DESIGN: We conducted a secondary analysis of data from a randomized controlled trial of chlorhexidine-alcohol vs iodine-alcohol for skin antisepsis at cesarean delivery from 2011-2015. The primary outcome for this analysis was a composite of wound complications that included surgical site infection, cellulitis, seroma, hematoma, and separation within 30 days. Risk of wound complications in women who received all 4 evidence-based measures (prophylactic antibiotics within 60 minutes of cesarean delivery and before skin incision, chlorhexidine-alcohol for skin antisepsis with 3 minutes of drying time before incision, closure of subcutaneous layer if ≥2 cm of depth, and subcuticular skin closure with suture) were compared with those women who did not. We performed logistic regression analysis limited to patients who received all the evidence-based measures to estimate residual risk factors for wound complications and surgical site infection. RESULTS: Of 1082 patients with follow-up data, 349 (32.3%) received all the evidence-based measures, and 733 (67.7%) did not. The risk of wound complications was significantly lower in patients who received all the evidence-based measures compared with those who did not (20.3% vs 28.1%; adjusted relative risk, 0.75; 95% confidence interval, 0.58-0.95). The impact appeared to be driven largely by a reduction in surgical site infections. Among patients who received all the evidence-based measures, unscheduled cesarean delivery was the only significant risk factor for wound complications (27.5% vs 16.1%; adjusted relative risk, 1.71; 95% confidence interval, 1.12-2.47) and surgical site infection (6.9% vs 1.6%; relative risk, 3.74; 95% confidence interval, 1.18-11.92). Other risk factors, which include obesity, smoking, diabetes mellitus, chorioamnionitis, surgical experience, and skin incision type, were not significant among patients who received all of the 4 evidence-based measures. CONCLUSION: Implementation of evidence-based measures significantly reduces wound complications, but the residual risk remains high, which suggests the need for additional interventions, especially in patients who undergo unscheduled cesarean deliveries, who are at risk for wound complications even after receiving current evidence-based measures.

Impact of fetal growth on pregnancy outcomes in women with severe preeclampsia.

OBJECTIVE: To estimate whether pregnancy outcomes in women with severe preeclampsia (sPE) with small for gestational age (SGA) fetuses differ from those with sPE without SGA or isolated SGA. STUDY DESIGN: We conducted a retrospective cohort study of consecutive non-anomalous, livebirths in a single tertiary care institution from 2004 to 2008. We compared pregnancy outcomes in women who had sPE with SGA (birthweight<10th percentile), and sPE without SGA to those with isolated SGA as reference. The primary outcome was a neonatal composite score including low 5-min APGAR, NICU admission and neonatal death. Secondary outcomes were components of the composite as well as placental abruption and cesarean delivery. Analysis was repeated with SGA defined as birthweight<5th percentile. Multivariable logistic regression was used to adjust for confounders. RESULTS: 1905 women met inclusion criteria: 156 sPE with SGA, 746 sPE without SGA, 1003 isolated SGA. The risk of the neonatal composite score was higher for sPE with SGA (adjusted odds ratio [aOR] 2.29; 95% confidence interval [CI] 1.39-3.79) and sPE without SGA (aOR 3.66; 95% CI 2.71-4.93) compared to isolated SGA. The risk of abruption and cesarean were similarly increased in women with sPE with SGA and sPE without SGA compared to those with isolated SGA. CONCLUSION: Similar to women with sPE without SGA fetus, women who have sPE with SGA are at a higher risk for several adverse maternal and neonatal outcomes compared to isolated SGA. These findings suggest that women with preeclampsia and SGA should be managed as sPE rather than as isolated SGA.

Delivery Outcomes after Term Induction of Labor in Small-for-Gestational Age Fetuses.

Objective The objective of this study was to estimate the delivery outcomes after induction of labor (IOL) at term in patients with small-for-gestational age (SGA) fetuses. Study Design A secondary analysis of a prospective cohort study of all term, singleton deliveries from 2010 to 2014. Patients who underwent an IOL for any indication were included. Delivery outcomes were compared between patients with and without SGA fetuses (defined as birth weight < 10th percentile for gestational age). Analysis was stratified by parity. Indication for cesarean was compared between the two groups for those who did not achieve vaginal delivery. Logistic regression was used to adjust for confounders. Results Of 3,787 patients who underwent an IOL, 644 patients had SGA fetuses and 3,143 were included in the non-SGA group. There was no significant difference in rate of successful vaginal delivery for patients with and without SGA fetuses (77.2 vs. 72.0% [adjusted odds ratio: 1.22, 95% confidence interval 1.00-1.50]). Of the patients who were delivered by cesarean, women with SGA fetuses were more likely to undergo cesarean for nonreassuring fetal status and less likely for arrest disorders than women without an SGA fetus. Conclusion Term patients undergoing IOL with SGA fetuses are as likely to achieve a vaginal delivery as patients with non-SGA fetuses.

Comparison of suture materials for subcuticular skin closure at cesarean delivery.

BACKGROUND: Subcuticular skin closure with suture after cesarean has been shown to result in lower rates of wound complications than with staple closure. However, the optimal choice of suture material for subcuticular skin closure is unclear. Vicryl (a braided multifilament synthetic suture; Ethicon, Somerville, NJ) and Monocryl (a monofilament synthetic suture; Ethicon) are the commonly used suture materials for subcuticular closure of transverse skin incisions after cesarean in the United States. Whereas in vitro and animal studies suggest multifilament suture materials may be associated with a higher risk of wound infection than monofilament sutures, clinical data on their relative effectiveness are limited. OBJECTIVE: We sought to test the hypothesis that Vicryl is associated with a higher rate of wound complications than Monocryl. STUDY DESIGN: This is a secondary analysis of data from a randomized trial in which pregnant women undergoing scheduled or unscheduled cesareans were randomly assigned to preoperative skin preparation with either chlorhexidine-alcohol or iodine-alcohol. Women with low transverse skin incisions who were closed with either 4-0 Monocryl or 4-0 Vicryl were included in this analysis. Choice of suture material was at the discretion of the operating physician. The primary outcome was superficial or deep surgical site infection within 30 days after cesarean. Secondary outcomes were other wound complications. Outcomes were compared between the 2 groups using univariable and multivariable statistics. RESULTS: Of 1082 patients who had follow-up after discharge in the primary trial, 871 had subcuticular suture: 180 with 4-0 Vicryl and 691 with 4-0 Monocryl. Skin closure with Vicryl or Monocryl did not significantly differ between women allocated to chlorhexidine-alcohol or iodine-alcohol (51.1% vs 49.4%, P = .67). There was no significant difference in the risk of surgical site infection in women closed with Vicryl compared with Monocryl (11 [6.1%] vs 35 [5.1%]; P = .58; adjusted odds ratio, 1.23; 95% confidence interval, 0.60-2.49). Rates of other wound complications were also not significantly different. Risks of surgical site infection were similar with Vicryl and Monocryl closure in all subgroups assessed. The relative risks were not materially affected by whether diabetes or obesity was present, cesarean was scheduled or unscheduled, primary or repeat cesarean, or the subcutaneous layer was closed. Post hoc power analysis indicated that we had 80% power to detect >2-fold difference in surgical site infections. CONCLUSION: Subcuticular skin closure with 4-0 Vicryl is associated with comparable rates of surgical site infection and other wound complications as 4-0 Monocryl. While this is an observational study with the potential for selection bias and residual confounding, our results suggest physician preference is acceptable for choice of subcuticular suture material at cesarean.

Pregnancy in Women With Solid-Organ Transplants: A Review.

IMPORTANCE: Advances in solid-organ transplantation have allowed many women to reach reproductive potential, and pregnancy is no longer a rarity for these women. OBJECTIVE: To identify (1) potential complications to allograft function posed by pregnancy, (2) expected perinatal outcomes in women with solid-organ transplants, (3) risks of potential immunosuppressant regimens, (4) safety of lactation, and (5) contraceptive options for women with solid-organ transplants. EVIDENCE ACQUISITION: Single-center, registry data, and previous systematic reviews were evaluated in women with solid-organ transplants to identify the objectives of this review. In addition, recommendations from public health organizations were examined in regard to safety of medications and contraceptive methods. RESULTS: Women with solid-organ transplants are at risk for premature birth, low birth weight, cesarean delivery, and hypertensive disorders of pregnancy. Most immunosuppressant regimens are safe; however, mycophenolate mofetil should be avoided. Lactation with tacrolimus, cyclosporine, azathioprine, and prednisone appears safe. Long-acting reversible contraceptive methods are safe and effective for transplant recipients. CONCLUSIONS: Many successful pregnancies have been achieved in women following transplantation; however, optimal perinatal outcomes require stable allograft function. RELEVANCE: As more women are becoming pregnant after organ transplantation, a review of obstetric recommendations and perinatal outcome is warranted.

The timing of antibiotics at cesarean: a randomized controlled trial.

We compared maternal and neonatal outcomes in women who received prophylactic antibiotics prior to skin incision to those who received antibiotics at cord clamp. We performed a randomized clinical trial at two sites. Eligible women included those undergoing nonemergency cesarean at 36 weeks' gestation or greater. Subjects were randomized (permuted blocks) into one of two treatments: "preoperative antibiotics" (cefazolin 1 g given <30 minutes prior to skin incision) or "intraoperative antibiotics" (cefazolin 1 g at cord clamping). Patients who reported an allergy to penicillin received clindamycin 900 mg. The trial primary outcome was a composite of maternal infectious morbidities, defined as having any one of the following: (1) postoperative fever (defined as oral temperature >38°C on two separate occasions more than 6 hours apart, after the initial 24-hour postoperative period); (2) wound infection (defined as purulent discharge from the incision); (3) endomyometritis (defined as fundal tenderness and fever malodorous lochia, fever); (4) urinary tract infection (defined as fever, positive urine culture). We enrolled a total of 434 subjects in this study, with 217 in each group. Overall, we found no difference in composite maternal infectious morbidity between those who received antibiotics preoperatively and those who received antibiotics at cord clamp (relative risk = 1.2, 95% confidence interval 0.7 to 1.5). Neonatal outcomes were also similar between the two intervention arms. The rate of suspected sepsis was similar between the two groups. There were no cases of antibiotic resistance in the neonates. Either preoperative antibiotic therapy or antibiotic administration after cord clamp is a reasonable clinical method for reducing the risk of postcesarean infectious morbidity.

Assessing the optimal definition of oligohydramnios associated with adverse neonatal outcomes.

OBJECTIVES: The purpose of this study was to compare the use of an amniotic fluid index (AFI) less than 5 cm to the use of an AFI less than the fifth percentile for gestational age in predicting adverse perinatal outcomes. METHODS: This was a retrospective cohort study from 1998 to 2008. Patients with an AFI less than 5 cm and those with an AFI less than the fifth percentile were compared to patients with a normal AFI. The primary outcome measure was neonatal intensive care unit (NICU) admission. RESULTS: A total of 17,887 patients had complete information for analysis. There were 145 NICU admissions in patients with an AFI less than 5 cm (relative risk, 2.2) compared to 235 in patients with an AFI less than the fifth percentile for gestational age (relative risk, 2.37). The sensitivity and specificity for NICU admission using an AFI less than 5 cm were 10.9% and 95.2% compared to 17.6% and 92.5% for an AFI less than the fifth percentile for gestational age. CONCLUSIONS: Oligohydramnios defined as an AFI less than the fifth percentile better predicts fetuses at risk for adverse perinatal outcomes compared to an AFI less than 5 cm.

Perinatal outcomes in women with preeclampsia and superimposed preeclampsia: do they differ?

OBJECTIVE: The purpose of this study was to determine whether superimposed preeclampsia results in worse perinatal outcomes than preeclampsia. STUDY DESIGN: We conducted a retrospective cohort study using our perinatal database (1990-2008). Perinatal outcomes among women with chronic hypertension (n = 1032), superimposed preeclampsia (n = 489), and preeclampsia (n = 4217) were compared with outcomes of control subjects (n = 57,103). Outcomes among women with superimposed preeclampsia were also compared with outcomes of women with preeclampsia. Multivariable analysis was used to control for confounders. RESULTS: Rates of small-for-gestational age, abruption, stillbirth, and eclampsia were not significantly different with superimposed preeclampsia compared with preeclampsia. Delivery at <34 weeks' gestation (17.3% vs 8.7%; P < .001), cesarean delivery (46.2% vs 36.3%; P < .001), and neonatal intensive care unit admission (16.3% vs 11.4%; P < .002) were significantly higher among women with superimposed preeclampsia. These risks persisted after we controlled for confounders. CONCLUSION: Women with superimposed preeclampsia have higher risks of intervention-related events compared with those with preeclampsia.

Staples compared with subcuticular suture for skin closure after cesarean delivery: a systematic review and meta-analysis.

OBJECTIVE: To estimate whether staples or subcuticular suture closure is associated with a higher risk of wound complications when used for transverse skin incisions after cesarean delivery. DATA SOURCES: A systematic review and meta-analysis were performed through electronic database searches (MEDLINE, Cochrane, and Trial Registries). METHODS OF STUDY SELECTION: We searched electronic databases from 1966 to September 2010 for randomized controlled trials (RCTs) and prospective cohort studies comparing staples to subcuticular sutures after cesarean delivery. The primary outcome was occurrence of a wound complication (infection or separation). Secondary outcomes were components of the composite outcome, operating time, postoperative pain, cosmesis, and patient satisfaction. Heterogeneity was assessed using the χ test for heterogeneity, and I test. Pooled odds ratios (ORs) were calculated using a fixed-effects model. We assessed publication bias using funnel plots and Egger test. RESULTS: Six studies met inclusion criteria: five RCTs and one prospective cohort study. Staple closure (n=803) was associated with a twofold higher risk of wound infection or separation compared with subcuticular suture closure (n=684) (13.4% versus 6.6%, pooled OR 2.06, 95% confidence interval [CI] 1.43-2.98). The number needed to harm associated with staple closure was 16. The increased risk persisted when analysis was limited to the RCTs (OR 2.43, 95% CI 1.47-4.02). There was no evidence of significant statistical heterogeneity among studies (χ=0.74, P=.327, I=13.7%) or publication bias (Egger test, t=-0.86, P=.439). Staple closure was associated with shorter duration of surgery, whereas the two techniques appeared equivalent overall with regard to pain, cosmesis, and patient satisfaction. CONCLUSION: Staple closure is faster to perform but associated with a higher risk of wound complications.

Prenatal screening for thrombophilias: indications and controversies.

A thrombophilia is defined as a disorder of hemostasis that predisposes a person to a thrombotic event. Data suggest that at least 50% of cases of venous thromboembolism in pregnant women are associated with an inherited or acquired thrombophilia, which can lead to an increased risk of maternal thromboembolism and adverse pregnancy outcomes such as recurrent pregnancy loss, intrauterine fetal demise, preterm preeclampsia, and intrauterine growth restriction. Inherited and acquired thrombophilias have different indications for testing. This article examines screening procedures for thrombophilias in the setting of adverse pregnancy outcomes.

Prevalence and likelihood ratios for aneuploidy in fetuses diagnosed prenatally with isolated congenital cardiac defects.

OBJECTIVE: To determine the prevalence and likelihood ratios for aneuploidy in fetuses diagnosed prenatally with isolated congenital cardiac defects. STUDY DESIGN: Retrospective cohort study over a 16-year period using our computerized perinatal database. Cardiac diagnosis was confirmed before establishing karyotype by prenatal diagnosis or postnatal chromosome testing. The screening efficiency and likelihood ratios for any aneuploidy and for trisomy 21, 18, 13, and 45, X were calculated with 95% confidence intervals. RESULTS: A total of 233 (0.4%) isolated congenital cardiac defects were diagnosed among 62,111 patients who had obstetric ultrasounds during the study period. The likelihood ratio (LR+) for any aneuploidy was 24.9 (95% confidence interval [CI], 17.8-35.0). The corresponding likelihood ratio for trisomy 21, 18, and 13 were 29.8 (95% CI, 19.6-45.4), 26 (95% CI, 10.5-64.6), and 19.7 (95% CI, 4.7-82.2), respectively. CONCLUSION: Prenatal diagnosis of congenital cardiac defects is highly associated with aneuploidy.

Do vaginal birth after cesarean outcomes differ based on hospital setting?

OBJECTIVE: The objective of the study was to test the null hypothesis that outcomes of vaginal birth after cesarean (VBAC) do not differ on the basis of the hospital setting. STUDY DESIGN: The study was a retrospective cohort study of women who were offered VBAC in 17 hospitals from 1996 to 2000. VBAC attempts occurring in hospitals with and without obstetrics-gynecology residency programs were compared, as were outcomes from university and community hospitals. Bivariate and multivariate logistic regression analyses assessed the association between hospital setting and VBAC outcomes. RESULTS: Of 25,065 women with 1 or more prior cesareans, the VBAC attempt rate was 56.1% at hospitals with obstetrics-gynecology residencies, 51.3% at hospitals without obstetrics-gynecology residencies, 61% at university hospitals, and 50.4% at community hospitals. The occurrence of failed VBAC, blood transfusion, or composite adverse outcome did not differ by hospital setting. There was a significant increase in the uterine rupture rate at community (1.2%) vs university hospitals (0.6%), but the absolute risk remained low. CONCLUSION: The rate of VBAC-associated complications is low, independent of hospital setting.

Trophoblast biology, responses to hypoxia and placental dysfunction in preeclampsia.

Preeclampsia is a hypertensive disorder unique to human pregnancy that can result in significant morbidity and mortality for mother and fetus. While the etiology of preeclampsia is unknown, the placenta in general and trophoblast in particular is a prerequisite for the disease. We overview normal development of the human placenta, describe the role of hypoxia and other insults in placental injury, and highlight how the dysregulation of villous trophoblast biology in the second half of pregnancy may incite the pathophysiology of preeclampsia in the mother.