Outcomes of pregnancy and delivery in women with cardiac disease compared to matched healthy controls.

OBJECTIVE: We compared pregnancy and delivery outcomes between women with cardiac disease versus matched healthy controls. The primary outcome was the frequency of unplanned cesarean delivery. METHODS: In this single-center retrospective case-control study, women with cardiac disease were identified and matched (1:2 ratio, according to maternal age, parity, number of prior cesareans, gestational age, delivery onset and fetal presentation) to healthy controls who delivered within the same year. Outcomes were frequency of unplanned cesarean delivery, complications during pregnancy and postpartum course, intensive care unit (ICU) admissions, and length of hospitalization. RESULTS: One hundred and twelve women with cardiac disease (exposed group, 225 deliveries) were identified and matched with 450 healthy women (controls, 2003-2014). The cohort comprised of 103 women (204 deliveries) with acquired heart disease (valve disease [n = 69], arrhythmia [n = 31], 3 with cardiomyopathy and peri/myocarditis, and 9 women (21 deliveries) with congenital heart disease. The frequency of unplanned cesarean was 14 (7.9%) for the exposed group as compared with 12 (3.4%) in controls with an odds ratio of 2.33 (95% CI = 1.0.2-5.32, p = .045). This difference was accentuated in a sub-group of women with severe cardiac disease (15% vs. 4.2% in matched control group, p = .028). Seventy-one (31.6%) exposed women exhibited obstetric and cardiovascular complications during pregnancy as compared with 65 (14.4%) controls, p < .001. Twenty-five (13.9%) exposed women experienced postpartum complications versus 26 (7.5%) in the control group (p = .019). Maternal ICU admission occurred in 13 (7.3%) of the exposed group as compared with only 2 (0.6%) in controls (p < .001). CONCLUSIONS: Women with a background cardiac condition, particularly those with severe disease, are at a higher risk for an unplanned cesarean delivery and other peripartum complications as compared with matched healthy controls.

History-indicated cervical cerclage in management of twin pregnancy.

OBJECTIVE: Cervical cerclage, when performed in twin gestation, has been reported to be associated with poor outcome. However, the role of first-trimester history-indicated cerclage among women with a twin pregnancy and a history of preterm birth has not been evaluated. The aim of this study was to assess pregnancy outcomes among women with a twin pregnancy who underwent first-trimester history-indicated cervical cerclage compared with outcomes in those managed expectantly. METHODS: This was a retrospective matched case-control study. The study group comprised all women with a twin pregnancy who had undergone first-trimester history-indicated cerclage during the period 2006 to 2017 at Hadassah-Hebrew University Medical Center. A control group of women with a twin pregnancy who were managed expectantly was established by matching age, history of spontaneous preterm birth (20-36 weeks' gestation) and year of delivery. Pregnancy and delivery characteristics and neonatal outcomes were compared between the two groups. RESULTS: Data from 82 women with a twin gestation were analyzed, of whom 41 underwent first-trimester history-indicated cerclage and 41 were matched controls who were managed expectantly. Gestational age at delivery was higher in the cerclage group than in those managed expectantly (median 35 vs 30 weeks; P < 0.0001). Rates of spontaneous preterm birth before 24 weeks (2.4% vs 19.5%; odds ratio (OR), 0.10 (95% CI, 0.01-0.87); P = 0.03), before 28 weeks (12.2% vs 34.1%; OR, 0.27 (95% CI, 0.09-0.84); P = 0.03), before 32 weeks (22.0% vs 56.1%; OR, 0.22 (95% CI, 0.08-0.58); P = 0.003) and before 34 weeks (34.1% vs 82.9%; OR, 0.11 (95% CI, 0.04-0.30); P < 0.0001) were significantly lower in the cerclage group than in the control group. Median birth weight was higher in the cerclage group (2072 g vs 1750 g; P = 0.003), with lower rates of low birth weight (< 2500 g) (65.0% vs 89.4%; P = 0.001) and very low birth weight (< 1500 g) (21.3% vs 37.9%; P = 0.03) than in the group managed expectantly. Rates were also lower in the cerclage group for stillbirth, admission to the neonatal intensive care unit, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, neonatal mortality and composite adverse neonatal outcome. CONCLUSIONS: History-indicated cerclage performed in the first trimester, as compared with expectant management, in women with a twin pregnancy had an overall positive effect on pregnancy and neonatal outcomes. These findings suggest the need for adequate randomized trials on cerclage placement in this subset of women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The risk of overt diabetes mellitus among women with gestational diabetes: a population-based study.

AIMS: To determine the incidence of postpartum diabetes mellitus in the years following a diagnosis of gestational diabetes mellitus (GDM) and to determine whether the severity of GDM, represented by the magnitude of the deviation of diagnostic tests from the normal values or requirement for medications, is associated with the development of diabetes. METHODS: A retrospective cohort study was performed among 185 416 pregnant women who had glucose challenge test or 3 h oral glucose tolerance test (OGTT) in a large health maintenance organization in Israel. Subsequent diagnosis of diabetes was ascertained by using an automated patient registry. RESULTS: A total of 11 270 subjects were diagnosed with GDM, comprising 6.07% of the cohort. During a total follow-up period of 1 049 334 person-years there were 1067 (16.9 per 1000 person-years) and 1125 (1.1 per 1000 person-years) diagnoses of postpartum diabetes among GDM and non-GDM women, respectively. The cumulative risk of incident diabetes in GDM patients with up to 10 years of follow-up was 15.7%, compared with 1% among the non-GDM population. Gestational diabetes mellitus was associated with nearly an eightfold higher risk of postpartum diabetes after adjusting for important confounders, such as socioeconomic status and body mass index. Among women with a history of GDM, the number of abnormal OGTT values and use of insulin were associated with a substantially higher risk for developing diabetes. CONCLUSIONS: Three or four abnormal OGTT values and GDM requiring insulin or oral hypoglycaemic medications are important predictors of postpartum diabetes risk in women with a history of GDM.

Randomized controlled trial of external cephalic version in term multiparae with or without spinal analgesia.

BACKGROUND: Neuraxial analgesia significantly increases the success rate of external cephalic version (ECV) among nulliparae. The study objective was to compare ECV success among multiparae with and without spinal analgesia. METHODS: Prospective randomized controlled trial performed over a pre-defined 6 yr period in a tertiary referral delivery suite. Healthy multiparae at term requesting ECV for breech presentation, without fetal or uterine anomaly, were enrolled after written informed consent. Women were randomized to receive either spinal analgesia (bupivacaine 7.5 mg) or no analgesia before the ECV. The primary outcome was successful conversion from breech to vertex presentation, confirmed by ultrasound. Visual analogue pain score and adverse outcomes (complications of anaesthesia or ECV) were recorded. Statistical analysis was performed according to intention to treat using two-sided tests. RESULTS: Among 265 multiparae who underwent ECV, 65 consented to enrol, one subsequently refused ECV; therefore, data from 64 women were analysed. ECV was successful in 27 of 31 patients (87.1%) receiving spinal analgesia vs 19 of 33 (57.5%) with no analgesia (P=0.009; 95% CI of difference: 0.075-0.48). ECV with spinal analgesia reduced visual analogue pain score, mean (sd) 1.7 (2.4) vs 5.5 (2.9) without (P<0.0001). Maternal hypotension was seen after spinal analgesia in 10 of 31 (32%) (P=0.0003) and easily treated without adverse outcome. No complications were noted after the ECV. CONCLUSIONS: Administration of spinal analgesia significantly increased the rate of successful ECV among multiparae at term with increased patient comfort. The trial was registered at the National Institute of Health Trials Registry, NCT00119184, www.clinicaltrials.gov.

Walking reduces the post-void residual volume in parturients with epidural analgesia for labor: a randomized-controlled study.

BACKGROUND: The post-void residual volume is higher among parturients who received epidural analgesia than those who received no or alternative analgesia. METHODS: This prospective, randomized, controlled, non-blinded study was performed in a tertiary referral center labor suite. The post-void residual volume was measured by a transabdominal ultrasound following a voiding attempt. Healthy parturients with low-dose epidural analgesia in active labor were randomized either to walk to the toilet or to use a bedpan for voiding. The primary outcome measure (post-void residual volume in labor) was compared between the study groups. RESULTS: The toilet group (n=34) and the bedpan group (n=28) demonstrated similar post-void residual volumes (212 +/- 100 vs. 168 +/- 93 ml, P=0.289). Twenty patients (59%) randomized to the toilet group were unable to walk and actually voided in a bedpan. A secondary analysis was performed analyzing the groups as treated. The post-void residual volume was significantly lower in the actual toilet group (n=14, 63 +/- 24 ml) vs. the bedpan group (n=48, 229 +/- 200 ml), P=0.0052. Thirteen (93%) women who walked to the toilet managed to void before the ultrasound measurement vs. 20/48 (42%) using the bedpan, P=0.001. Fewer women who managed to walk to the toilet required urinary bladder catheterization during the labor than women who used the bedpan (6/14, 43% vs. 36/48, 75%) P=0.028. CONCLUSION: Women who were randomized to walk to the bathroom with epidural analgesia and were able to do so during labor had a significantly reduced post-void residual volume and a reduced requirement for urinary catheterization.

Early diagnosis and treatment of atrioventricular block in the fetus exposed to maternal anti-SSA/Ro-SSB/La antibodies: a prospective, observational, fetal kinetocardiogram-based study.

BACKGROUND: A fetus exposed to maternal anti-SSA/Ro or anti-SSB/La antibodies (or both) may develop complete atrioventricular block (AVB), which results in high prenatal and postnatal morbidity and mortality. Until recently, only high-grade AVB could be diagnosed in utero. The tissue velocity-based fetal kinetocardiogram (FKCG) enables accurate measurement of AV conduction time and diagnosis of low-grade AVB. In the present multicenter observational study, we used FKCG to detect first-degree AVB in fetuses at risk. METHODS AND RESULTS: FKCG was performed in 70 fetuses of 56 mothers who were positive for anti-SSA/Ro and/or anti-SSB/La. Fetuses were monitored with weekly FKCG from 13 to 24 weeks' gestation, followed by monthly assessments until delivery in unaffected fetuses and weekly assessments in affected fetuses. AV conduction in 70 at-risk and 109 normal fetuses was compared. FKCG was obtained readily in all fetuses; 6 showed first-degree AVB (AV conduction time >2 z scores above normal mean) at 21 to 34 gestational weeks. Immediate maternal treatment with dexamethasone resulted in normalization of AV conduction in all affected fetuses within 3 to 14 days. AV conduction time in the remaining 64 untreated fetuses remained normal throughout gestation. The ECG PR interval immediately after birth was normal in all affected newborns. No child developed AVB or cardiomyopathy in the subsequent 1- to 6-year (median 4-year) follow-up. CONCLUSIONS: The present findings suggest that an FKCG can detect first-degree AVB in the fetus exposed to maternal anti-SSA/Ro or anti-SSB/La antibodies (or both). Dexamethasone given on detection was associated with normalized AV conduction in fetuses with first-degree AVB. No fetus in the present study developed complete prenatal or postnatal AVB.

Antepartum continuous epidural ropivacaine therapy reduces uterine artery vascular resistance in pre-eclampsia: a randomized, dose-ranging, placebo-controlled study.

BACKGROUND: No therapy is currently available to improve the reduced uteroplacental blood flow (UPBF) that characterizes pre-eclampsia. We hypothesized that sympathectomy induced by epidural local anaesthesia reduces uterine vascular resistance (which is inversely correlated with UPBF) in pre-eclampsia. METHODS: Ten pregnant women between 24 and 32 weeks of gestation with pre-eclampsia and uterine artery flow abnormalities were randomized to antepartum continuous epidural therapy (ACET) or control. ACET was initiated by a 5 day dose-ranging trial (ACET-1) of 0.04, 0.06, 0.08, and 0.1% ropivacaine and saline placebo, each at 10 ml h(-1) for 24 h. Doses were randomized and double-blind. Doppler ultrasound indices of vascular resistance were assessed at baseline and after each 24 h dosing period in both uterine arteries. Subsequently, these ACET patients were administered 0.1% ropivacaine until delivery (ACET-2), with one additional randomized double-blind placebo day. RESULTS: Five patients were randomized to ACET. In each patient, one uterine artery exhibited a dose-dependent reduction in vascular resistance (P=0.035), a response that returned to baseline following placebo (P<0.001). The contralateral uterine artery exhibited either increased vascular resistance or no change. In all cases, the uterine artery that responded to ACET had higher baseline resistance than its pair (P=0.043). Baseline right-left difference in resistance between paired uterine arteries was greatly diminished following ACET. Although ACET patients had a mean (sd) duration to delivery of 19 (9) days compared with control 2 (1) days (P=0.008), this should be interpreted with caution because of demographic differences between groups. CONCLUSIONS: ACET reduces uterine artery resistance in pre-eclampsia <32 weeks. Uteroplacental re-distribution is a novel observation and warrants further investigation.

Maternal morbidity following routine second trimester genetic amniocentesis.

Two cases of septic complications of routine second trimester amniocentesis are presented. The first case is a 37-year-old gravida suffering from ulcerative colitis who was admitted for amniocentesis in the 18th week of her third pregnancy. An uncomplicated transabdominal amniocentesis was performed using a sterile technique and ultrasound guidance. Twenty-eight hours later the patient had a septic abortion and sepsis. The second case is a 34-year-old gravida in the 24th week of her pregnancy who was admitted with amnionitis 10 h after an uncomplicated amniocentesis, and subsequently had a septic abortion. A high index of suspicion and rapid intervention were crucial in both cases.

Post-void residual volume in labor: a prospective study comparing parturients with and without epidural analgesia.

BACKGROUND: This prospective, non-randomized study compared post-void residual volume in laboring and postpartum women with or without epidural analgesia. METHODS: The study was conducted over 1 year with institutional review board approval. Parturients were recruited in early labor and self-selected to either the study (with epidural) or control (without epidural) group. Post-void residual volume was compared between groups, using transabdominal ultrasound during labor, and on postpartum day 1 and 2. Main outcome measure was intrapartum residual bladder volume. RESULTS: Thirty patients were recruited to each group. During labor, residual bladder volume was significantly larger in the epidural group compared with the non-epidural group [median (range)] 240 (12-640), ml vs. 45 (13-250) ml, respectively, P < 0.001], but was similar on postpartum day 1 and 2. Twenty-five (83%) women with epidural analgesia required bladder catheterization during labor vs. one (3.3%) without (P < 0.0001). CONCLUSION: The greater post-void residual volume and increased inability to void in parturients with epidurals suggests that epidural analgesia plays a role in intrapartum urinary retention.

Holy consent--a dilemma for medical staff when maternal consent is withheld for emergency caesarean section.

A parturient (grand multipara) developed arrested labour complicated by severe fetal heart rate decelerations. Senior physicians explained the need for a caesarean section, but she chose to deliver vaginally since rabbinical blessing could not be obtained. Forcing the mother to have a cesarean section without consent is considered "civil battery." The dilemma faced by medical staff and the implications of her refusal for the treating medical staff are described.