Accuracy and utilization patterns of intraabdominal imaging for major trauma in pregnancy.

BACKGROUND: Imaging protocols for major maternal trauma during pregnancy are not standardized, and it is uncertain whether focused assessment with sonography for trauma or computed tomography of the abdomen/pelvis is preferred for detecting intraabdominal hemorrhage. OBJECTIVE: This study aimed to estimate the accuracy of focused assessment with sonography for trauma compared with computed tomography of the abdomen/pelvis, validate imaging accuracy with clinical outcomes, and describe clinical factors associated with each imaging mode. STUDY DESIGN: A retrospective cohort study of pregnant patients evaluated for major trauma at one of two Level 1 trauma centers between 2003 and 2019. We identified 4 imaging groups: no intraabdominal imaging, focused assessment with sonography for trauma only, computed tomography of the abdomen/pelvis only, and both focused assessment with sonography for trauma and computed tomography of the abdomen/pelvis. The primary outcome was a composite maternal severe adverse pregnancy outcome, including death and intensive care unit admission. We estimated sensitivity, specificity, and positive and negative predictive values of focused assessment with sonography for trauma for hemorrhage with computed tomography of the abdomen/pelvis as the reference standard. We performed analysis of variance and chi-square tests to compare clinical factors and outcomes across imaging groups. Multinomial logistic regression was used to estimate associations between selected imaging mode and clinical factors. RESULTS: Of 119 pregnant trauma patients, 31 (26.1%) experienced a maternal severe adverse pregnancy outcome. Intraabdominal imaging modes included none in 37.0%, focused assessment with sonography for trauma only in 21.0%, computed tomography of the abdomen/pelvis only in 25.2%, and both modes in 16.8%. With computed tomography of the abdomen/pelvis as the reference, focused assessment with sonography for trauma had sensitivity, specificity, positive predictive value, and negative predictive value of 11%, 91%, 50%, and 55%, respectively. One patient had a maternal severe adverse pregnancy outcome with a positive focused assessment with sonography for trauma and negative computed tomography of the abdomen/pelvis, and 2 patients with a positive computed tomography of the abdomen/pelvis did not have an adverse outcome. Use of computed tomography of the abdomen/pelvis with or without focused assessment with sonography for trauma was associated with a higher injury severity score, lower systolic blood pressure nadir, higher motor vehicle collision speed, and higher rates of hypotension, tachycardia, bone fracture, maternal severe adverse pregnancy outcome, and fetal demise. The association of computed tomography of the abdomen/pelvis use with higher injury severity score, tachycardia, and lower systolic blood pressure nadir persisted in multivariable analysis. With each 1-point increase in the injury severity score, there was an 11% higher likelihood of using computed tomography of the abdomen/pelvis over focused assessment with sonography for trauma for intraabdominal imaging. CONCLUSION: The sensitivity of focused assessment with sonography for trauma in detecting intraabdominal hemorrhage in pregnant trauma patients is poor, and computed tomography of the abdomen/pelvis has a low false-negative rate. Providers seem to prefer computed tomography of the abdomen/pelvis to focused assessment with sonography for trauma in patients with the most severe trauma. Computed tomography of the abdomen/pelvis with or without focused assessment with sonography for trauma is more accurate than focused assessment with sonography for trauma alone.

Neonatal morbidity associated with maternal Group B Streptococcal colonization in individuals undergoing planned cesarean delivery.

OBJECTIVE: To examine the association between unknown maternal Group B Streptococcal (GBS) colonization and the risk of severe neonatal morbidity among individuals undergoing planned cesarean delivery. METHODS: We performed a secondary analysis of a multicenter, prospective observational study of individuals with singleton gestations and planned cesarean delivery ≥37 weeks gestation with cervical dilation ≤3 cm, intact membranes, and no evidence of labor or induction. GBS status was categorized as positive, negative, or unknown. The primary outcome was a composite of severe neonatal morbidity, including clinical or culture-proven sepsis, ventilator support in the first 24 h, respiratory distress syndrome, hypotension requiring treatment, intubation, necrotizing enterocolitis, hypoxic-ischemic encephalopathy, or death. We compared individuals with unknown GBS status to those with positive and negative GBS status. RESULTS: In this cohort, 4,963 individuals met inclusion criteria; 72% had unknown GBS status, 25% were GBS negative and 3% were GBS positive. Among individuals with unknown GBS status, 208 (5.9%) had the primary composite neonatal outcome, compared with 75 (6%) of GBS negative individuals and 6 (4%) of GBS positive individuals. There was no difference in composite severe neonatal morbidity among GBS unknown, GBS negative, and GBS positive individuals (5.9% vs 6% vs 4%, p = .61). After adjusting for male sex and intrapartum antibiotic exposure, unknown GBS status was not associated with severe neonatal morbidity (adjusted risk ratio, 0.95; 95% confidence interval, 0.73-1.22). CONCLUSION: GBS status at time of planned cesarean delivery does not appear to be associated with composite severe neonatal morbidity. The cost effectiveness and clinical utility of GBS screening among individuals undergoing planned cesarean delivery requires further investigation.

Association of Maternal Obesity with Child Cerebral Palsy or Death.

Objective The primary aim of this study was to determine if there is an association between maternal obesity and cerebral palsy or death in children. Study Design This is a retrospective cohort analysis of a randomized controlled clinical trial previously performed by the Maternal-Fetal Medicine Units Network. Women in the original trial were included if at high risk for preterm delivery. The present study included singletons enrolled in the original study with complete data. Obese and nonobese women were compared. A secondary analysis comparing class 3 obese or classes 1 to 2 obese women to nonobese women was performed. The primary outcome was a composite of cerebral palsy or perinatal death. Results In this study, 1,261 nonobese, 339 obese, and 69 morbidly obese women were included. When adjusted for gestational age at delivery and magnesium exposure, there was no association between maternal obesity and child cerebral palsy or death. In the analysis using obesity severity categories, excess risk for adverse outcome appeared confined to the class 3 obese group. Conclusion In women at high risk of delivering preterm, maternal obesity was not independently associated with child cerebral palsy or death. The association in unadjusted analysis appears to be mediated by preterm birth among obese patients.

Genomics of Preterm Birth--Evidence of Association and Evolving Investigations.

Preterm birth (PTB) is a large public health problem in the United States and worldwide. There is a clear genetic component to the pathogenesis of PTB, as evidenced by twin studies, heritability studies, and investigations from large population databases. Although numerous single nucleotide polymorphisms have been associated with PTB, results have been inconsistent and overall disappointing. With recent advances in genetic technology, investigations are moving beyond simple, more traditional candidate gene studies, and have expanded to encompass more exploratory analyses using high-throughput genetic techniques. Care should be taken to consider the potential impact of fetal genotype, the environment, and gene-drug interactions (pharmacogenomics) in addition to maternal genotype. Future research should capitalize on evolving analytic techniques, including pathway analyses and correlation of genetic and functional data to optimize discovery, increase knowledge regarding prematurity pathogenesis, and begin to develop novel therapeutic strategies.

Maternal obesity and neuroprotective magnesium sulfate.

OBJECTIVE: Given the association between risk of cerebral palsy and children born to obese women, the study aim was to estimate whether maternal obesity is associated with reduced effectiveness of conventional antenatal magnesium sulfate dosing for the prevention of cerebral palsy and death. STUDY DESIGN: This is a secondary cohort analysis of a multicenter randomized clinical trial completed by the Maternal-Fetal Medicine Units Network. Women were included in the original trial if deemed high risk for preterm delivery in the subsequent 24 hours. The present study included singleton, nonanomalous fetuses that were randomized to and received magnesium sulfate with complete data available. Outcomes between obese (body mass index ≥30 kg/m(2)) and nonobese women were compared. A secondary analysis of outcomes between morbidly obese (body mass index ≥40 kg/m(2)) and nonmorbidly obese women was performed. The primary outcome was a composite of cerebral palsy or perinatal death before 15 months corrected age. Secondary outcomes included moderate to severe cerebral palsy or death, any cerebral palsy, moderate to severe cerebral palsy, and death. A logistic regression analysis was used to estimate the odds ratio of each outcome. Based on sample size, exposure rate (obesity) and an outcome rate of 10%, assuming an 80% power and a 0.05 alpha error, this study had sufficient power to detect a 2-fold increase in the primary outcome. RESULTS: Of 1188 women randomized to receive magnesium sulfate, 806 were included in this analysis. After adjusting for gestational age at delivery, maternal obesity was not associated with an increased risk of cerebral palsy or death in children born to women who received magnesium sulfate. Women with morbid obesity had higher rates of the primary outcome and cerebral palsy in an unadjusted analysis but did not have increased risks after adjusting for gestational age at delivery. In analyses stratified on gestational age, morbidly obese women who delivered after 28 weeks had increased risks of children with cerebral palsy or death and cerebral palsy, although case numbers were small. CONCLUSION: Among women receiving antenatal neuroprotective magnesium sulfate, maternal obesity is not associated with an increased risk of having a child with cerebral palsy or death.

Association between Cerebral Palsy or Death and Umbilical Cord Blood Magnesium Concentration.

OBJECTIVE: This study aims to evaluate whether magnesium sulfate (MgSO4) infusion at the time of delivery or magnesium cord blood concentration is associated with cerebral palsy (CP) or death diagnosed by the age of 2 years. METHODS: Secondary analysis of data from a randomized trial of MgSO4 versus placebo for prevention of CP or death among offspring of women with anticipated preterm delivery. This study cohort included singleton, nonanomalous fetuses, whose mothers received MgSO4 as neuroprophylaxis. The primary outcomes were CP or death diagnosed by the age of 2 years. RESULTS: A total of 936 neonates (93 with CP or death, 843 controls) were included in the analysis. Infants in the group with CP or death had MgSO4 infusing at delivery at a similar frequency to that of controls (49 [52.7%] vs. 463 [54.9%], p = 0.68). Mean concentrations of cord blood magnesium, available for 596 neonates, also were not different between the two groups (2.7 ± 0.9 vs. 2.6 ± 0.9 mEq/L, p = 0.66, respectively). Multivariable analyses did not alter these findings. CONCLUSION: Among the offspring of women exposed to MgSO4, in utero, neither MgSO4 infusion at the time of delivery nor magnesium cord blood concentration is associated with CP or death.

Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomes.

OBJECTIVE: To evaluate the association of duration of magnesium sulfate infusion with stillbirth or death, cerebral palsy, and select adverse maternal and neonatal outcomes. METHODS: This is a secondary cohort analysis of women randomized to receive magnesium sulfate within a previously reported Maternal-Fetal Medicine Units Network prospective clinical trial. The association of antenatal infusion of magnesium sulfate for less than 12 hours, 12-18 hours, and greater than 18 hours on maternal and perinatal outcomes was compared. The primary outcome was cerebral palsy of any severity or death. Secondary outcomes included cerebral palsy, death, and select maternal and neonatal outcomes. Stratified and logistic regression analyses were used. The models were adjusted for race, gestational age at birth, time since last magnesium sulfate, any magnesium sulfate at delivery, and eligibility criteria as appropriate. RESULTS: Of 933 women available for analysis, 356, 341, and 236 received antenatal magnesium sulfate infusion for a total of less than 12 hours, 12-18 hours, or greater than 18 hours, respectively. Any cerebral palsy or death occurred in 39 women (11.7%) who received magnesium sulfate less than 12 hours, 34 women (10.3%) who received 12-18 hours of magnesium sulfate, and 20 women (8.8%) who received greater than 18 hours of magnesium sulfate. There was no difference in death or cerebral palsy among groups (less than 12 hours as reference; adjusted odds ratio [OR] 1.03, 95% confidence interval [CI] 0.60-1.77 for 12-18 hours; adjusted OR 1.08, 95% CI 0.57-2.03 for greater than 18 hours). Select maternal adverse drug affects and neonatal morbidities were also similar across groups. CONCLUSION: The duration of antenatal magnesium sulfate infusion is not associated with risk of death or cerebral palsy. The optimal treatment duration needed for maximal neuroprotection remains unknown. LEVEL OF EVIDENCE: : II.

Nonreassuring fetal status during trial of labor after cesarean.

OBJECTIVE: Concern for uterine rupture has led to the decline in vaginal births after cesarean. Nonreassuring fetal status (NRFS) may precede uterine rupture. The objective of this study was to estimate the risks of uterine rupture, uterine dehiscence, and adverse fetal outcomes associated with NRFS during trial of labor after cesarean (TOLAC). STUDY DESIGN: In a retrospective cohort study of the previously reported Maternal-Fetal Medicine Units Network prospective cohort cesarean registry, we compared women undergoing repeat cesarean for NRFS after TOLAC to those requiring repeat cesarean for other intrapartum indications. Exclusion criteria included women with a prior cesarean who underwent elective or indicated repeat cesarean or women with a multiple gestation. Primary outcomes included uterine rupture or dehiscence. Secondary outcomes included 5-minute Apgar score <7 and neonatal intensive care unit admission. Planned subanalyses for term and preterm deliveries were performed. Stratified and logistic regression analyses were used. RESULTS: Of 17,740 women undergoing TOLAC, 4754 (26.8%) had a failed vaginal birth after cesarean. Of those, NRFS was the primary indication for cesarean in 1516 (31.9%). Women with NRFS as the primary indication for repeat cesarean were at increased risk of uterine rupture (adjusted odds ratio, 3.32; 95% confidence interval, 2.21-5.00), uterine dehiscence (adjusted odds ratio, 1.70; 95% confidence interval, 1.09-2.65), 5-minute Apgar score <7, and neonatal intensive care unit admission compared to women with other primary indications. CONCLUSION: Women attempting TOLAC who require repeat cesarean for NRFS are at increased risk of uterine rupture and uterine dehiscence.

Labor progression in teenage women.

OBJECTIVE: Compare labor progression in first and second stages in women < 18 years with those ≥18 years. STUDY DESIGN: Retrospective cohort study of consecutive women at term that reached the second stage of labor between 2004 and 2008. The first stage in women < 18 years was compared with women ≥18 years. Average labor curves were constructed and median time spent to progress 1 cm in dilation and total time from 4 to 10 cm was estimated. Time spent pushing and total duration of second stage were compared between groups. Analyses were then stratified by parity. RESULTS: There was no significant difference in progress of the first stage of labor between women < 18 years and those ≥18 years. In the second stage, nulliparous teenage women were less likely to have a duration > 60 or 120 minutes. CONCLUSION: Laboring women < 18 years should be managed with the same expectations of labor as women ≥18 years.

Maternal seizure disorder and risk of adverse pregnancy outcomes.

OBJECTIVE: We sought to estimate the association between maternal seizure disorder and adverse pregnancy outcomes. STUDY DESIGN: We performed a retrospective cohort study of singleton, nonanomalous pregnancies. Women with self-reported seizure disorder were compared to women without medical problems. The primary outcome was intrauterine growth restriction (IUGR) <10th percentile. Secondary outcomes included IUGR <5th percentile, stillbirth, preeclampsia, and preterm delivery. A sensitivity analysis was performed using women who reported using antiepileptics to estimate the impact of disease severity on pregnancy outcomes. RESULTS: Of 47,118 women, 440 reported a seizure disorder. Women with seizure disorder were not at increased risk of IUGR <10th percentile (adjusted odds ratio, 1.11; 95% confidence interval, 0.82-1.50), IUGR <5th percentile, stillbirth, preeclampsia, or preterm delivery. The results were similar in the sensitivity analysis of women taking antiseizure medications. CONCLUSION: Our results suggest women with a seizure disorder are not at increased risk of IUGR, stillbirth, preeclampsia, or preterm delivery.

Adverse outcomes in twin pregnancies complicated by early vaginal bleeding.

OBJECTIVE: We sought to estimate the risks of adverse pregnancy outcomes associated with early vaginal bleeding in twin pregnancies. STUDY DESIGN: In a retrospective cohort study of consecutive twin pregnancies undergoing anatomic survey, we compared women who reported vaginal bleeding at <22 weeks to those who did not. Exclusion criteria included monoamniotic pregnancies, twin-to-twin transfusion syndrome, and placenta previa. Primary outcomes included preeclampsia, abruption, preterm premature rupture of membranes (PPROM), preterm birth <34 weeks, and intrauterine growth restriction. RESULTS: Of 2106 pregnancies meeting inclusion criteria, 175 reported vaginal bleeding. Twin pregnancies with early vaginal bleeding had significantly higher risks of abruption, PPROM, and preterm birth compared to twin pregnancies without bleeding. The findings were similar when twin pairs were stratified by parity or maternal comorbidities. CONCLUSION: Twin pregnancies complicated by vaginal bleeding in early pregnancy have an increased risk of abruption, PPROM, and preterm birth <34 weeks.

Impact of chorionicity on risk and timing of intrauterine fetal demise in twin pregnancies.

OBJECTIVE: We sought to estimate the association between chorionicity and intrauterine fetal demise (IUFD) of one or both fetuses in twin pregnancies. STUDY DESIGN: In a retrospective cohort of twins undergoing anatomic survey, risk of IUFD in monochorionic and dichorionic twins was compared. The primary outcome was IUFD of one or both fetuses; secondary outcomes included nonanomalous fetal deaths. RESULTS: Of 2161 twin pregnancies meeting inclusion criteria, 86 had at least 1 IUFD and 32 experienced a double fetal loss. Monochorionic pregnancies had an increased risk of a single demise (adjusted odds ratio, 1.69; 95% confidence interval, 1.04-2.75) and a double demise (adjusted odds ratio, 2.11; 95% confidence interval, 1.02-4.37). Of all double demises, 70% occurred <24 weeks. CONCLUSION: Monochorionic twins carry an increased risk of fetal death compared to dichorionic twins. Double demise occurs primarily <24 weeks, regardless of chorionicity.