Effects of Gestational Weight Gain on Delivery Outcomes in an Obese, Low-Income Population.

OBJECTIVE: To examine the effects of weight gain/loss on delivery outcomes stratified by class of obesity in an obese, low-income, predominantly minority population. METHODS: A retrospective review of a cohort of 1428 women receiving care at a large Medicaid clinic from 2013 to 2016 with pregravid body mass index ≥30 was conducted. Multinomial logistic regression analysis was used to compare differences in gestational weight change to the primary outcomes of birth-weight percentile and delivery type and secondary outcomes of preterm delivery, preterm labor, gestational diabetes mellitus, and gestational hypertension. RESULTS: Obesity class 1 patients who lost weight were more likely to have a small-for-gestational-age (SGA) infant compared with those who had recommended weight gain. Obesity classes 2 and 3 patients had no statistically significant increase in SGA infants with weight loss or weight gain below current recommendations. Obesity classes 1 and 2 patients with weight loss had a statistically significant increase in both preterm delivery and preterm labor; however, class 3 patients did not. Obesity class 3 patients who lost weight were significantly more likely to have gestational diabetes mellitus. CONCLUSIONS: Obesity class 3 women may benefit from less weight gain than current recommendations without increasing their risk of SGA infants or preterm birth, especially if gestational diabetes mellitus is present.

Social Determinants of Gestational Weight Gain in an Obese, Low-Income Population.

OBJECTIVE: To examine how social support factors affect compliance with gestational weight gain (GWG) recommendations in an obese, low-income, predominantly minority population. STUDY DESIGN: A retrospective cohort of 772 pregnant women with body mass index > 30 was reviewed. Univariate and multinomial logistic regression analyses were used to compare GWG with pregnancy planning, relationship status, participation in group prenatal care, nutritional education, and demographic factors. Subgroup analysis was performed to determine if differences existed in entry into prenatal care. RESULTS: Planned nature of pregnancy, relationship status, nutritional education, and group prenatal care did not significantly affect GWG. Women with planned pregnancies and in group prenatal care had their first appointment during the first trimester at a higher rate than those with unplanned pregnancy and in traditional care, respectively. Regardless of timing of nutrition consult, GWG was not affected. Nulliparous patients and Class 1 obese patients were more likely to have excessive GWG. CONCLUSION: Social support factors in this study did not individually affect compliance with GWG recommendations in a low-income, obese pregnant population, although some factors were associated with earlier entry to prenatal care. Multimodal, longitudinal programs are likely necessary to achieve increased compliance with GWG recommendations in this population.

Improving Documentation of Obstetric Anal Sphincter Injuries (OASIS) Using a Standardized Electronic Template at Two University-Affiliated Institutions.

OBJECTIVES: Adequate repair is vital to reduce the long-term sequelae of obstetric anal sphincter injuries (OASIS). Sufficient documentation is necessary to reflect the quality of care provided, to guide future management, and to reduce medicolegal liability. With the advent of electronic health records, proper methods of documentation can be more easily disseminated and applied for general use. The objectives of our study were to assess whether documentation of OASIS management is improved by introducing a standardized electronic operative report, determining rates of readmission due to complications, and measuring adherence to practice guidelines. METHODS: A pre- and postintervention study was conducted by auditing electronic charts of patients affected by OASIS at two university-affiliated delivery units throughout the 2016 calendar year. Unit A is a safety-net hospital and unit B is private. A standardized electronic template was created in the electronic health records of both units. The primary outcome was the quality of repair documentation, which was quantified using a scale that included all relevant aspects of the repair. RESULTS: Analyzing both units separately, baseline characteristics including operator training level, episiotomy rate, and operative delivery were similar pre- and postintervention. The quality of documentation measured by the scale score improved significantly postintervention. Proper use of antibiotics and bowel regimen significantly increased after the intervention at both units. CONCLUSIONS: The use of a standardized electronic template for reporting the diagnosis and repair of OASIS improves the thoroughness of documentation and appears to promote the implementation of best practice guidelines.

An Ethical Framework for Research in Maternal-Fetal Intervention in the Presence of Maternal Human Immunodeficiency Virus or Hepatitis B and C Infection.

Maternal-fetal interventions continue to be a groundbreaking and rapidly expanding area. In this article, we examine whether it is ethically permissible to conduct investigation into the expansion of inclusion criteria for existing maternal-fetal interventions to include pregnant patients with human immunodeficiency virus (HIV) and hepatitis B or C infection with low or undetectable viral loads. We addressed this ethical question by appealing to ethical principle of respect for the autonomy of the pregnant patient; the patient status of the fetus; the balance of overall benefits and risks of the procedure(s) to pregnant, fetal, and neonatal patients; and to the ethical principle of justice. The ethical framework we have provided supports the conclusion that research on maternal-fetal interventions with pregnant women with HIV and hepatitis B and C infection with low or undetectable viral loads is ethically permissible. To accumulate sufficient numbers, such research should be multicenter.

Management of Labor and Delivery After Fetoscopic Repair of an Open Neural Tube Defect.

OBJECTIVE: To report labor, delivery, and neonatal outcomes in a cohort of women delivering neonates who had undergone fetoscopic neural tube defect repair. METHODS: We conducted a retrospective cohort study from April 2014 to January 2018. All patients met Management of Myelomeningocele Study eligibility criteria. We included patients with completed second-trimester fetoscopic neural tube defect repair (laparotomy, uterine exteriorization, and minimally invasive access through two or three uterine ports) followed by standardized management of labor and delivery at our institution. Outcomes included rates of vaginal delivery, term delivery, and intrapartum cesarean delivery as well as obstetric and neonatal outcomes after oxytocin. Complications of interest included preterm prelabor rupture of membranes, chorioamnionitis, uterine dehiscence or rupture, 5-minute Apgar score less than 7, and neonatal acidosis (umbilical artery pH less than 7.15). RESULTS: Thirty-four patients had fetoscopic repair, followed by 17 vaginal deliveries (50%, 95% CI 32-68%). Median gestational age was 38 1/7 weeks at vaginal delivery (range 26 0/7-40 2/7 weeks of gestation) and 37 1/7 weeks of gestation at cesarean delivery (range 25 5/7-40 5/7 weeks of gestation); 62% of deliveries occurred at term. Eight patients had prelabor cesarean delivery: three nonurgent and five urgent (for nonreassuring fetal heart tracings). Twenty-six patients labored; six were induced and 20 labored spontaneously. Of the latter, five were augmented. Of 26 laboring patients, 17 delivered vaginally and nine underwent urgent cesarean delivery (35%, 95% CI 17-56%; seven nonreassuring fetal heart tracings and two breech). There were no cases of uterine rupture or dehiscence. Most (94%, 95% CI 80-99%) had normal 5-minute Apgar scores; one neonate (3%, 95% CI 0-15%) had acidosis but normal Apgar scores. CONCLUSION: Our data regarding trial of labor, use of low-dose oxytocin, and vaginal delivery after prenatal fetoscopic neural tube defect repair are reassuring. Importantly, fetoscopic repair may permit delivery at advanced gestational ages.