American journal of obstetrics and gynecology
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Am. J. Obstet. Gynecol. · Feb 2016
Effect of obesity on neonatal outcomes in pregnancies with preterm premature rupture of membranes.
Maternal obesity is associated with increased systemic inflammation and an increased risk of preterm premature rupture of membranes. There is an established association between an inflammatory intrauterine environment and adverse neonatal outcomes that is independent of gestational age and mediated by the fetal inflammatory response. It is unknown whether the maternal systemic inflammation that is present in obese women influences the intrauterine environment and predisposes the fetus to adverse neonatal outcomes after preterm premature rupture of membranes. ⋯ Maternal obesity was not associated independently with adverse neonatal outcomes in pregnancies that were affected by preterm premature rupture of membranes after adjustment for gestational age at birth. However, obese African American women rupture and deliver earlier than other women, which causes increased neonatal morbidity.
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Am. J. Obstet. Gynecol. · Feb 2016
Reoperation for urinary incontinence: a nationwide cohort study, 1998-2007.
The synthetic midurethral slings were introduced in the 1990s and were rapidly replaced the Burch colposuspension as the gold standard treatment for urinary incontinence. It has been reported that the retropubic midurethral tape has an objective and subjective cure rate of 85% at 5 years of follow-up, but the rate of reoperation after retropubic midurethral tape at the long-term follow-up is less well described. The existing literature specifies an overall lifetime rate of reoperation of about 8-9% after an initial operation for urinary incontinence. There are, however, conflicting statements about the risk of reoperation after specific surgical procedures for urinary incontinence. ⋯ This nationwide cohort study provides physicians with a representative evaluation of the rate of reoperations after surgical procedures for urinary incontinence. Pubovaginal slings, Burch colposuspension, and retropubic midurethral tape had a similar risk of reoperation (6%). Women who were operated with transobturator tape had a significantly higher risk of reoperation compared with retropubic midurethral tape.
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Am. J. Obstet. Gynecol. · Jan 2016
Endoscopic surgery for the antenatal treatment of myelomeningocele: the CECAM trial.
A recent randomized clinical trial named Management of Myelomeningocele Study (MOMS trial) showed that prenatal correction of open spina bifida (OSB) via open fetal surgery was associated with improved infant neurological outcomes relative to postnatal repair, but at the expense of increased maternal morbidity. ⋯ Our study suggests that the antenatal treatment of OSB using a fetoscopic approach and our unique surgical technique can result in a watertight seal, reversal of the hindbrain herniation, and better than expected motor function. Our technique differs substantially from the classic repair of OSB used in prior open fetal surgery and fetoscopic studies, in which the dura mater is dissected and the defect is closed in multiple layers. Instead, we use a biocellulose patch placed over the lesion and simple closure of the skin. As such, our technique is an alternative to the current paradigms in the antenatal treatment of OSB. Our clinical outcomes are in line with the results of our extensive prior animal work. Maternal benefits of our approach and technique include minimal morbidity and no myometrial legacy. Current limitations of the approach include potential loss of access, premature rupture of membranes, and attendant prematurity. Phase II trials are needed to prevent these complications and to further assess the risks and benefits of our distinct surgical approach and technique.
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Am. J. Obstet. Gynecol. · Jan 2016
Hospital variation in cesarean delivery rates: contribution of individual and hospital factors in Florida.
Primary cesarean deliveries are a major contributor to the large increase in cesarean delivery rates in the United States over the past 2 decades and are an essential focus for the reduction of related morbidity and costs. Studies have shown that primary cesarean delivery rates among low-risk women in the United States vary 3-fold across hospitals and are not explained by differences in patient case-mix. However, the extent to which maternal vs hospital characteristics contribute to this variation remains poorly understood because previous studies were limited in scope and did not assess the influence of factors such as maternal ethnicity subgroups or prepregnancy obesity. ⋯ Hospital geographic location contributes to hospital variation in primary cesarean delivery rates among low-risk women in Florida. In contrast to previous studies, our findings suggest that individual level risk factors such as maternal ethnicity also contribute to some of this variation, with differing extent by region. These individual factors likely interact with practice factors and add to the variation. This study was limited by not including maternal Bishop score before induction or obstetrics provider in the analysis. These were not available on the dataset but likely contribute to the variation. Our findings suggest potential issues to consider in quality improvement efforts, such as the need for future qualitative research that focuses on mothers in higher-risk ethnic subgroups and providers in high-rate hospitals, particularly those in Miami-Dade County. These studies may help to identify potential cultural differences in maternal beliefs and expectations for delivery and maternal reasons for differences in obstetrics practices.
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Am. J. Obstet. Gynecol. · Jan 2016
Randomized Controlled Trial Multicenter StudyCervical pessary placement for prevention of preterm birth in unselected twin pregnancies: a randomized controlled trial.
Preterm birth is the leading cause of neonatal death and handicap in survivors. Although twins are found in 1.5% of pregnancies they account for about 25% of preterm births. Randomized controlled trials in singleton pregnancies reported that the prophylactic use of progestogens, cervical cerclage and cervical pessary reduce significantly the rate of early preterm birth. In twin pregnancies, progestogens and cervical cerclage have been shown to be ineffective in reducing preterm birth. ⋯ In women with twin pregnancy, routine treatment with cervical pessary does not reduce the rate of spontaneous early preterm birth.