Difference In Maternal Morbidity Research Articles

Maternal and neonatal health outcomes for First Nations Australian women and children: A retrospective cohort study in a Western Sydney metropolitan tertiary referral centre.

To analyse key pregnancy and birth outcomes for First Nations women and children at a Western Sydney metropolitan tertiary referral centre. The birth and health-determining characteristics of 470 First Nations infants born at Nepean Hospital in 2018 and their mothers were included in a retrospective audit and compared with a contemporaneous control group of 470 infants and their mothers. Mothers of First Nations infants had significantly higher rates of socioeconomic disadvantage (P < 0.001), psychosocial vulnerability (P < 0.007), mental illness (P < 0.001), teenage pregnancy (P < 0.001), smoking (45.6% vs. 19.4%, P < 0.001) and drug and alcohol use than control mothers (P < 0.001, P < 0.048). First Nations peoples did not have increased rates of maternal morbidity, nor any difference in rates of Caesarean section, resuscitation at birth, NICU admission, preterm birth or low birth weight in multivariable analysis. However, multivariable analysis demonstrated significant associations between low birth weight and maternal smoking (P < 0.001), hypertension (P < 0.01) and drug use (P < 0.01). Despite challenges facing First Nations mothers and infants, our study found no significant difference in maternal morbidity nor adverse birth outcomes for First Nations infants. The study occurred in the context of culturally specific, First Nations-led antenatal and infant services. Future studies should further investigate relationships between participation in these services and health outcomes. This could identify strengths and areas for improvement in current services, with the goal of further improving outcomes for First Nations peoples through targeted health services that address their psychosocial vulnerabilities and support women to make healthy choices during pregnancy.

Trial of labor after two cesarean sections: A retrospective case-control study.

The objective of this study was to compare neonatal and maternal outcomes among women with two previous cesarean deliveries who undergo trial of labor after two cesarean section (TOLA2C) versus elective repeat cesarean delivery (ERCD). Our primary outcome was neonatal intensive care unit (NICU) admission. Secondary outcomes included APGAR score <7 at 5 min, TOLA2C success rate, uterine rupture, postpartum hemorrhage, maternal blood transfusion, maternal bowel and bladder injury, immediate postpartum infection, and maternal mortality. This retrospective cohort study was undertaken at a community medical center from January 1, 2008 to December 31, 2018. Inclusion criteria were women with a vertex singleton gestation at term and a history of two prior cesarean sections. Exclusion criteria included a previous successful TOLA2C, prior classical uterine incision or abdominal myomectomy, placenta previa or invasive placentation, multiple gestation, nonvertex presentation, history of uterine rupture or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test. A total of 793 patients fulfilled study criteria. There were no differences in neonatal intensive care unit admissions or 5-min APGAR scores <7 between the two groups. Sixty-eight percent of women who underwent TOLAC (N=82) had a successful vaginal delivery. The uterine rupture rate was 1.16% (N=1) in the TOLA2C group with no case of uterine rupture in the ERCD group. No difference in maternal morbidity was noted between the two groups. No maternal or neonatal mortalities occurred in either group. There was no difference in maternal or neonatal morbidity among patients in our study population with two previous cesarean sections who opted for TOLA2C versus ERCD.

Study on role of ascorbic acid levels in PPROM and its maternal and perinatal outcome

Background: Preterm premature rupture of membranes (PPROM) complicates 1–5% of all pregnancies and is the major contributory factor for perinatal morbidity and mortality. Micronutrient deficiency (vitamin C) is associated with increased risk of PPROM. This study was conducted to establish the association between maternal plasma vitamin C concentration in women with PPROM and women without PPROM and to study the difference in maternal morbidity, neonatal morbidity, and mortality. Objectives 1. Establish the association between maternal plasma vitamin C concentration in women with PPROM and women without PPROM.2. Study the association of anemia in vitamin C deficient patients with PPROM3.Study the difference in maternal and perinatal morbidity and mortality in both the groups Methods: This case controlstudy was conducted in Department of Obstetrics and Gynecology, EPIONE Hera Hospitals100 patients were studied, 50 were in study group (patients admitted to labour room with h/o PPROM) and 50 in the control group (patients admitted to labour room at term for delivery). Fasting blood sample was taken to measure the plasma vitamin C levels in both the groups. Results: Plasma vitamin C levels were low in PPROM patients and the concentration decreased as the pregnancy advanced, this proves linear relationship between plasma vitamin C levels and PPROM. The results of this study showed decreased plasma vitamin C levels leading to PPROM, preterm deliveries, increased NICU admissions, increased perinatal morbidity, mortality, maternal anemia in study group than in control group. Conclusion: As vitamin C deficiency during pregnancy leads to PPROM, it’s supplementation during pregnancy along with iron and calcium in second and third trimester should be made mandatory.

Placental growth factor in assessment of women with suspected pre-eclampsia to reduce maternal morbidity: a stepped wedge cluster randomised control trial (PARROT Ireland)

ObjectiveTo determine whether the addition of placental growth factor (PlGF) measurement to current clinical assessment of women with suspected pre-eclampsia before 37 weeks' gestation would reduce maternal morbidity without increasing...

FETAL OUTCOME AND VAGINAL DELIVERY RATES AMONG PRIMIGRAVIDAE WITH UNENGAGED HEAD AT ONSET OF LABOR

Background: The criteria for diagnosing delivery disorders in the first and second stages of labor remain controversial. It is generally accepted that an elevated position of the fetus in primigravidas during short-term labor may indicate a threat to normal progression of labor due to fetal-pelvic disproportion or obstruction of the fetal passage by tumor or placenta. Objective: To determine fetal outcome and vaginal delivery rates among primigravida with unengaged head at onset of labor. Patients and Methods: This study was conducted on 250 primigravidae with unengaged fetal head presented at term in active labor during the period from January 2019 to December 2019. Any solid indication for cesarean section whether in the mother or the fetus was excluded. These cases were given a full trial of labor and the progress of each was recorded on a partogram, The mode of delivery, the duration of labor (first and second stage), the weight of the new born and the Apgar score, were all recorded. Also maternal morbidity and mortality were recorded. Epidural anesthesia was given to the patients on demand, and the effect of it on the mode of delivery, the duration of the first and second stage and the Apgar score were reported. Results: Most of the patients included in the study delivered vaginally (82%) while only 18% delivered by cesarean section. The primigravida with unengaged fetal head at onset of labor, although at risk for C.S, most of them delivered vaginally when were given a full trial of labor and watched carefully. The length of the first and second stage of labor prolonged slightly in these patients. The need for oxytocin augmentation also increased in those patients. The Apgar score at 1 minute and 5 minutes also decreased in the new-born of these primigravidae. There were no differences in maternal morbidity among the primigravidas presented with unengaged fetal head and those presented with engaged fetal heads. The use of epidural anesthesia did not affect the rate of C.S. although it may lengthen the duration of the first and second stage of labor. In addition, Apgar score was not affected by the use of epidural. Conclusion: The primigravida with unengaged fetal head at onset of labor, although at risk for C.S., most of them delivered vaginally with a full trial of labor and watching carefully.

PREGNANCY OUTCOME IN ECLAMPSIA INFLUENCED BY THE MODE OF DELIVERY

BACKGROUND: To study the association between mode of delivery and maternal and perinatal outcome in eclampsia. METHODS: This was a tertiary care based prospective observational study conducted in the Department of Obstetrics and Gynecology, between the study period October 2018-September 2020.Atotal 165 cases of eclampsia, with &gt;32 weeks gestation, reassuring foetal heart and no other complications were included in the study. They were divided into two groups; Group I undergoing planned vaginal delivery, Group II undergoing early caesarean delivery, maternal and perinatal outcome was analysed and compared between the two groups. RESULT: Maximum number 75 (45.45%) of the study participants were in between 37.1-40 weeks of gestation at the time of admission, Majority of the study participants 125 (75.76%) had an unfavorable cervix i.e., Bishop's score ≤5 on initial assessment at the time of admission. There was no maternal mortality in our study. There was no statistically signicant difference in maternal morbidity. The still births and perinatal deaths were seen to be higher in the planned vaginal delivery group (1 still birth and 3 perinatal deaths). Perinatal morbidity was affected by mode of delivery of delivery, gestational age, BISHOP's score, number of convulsions at time of induction and convulsion delivery interval. CONCLUSIONS:The maternal outcome was seen to be comparable between both the groups and there was no statistically signicant difference between them, the perinatal outcome was better in the early caesarean delivery group as compared to the planned vaginal delivery group, specically in those with an unfavorable cervix and away from term. Early caesarean section to expedite delivery cannot be recommended for all cases of ante partum eclampsia.

Racial Disparities in Maternal Critical Care: Are There Racial Differences in Level of Care?

Obstetric care in the US is complicated by marked racial and ethnic disparities in maternal obstetric outcomes, including severe morbidity and mortality, which are not explained by underlying differences in patient characteristics. Understanding differences in care delivery related to clinical acuity across different racial groups may help elucidate the source of these disparities. This study examined the association of maternal race with utilization of critical care interventions. This is a retrospective cohort study conducted as a secondary analysis of a large, multicenter observational study of women undergoing cesarean delivery. All women with a known delivery date were included. The primary outcome measure, a composite of critical care interventions (CCI) at delivery or postpartum that included mechanical ventilation, central and arterial line placement, and intensive care unit (ICU) admission were compared by racial/ethnic group-non-Hispanic white, non-Hispanic black, Hispanic, Asian, and Native American. We evaluated differences in utilization of critical care with a multivariable regression model accounting for selected characteristics present at admission for delivery, including maternal age, BMI, co-morbidities, parity, and plurality. Maternal mortality was also evaluated as a secondary outcome and the frequency of CCI by significant maternal co-morbidity, specifically heart disease, renal disease, and chronic hypertension was assessed to ascertain the level of care provided to women of different race/ethnicity with specific baseline co-morbidities. 73,096 of 73,257 women in the parent trial met inclusion criteria, of whom 505 (0.7%) received a CCI and 3337 (4.6%) had a significant medical co-morbidity (1.2% heart disease, 0.8% renal disease, 2.5% chronic hypertension). The mortality rate was significantly higher among non-Hispanic black women, compared to non-Hispanic white and Hispanic women. In the adjusted model, there was no significant association between CCI and race/ethnicity. This study suggests that differences in maternal morbidity by race may be accounted for by differential escalation to higher intensity care. Further investigation into processes for care intensification may continue to clarify sources of racial and ethnic disparities in maternal morbidity and potential for improvement.

735 TOLAC versus repeat cesarean section amongst women with a twin gestation: a retrospective cohort study

Greater than 90% of women with a previous cesarean section in the USA deliver by repeat cesarean section and one third of hospitals in the USA no longer offer a trial of labor after cesarean section (TOLAC). TOLAC amongst women with a singleton gestation is widely accepted but there is a paucity of data on TOLAC in twin gestations. We sought to assess maternal and neonatal outcomes amongst women with a current twin gestation and a prior cesarean section who opted to undergo TOLAC versus repeat cesarean section. This retrospective cohort study was undertaken at a community medical center from January 1st 2010 to December 31st 2019. Inclusion criteria were women with a current twin pregnancy at > 32 weeks gestation, presenting twin in vertex presentation and a history of one prior cesarean section. Exclusion criteria included a prior classical uterine incision or abdominal myomectomy, placenta previa or invasive placentation, non-vertex presenting twin, history of uterine rupture or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test. A total of 83 patients fulfilled study criteria. 81% of women who underwent TOLAC (N=21) had a successful vaginal delivery. There was no difference in mean gestational age between the two groups (37+2 vs 36+6 weeks, P=0.24). There were no differences in neonatal intensive care unit admissions for twin A (29% vs 28.6%, P=0.96) or twin B (27.4% vs 28.6%, P=0.94) and 5 minute APGAR scores for twin A (P=0.24) or twin B (P=0.63) amongst women who opted for TOLAC versus repeat cesarean section. Moreover, no difference in maternal morbidity was noted with regards to blood transfusion rates (4.8% vs 4.8%, P=1.0), bowel injury (0% vs 1.6 %, P=1.0) and immediate postpartum infection (0% vs 1.6 %, P=1.0). No hysterectomy, bladder injury, maternal or neonatal deaths occurred in either group. TOLAC following one prior cesarean section for women with a twin gestation has comparable maternal and neonatal morbidity with repeat cesarean section.

Racial Disparity in Pregnancy Risks and Complications in the US: Temporal Changes during 2007-2018.

Maternal race and ethnicity have been associated with differences in pregnancy related morbidity and mortality. We aimed to evaluate the trends of several pregnancy risk factors/complications among different maternal racial/ethnic groups in the US between 2007 and 2018. Specifically, we used the Center for Disease Control and Prevention (CDC) natality files for these years to assess the trends of hypertensive disorders of pregnancy (HDP), chronic hypertension (CH), diabetes mellitus (DM), advanced maternal age (AMA) and grand multiparity (GM) among non-Hispanic Whites, non-Hispanic Blacks and Hispanics. We find that the prevalence of all of these risk factors/complications increased significantly across all racial/ethnic groups from 2007 to 2018. In particular, Hispanic women exhibited the highest increase, followed by non-Hispanic Black women, in the prevalence of HDP, CH, DM and AMA. However, throughout the entire period, the overall prevalence remained highest among non-Hispanic Blacks for HDP, CH and GM, among Hispanics for DM, and among non-Hispanic Whites for AMA. Our results point to significant racial/ethnic differences in the overall prevalence, as well as the temporal changes in the prevalence, of these pregnancy risk factors/complications during the 2007–2018 period. These findings could potentially contribute to our understanding of the observed racial/ethnic differences in maternal morbidity and mortality.

Trial of Labor After Two Cesarean Sections Versus Repeat Cesarean Section: A Retrospective Cohort Study [37P

INTRODUCTION: Greater than 90% of women with a previous cesarean section in the USA deliver by repeat cesarean section and one third of hospitals no longer offer a trial of labor after cesarean section (TOLAC). We sought to assess maternal and neonatal outcomes amongst women with two prior cesarean sections who opted to undergo TOLAC versus repeat cesarean section. METHODS: This retrospective cohort study was undertaken at a community medical center from January 1st 2008 to December 31st 2018. Inclusion criteria were women with a vertex singleton gestation at term and a history of two prior cesarean sections. Exclusion criteria included a prior classical uterine incision or abdominal myomectomy, history of uterine rupture, placenta previa or invasive placentation, non-vertex presentation, or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test. RESULTS: A total of 796 patients fulfilled study criteria. 69% of women who underwent TOLAC (N=85) had a successful vaginal delivery. There were no differences in neonatal intensive care unit admissions (5.7% vs 5.9%, P=1.0) or mean APGAR scores at one (P=.38) and five (P=.42) minutes amongst women who opted for TOLAC versus repeat cesarean section. Moreover, no difference in maternal morbidity was noted with regards to blood transfusion rates (2.3% vs 2.1%, P=.71), bowel injury (0% vs 0.1%, P=1.0), bladder injury (1.1% vs 0.1%, P=.21), immediate postpartum infection (0% vs 0.8%, P=1.0) and hysterectomy (0% vs 0.1%, P=1.0). CONCLUSION: TOLAC following two cesarean sections has comparable maternal and neonatal morbidity with repeat cesarean section.

3453 The Spectrum of Homelessness and Its Association with Maternal Morbidity

OBJECTIVES/SPECIFIC AIMS: To examine maternal morbidity and its related social determinants among women experiencing homelessness during pregnancy. METHODS/STUDY POPULATION: This study will use an exploratory sequential mixed method design to explore and examine the structural, interpersonal and individual factors contributing to maternal morbidity among a convenience sample of 150 English speaking women experiencing homelessness during a pregnancy within the last 3 years in Baltimore. In the qualitative phase of the study, we will conduct semi-structured interviews with 15 women purposively sampled to refine the relationships between resilience, social determinants of health and multilevel factors that impact maternal morbidities. Factors of interest include prenatal care received, barriers and facilitators to receiving prenatal care, maternal morbidities, social support, and strategies used to manage their condition during this time. Using the findings from the qualitative phase, a quantitative survey will be developed to gather data on topics that emerged in the interviews. In addition, the Housing Instability Index will be used to measure the degree of homelessness as defined by the degree of housing instability in a 6-month period. Using the 25-item Connor-Davidson Resilience Scale, resilience levels among women in the sample will be assessed as a moderating factor in the examination of the relationship between a pregnant woman’s homeless status and maternal morbidity. Descriptive statistics and logistical regression tests will be used to analyze these relationships while controlling for other structural, interpersonal, and individual factors that may be associated with maternal morbidity. RESULTS/ANTICIPATED RESULTS: Qualitatively we expect to gain insight into the relationship between the extrinsic and intrinsic factors impacting maternal morbidities and the health behaviors and practices used by women to manage their pregnancy while homeless. These findings will inform the quantitative survey development and help generalize the quantitative findings. We expect to identify the common morbidities in this population we anticipate that there will be differences in maternal morbidity among the different types of homelessness. Maternal morbidity will be higher among women with a greater degree of homelessness. Resilience will have a moderating effect on the relationship between homelessness and maternal morbidity. DISCUSSION/SIGNIFICANCE OF IMPACT: This study, to our knowledge, is the first to look at maternal morbidity in this population. Additionally, this study seeks to move current research from examining infant outcomes at birth among mothers experiencing homelessness to understanding the maternal morbidities during this period. Long term, good maternal health has significant implications for the health of a mother’s future pregnancies and a risk reduction of adverse chronic conditions. Study results will provide the preliminary knowledge needed to guide further research leading to clinical approaches that promote better maternal health in this population. Lastly, the study findings will inform policy by characterizing the quality and strength of evidence of the adverse maternal health effects associated with the experience of homelessness.

580: Maternal morbidity after early preterm delivery (23-28 weeks)

To describe the differences in maternal morbidity following preterm birth by gestational age This is a retrospective cohort study of women who delivered at a tertiary care hospital between 1/2013 and 12/2017. Women were included if they delivered between 23w0d to 28w6d and the neonate was admitted to the neonatal intensive care unit. A composite maternal morbidity (blood transfusion, infection, placental abruption, postpartum depression diagnosed or screen positive) was compared for women who delivered between 23w0d to 25w6d (early) and 26w0d to 28w6d (late). T-test, Mann Whitney U or Fisher’s exact test were used where appropriate. During the study period, 82 women met the inclusion criteria. There were 38 women in the early group compared to 44 women in the late group. Maternal age, BMI, delivery type (vaginal vs cesarean), hypertensive disease, membrane status, smoking, drug use and multifetal gestations were similar between the groups. The early delivery group was significantly more likely to experience composite maternal morbidity (60.5% vs 29.5%, p=0.0072). The early group was also more likely to experience maternal infection (42.1% vs 15.9%, p=0.0131). While it is well-established that neonatal morbidity and mortality are increased with decreasing gestational age, our data suggest that maternal morbidity is higher with delivery at early gestational ages. Composite morbidity and maternal infection appear to be a particularly frequent complication in those delivering less than 26 weeks. Because maternal morbidity is an increasing burden with a national focus on reduction, the management of women at risk for imminent delivery at early gestational ages should include a discussion of increased maternal complications.

Maternal and Perinatal Outcome of Major Degree Placenta Previa at Mansoura University Hospital

AbstractBackground: To study risk factors, management, and outcome of major degree placenta previa in our tertiary health care hospital.Patients and Methods: A Prospective observational study was conducted in Obstetrics & Gynecology, Department, Mansoura University Hospital, Egypt during the period from July, 2014 to December, 2015. The patient criteria, method of diagnosis, management, fetal and maternal outcomes of cases with major degree PP were reported and analyzed.Results: This study included 115 cases. Mean age of our cases was 31.1 years (range: 21-40), mean gestational age at delivery was 36.8 weeks (range: 28-39). Previous cesarean deliveries were reported in 93.9% of the cases. Abnormal placental adhesions were found in 30.4%. A stepwise system was used for intraoperative interference. Peripartum hyster-ectomy was performed in 13 cases (11.3%). There were three cases of maternal mortality; one due to anesthetic complication, one due to uncontrolled atonic postpartum hemorrhage and the third was due to postoperative pneumonia.The mean gestational age at delivery was 36.82±1.6 weeks. There were 5 cases (4.3%) of IUFD and 2 cases (1.8%) of early neonatal deaths.Conclusions: Major placenta previa with accrete had significant difference in maternal morbidity and mortality than non-accrete type. Pathological placental adhesions should be excluded by Doppler ultrasound and or MRI. All surgical procedures to control bleeding must be done including hys-terectomy without hesitation to save the patient. Cases must be managed by a collaborative team work in a tertiary center with available ICU.

Effects of an Interdisciplinary Practice Bundle for Second-Stage Labor on Clinical Outcomes.

There is renewed interest in second-stage labor practices as recent evidence has challenged historical perspectives on safe duration of second-stage labor. Traditional practices and routine interventions during second-stage have uncertain benefit for low-risk women and may result in cesarean birth. The purpose of this quality improvement project was to implement an interdisciplinary second-stage practice bundle to promote safe outcomes including method of birth and women's birth experience. Standardized second-stage labor evidence-based practice recommendations structured into a 5 Ps practice bundle (patience, positioning, physiologic resuscitation, progress, preventing urinary harm) were implemented across 34 birthing hospitals in the Trinity Health system. Significant improvements were observed in second-stage practices. Association of Women's Health, Obstetric and Neonatal Nurses' perinatal nursing care quality measure Second-Stage of Labor: Mother-Initiated Spontaneous Pushing significantly improved [pre-implementation 43% (510/1,195), post-implementation 76% (1,541/2,028), p < .0001]. Joint Commission Perinatal Care-02: nulliparous, term, singleton, vertex cesarean rate significantly decreased (p = 0.02) with no differences in maternal morbidity, or negative newborn birth outcomes. Unexpected complications in term births significantly decreased in all newborns (p < 0.001), and for newborns from vaginal births (p = 0.03). Birth experience satisfaction rose from the 69th to the 81st percentile. Implementing 13 evidence-based second-stage labor practices derived from the Association of Women's Health, Obstetric and Neonatal Nurses and the American College of Nurse-Midwives professional guidelines achieved our goals of safely reducing primary cesarean birth among low-risk nulliparous women, and optimizing maternal and fetal outcomes associated with labor and birth. By minimizing routine interventions, nurses support physiologic birth and improve women's birth satisfaction.

Provider Differences in Outcomes of Low-Risk TOLAC Patients: Comparing Midwifery and Obstetrician Management [34H

INTRODUCTION: Provider management may influence the success of trial of labor after cesarean (TOLAC). This study examined the role of the provider, MD-obstetrician (OB) or certified nurse midwife (CNM), in explaining differences in unplanned cesarean delivery (uCD) during TOLAC for low-risk women. METHODS: We performed a secondary analysis of a cohort prospectively enrolled from 2005 to 2012 at the University of Colorado Hospital. We compared the probability of uCD by provider type in logistic regression and in multivariable modeling, adjusting for maternal, pregnancy, fetal, and neonatal covariates. Results are odds ratios with 95% confidence intervals. Maternal and combined neonatal-maternal adverse morbidity composites were compared by provider type. RESULTS: 216 OB-managed versus 286 CNM-managed deliveries were similar in average maternal age, BMI, and proportion of race/ethnicity and were not significantly different for risk of uCD (0.78, 0.45-1.37). Adjusting for onset of labor, race/ethnicity, obstetric history, and recurring indication showed no significant difference in risk of uCD between OB- versus CNM-managed deliveries (0.60, 0.32-1.12). While OB- versus CNM-managed deliveries did not significantly differ in overall adverse composite outcome (1.24, 0.81-1.90), odds of maternal morbidity were greater in OB-managed deliveries (1.62, 1.02-2.56). CONCLUSION: There is no significant difference in unplanned cesarean between provider types, suggesting that provider type alone does not predict TOLAC success in low-risk women but may predict differences in maternal morbidity in this specific population. Further investigation of individual between-provider differences rather than provider groups could help target interventions to reduce uCD and increase TOLAC success in the United States.

Increased Perinatal Morbidity and Mortality Among Asian American and Pacific Islander Women in the United States.

Asian American/Pacific Islanders (AAPIs) are the fastest-growing racial group in the United States. Despite a higher socioeconomic status, AAPI women experience higher rates of maternal morbidity and mortality. Using the National Inpatient Sample, we performed a retrospective cohort analysis of women who were hospitalized for delivery from 2002 to 2013. The primary outcome variable was inpatient mortality rate, and the presence of severe maternal morbidities was estimated using the Bateman Comorbidity Index, a validated tool for predicting obstetric morbidity. AAPI women presenting for delivery between 2003 and 2012 were older, more likely to reside in a zip code in the top quartile of annual income, be privately insured than Caucasian women, and less likely to have a higher Bateman Comorbidity Index. However, AAPI women had a higher likelihood of postpartum hemorrhage (3.4% vs 2.7%, P < .001), uterine atony, severe perineal lacerations, and severe maternal morbidities. Procedures such as transfusion, hysterectomy, and mechanical ventilation were also more common in AAPI women. Furthermore, AAPI women had a higher mortality rate that persisted despite adjustment for an apparently higher income and comorbidities (odds ratio 1.72, 95% confidence interval: 1.14-2.59, P = .01). Despite having a higher socioeconomic status, AAPI women had higher rates of maternal mortality during hospitalization for delivery. This increase persisted even after adjustment for factors known to affect peripartum outcomes. Further investigation is needed to better clarify the causes of racial differences in maternal morbidity and mortality.

Pronostic obstétrical des patientes présentant un antécédent de césarienne réalisée avant 32 semaines d’aménorrhée

ObjectiveTo assess delivery mode, maternal morbidity including uterine rupture and scar dehiscence and neonatal outcome, during a pregnancy after a previous caesarean delivery before 32 weeks of amenorrhea. MethodsA retrospective descriptive study was carried out at the Besançon University Hospital during an 8-year period. We identified 292 consecutive patients presenting a singleton pregnancy delivery before 32 weeks of amenorrhea. We analysed the next pregnancy. Patients presenting more than one caesarean section were excluded from this study. ResultsOut of the 292 patients, 62 met inclusion criteria. The average gestational age of the first caesarean section was 29 weeks and 3 days. Among these patients, 17 (27.4%) had a planned caesarean delivery after caesarean (CDAC) and 45 (72.6%) had a trial of vaginal delivery (TVD) with a success rate of 71.1%, that is a total of 51.6% of vaginal delivery after a previous early caesarean section. In case of a failed TVD, arterial pH (P<0.005), Apgar score at one minute (P<0.05) and at 10minutes (P<0.05) were significantly lower compared to the CDAC group. Regarding perinatal outcome, there was no significant difference (P=0.31) between the groups in intention to treat. The only uterine rupture (1.6%) was noticed during a caesarean section at 26 weeks and 3 days, in a patient initially included in the TVD group. Five uterine scar-dehiscences (8.1%) were discovered including 80% during caesarean section, at an average term of 32 weeks and 2 days of amenorrhea. ConclusionAfter an early caesarean section, trial of vaginal delivery can be implemented if local conditions are favorable. There is no difference in maternal morbidity, success of labour and neonatal outcome if previous caesarean section was performed before 32 weeks or at term. It appears however that uterine rupture rate (complete or incomplete) is slightly higher in comparison to a previous caesarean at term, which might occur prematurely and before labour.

Ascorbic Acid concentration and preterm premature rupture of membranes.

Preterm premature rupture of membranes (PPROM) complicates 1-5% of all pregnancies and is the major contributory factor for perinatal morbidity and mortality. Micronutrient deficiency (vitamin C) is associated with increased risk of PPROM. This study was conducted to establish the association between maternal plasma vitamin C concentration in women with PPROM and women without PPROM and to study the difference in maternal morbidity, neonatal morbidity, and mortality. A prospective study was conducted where 40 women (20 in each study and control group) with singleton pregnancies between 28 and 37weeks gestation were recruited. Women with anemia, diabetes, UTI, RTI, vaginal infection, bleeding, h/o PPROM in previous pregnancy, polyhydramnios, and smoker were excluded from the study. Maternal plasma vitamin C levels were measured. Ascorbic acid levels were low in women with PPROM 0.41±0.08 versus 0.84±0.19mg/dl. There is a linear decline in plasma vitamin C levels as the pregnancy advances. Inverse relationship was observed between duration of rupture of membranes and vitamin C levels. There was a significant difference in maternal morbidity, neonatal morbidity, and mortality. Ascorbic acid concentration was low in women with PPROM. Thus, vitamin C supplementation should be made mandatory along with iron and calcium to antenatal women to avoid the complications of PPROM.

Comparison of outcomes between operative vaginal deliveries and spontaneous vaginal deliveries in southeast Nigeria

ObjectiveTo evaluate the incidence of, indications for, and outcome of operative vaginal deliveries compared with spontaneous vaginal deliveries in southeast Nigeria. MethodsA retrospective cohort study was conducted involving cases of operative vaginal delivery performed at Ebonyi State University Teaching Hospital over a 10-year period. Data on the procedures were abstracted from the operation notes of the medical records of parturients. ResultsAn incidence of 4.7% (n=461) was recorded. The most common indications for vacuum and forceps delivery were prolonged second stage of labor (44.9%) and poor maternal effort (27.8%). The only indication for destructive operation was intrauterine fetal death (3.7%). The risk ratio (RR) for hemorrhage/vulvar hematoma was 1.14 (95% confidence interval [CI], 0.53–2.48) for vacuum-assisted delivery and 5.49 (95% CI, 0.82–36.64) for forceps delivery. The RR for genital laceration was 1.21 (95% CI, 0.44–3.30) for vacuum-assisted delivery and 9.41 (95% CI, 1.33–66.65) for forceps delivery. The risk of fetal scalp bruises and caput succedaneum was higher for operative vaginal delivery than for spontaneous vaginal delivery, with no significant difference in maternal morbidity. The perinatal mortality rate was 0.9 per 1000 live births. ConclusionOperative vaginal delivery by experienced healthcare providers is associated with good obstetric outcomes with minimal risk.

Expectant management of severe preeclampsia remote from term: the MEXPRE Latin Study, a randomized, multicenter clinical trial

The objective of the study was to determine whether expectant management of severe preeclampsia prior to 34 weeks of gestation results in improved neonatal outcome in countries with limited resources. This was a randomized clinical trial performed in 8 tertiary hospitals in Latin America. Criteria of randomization included gestational age between 28 and 33 weeks' gestation and the presence of severe hypertensive disorders. Patients were randomized to steroids with prompt delivery (PD group) after 48 hours vs steroids and expectant management (EXM group). The primary outcome was perinatal mortality. A total of 267 patients were randomized, 133 to the PD group and 134 to the EXM group. Pregnancy prolongation was 2.2 days for the PD group vs 10.3 days for the EXM group (P = .0001). The rate of perinatal mortality (9.4% vs 8.7%; P = .81; relative risk [RR], 0.91; 95% confidence interval [CI], 0.34-1.93) was not improved with expectant management, and neither was the composite of neonatal morbidities (56.4% vs 55.6%; P = .89; RR, 01.01; 95% CI, 0.81-1.26). There was no significant difference in maternal morbidity in the EXM group compared with the PD group (25.2% vs 20.3%; P = .34; RR, 1.24; 95% CI, 0.79-1.94). However, small gestational age (21.7% vs 9.4%; P = .005; RR, 2.27; 95% CI, 1.21-4.14) and abruption were more common with expectant management (RR, 5.07; 95% CI, 1.13-22.7; P = .01). There were no maternal deaths. This study does not demonstrate neonatal benefit with expectant management of severe preeclampsia from 28 to 34 weeks. Additionally, a conservative approach may increase the risk of abruption and small for gestational age.