Differences In Obstetric Outcomes Research Articles

Surgical Management of Adnexal Masses in Pregnancy

Our objective was to review the surgical management, surgical outcomes, and obstetric outcomes of adnexal masses in pregnancy. A retrospective review was performed of pregnant women before 20 weeks of gestation who underwent laparoscopy or laparotomy for management of an adnexal mass during the period of January 2005 to June 2012 at a university-affiliated hospital. Thirty-five pregnant women underwent surgical removal of adnexal masses during the 7.5-year study period: 21 (60.0%) underwent laparoscopic surgery, and 14 (40.0%) underwent laparotomy. The left upper quadrant entry technique was used in 20 women. Conversion to laparotomy was required in 2 women because of extensive pelvic adhesions. The mean gestational age at surgery was 15.2 ± 1.9 weeks. All women had undergone ovarian cystectomy. A malignant mass was found in 3 (8.6%) women. The laparoscopy group had a significantly less blood loss (67.4 ± 55.8 vs 153.6 ± 181.0 mL, P = .048) and shorter mean hospital stay (2.8 ± 1.0 vs 3.8 ± 1.1 days, P = .006) than the laparotomy group. One woman miscarried soon after surgery. There was no significant difference in obstetric outcomes between the laparoscopy and laparotomy groups. Surgical management of adnexal masses during pregnancy appears to have favorable outcomes for the mother and the fetus.

Can differences in obstetric outcomes be explained by differences in the care provided? The MFMU Network APEX study

Can differences in obstetric outcomes be explained by differences in the care provided? The MFMU Network APEX study

6: Can differences in obstetric outcomes be explained by differences in the care provided?

6 Can differences in obstetric outcomes be explained by differences in the care provided? William Grobman For the Eunice Kennedy Shriver National Institute of Health and Human Development, Maternal-Fetal Units Network, Bethesda, MD OBJECTIVE: Although many obstetric outcomes have been suggested as quality indicators, there is little direct evidence that institutional differences in these indicators are related to differences in the care provided. The objective of this study was to determine whether variation in the frequency of potential quality indicators could be related to differences in care. STUDY DESIGN: Data were obtained by trained abstractors, with ongoing data edits and audits, from all deliveries on 365 randomly selected days at 25 hospitals over a three-year period. Four outcome measures, selected a priori and rigorously defined, were chosen as potential quality indicators: severe postpartum hemorrhage (PPH), maternal peripartum infection (INF), perineal trauma (3rd or 4th degree laceration) at SVD (LAC), and a composite adverse neonatal outcome (NEO). Because the frequency of outcomes may be related to other patient, physician (e.g. years of experience), and institutional (e.g. in-house obstetrician 24 hours daily) factors, these characteristics were assessed for their associations with the above outcomes of interest through the use of hierarchical logistic regression, which was used to account for potential confounding and clustering of observations. Selected care processes were then placed into the model to assess whether these were independently associated with the outcomes. RESULTS: Data were collected on 115,502 women. After adjustment for patient, physician, and institutional characteristics, differential use of labor induction, cesarean delivery, and episiotomy, were associated with the outcomes of interest (Table). CONCLUSION: After controlling for differences in patients, physicians, and institutional factors, several care processes were found to be associated with variation in predefined adverse outcomes. These associations support the use of these outcomes as quality indicators, and also may suggest process measures that also are reasonable to use as quality indicators. 7 ROLO study: a randomized control trial of low glycemic index diet to prevent macrosomia in euglycemic women Jennifer Walsh, Rhona Mahony, Michael Foley, Fionnuala McAuliffe UCD Obstetrics and Gynaecology, School of Medicine and Medical Science, Dublin, Ireland OBJECTIVE: The macrosomic fetus is predisposed to a variety of adverse obstetric and neonatal outcomes, and significantly increases the risk of birth complications for the mother. In the long term, infants that are at the highest end of the distribution for weight are more likely to be obese in childhood. Eating primarily a high glycaemic carbohydrate diet can result in feto-placental overgrowth, excessive maternal weight gain and fetal macrosomia. Our hypothesis was that altering the source of maternal dietary carbohydrate could prevent macrosomia in euglycemic women. STUDY DESIGN: This is a randomised control intervention trial of 720 secundigravid women whose first baby was macrosomic (birth weight 4.0 Kg). Women were randomized to receive either no dietary intervention or a low glycemic index (GI) diet from early pregnancy. Those with pre-existing or previous gestational diabetes were excluded. The low GI group attended a small group dietetic session at 14-18 weeks’ gestation and continued the diet until term with written information and regular re-enforcement. The primary endpoint of the study was the difference in birth weight. Secondary outcomes included gestational weight gain and the development of glucose intolerance. RESULTS: There was no difference between the control and intervention groups in birthweight, customized birthweight centile or birthweight z-score. Fetal macrosomia recurred in 51% (n 184) of the intervention group and in 52 % (n 187) of controls. Women in the low GI group had significantly less gestational weight gain than those without any dietary intervention. (12.2kg vs 13.6kg p 0.01). The incidence of glucose intolerance was also significantly less in the low GI arm with 16.7% having a glucose challenge test result of 7.8 mmol/L compared with 23.4% of controls (p 0.04). CONCLUSION: Infant birthweight is a complex interplay of environmental and genetic factors. Despite a significant reduction in maternal gestational weight gain and glucose intolerance, a low GI diet in pregnancy has no effect on infant birthweight.

Racial Differences in Pelvic Anatomy by Magnetic Resonance Imaging

To use static and dynamic magnetic resonance imaging (MRI) to compare dimensions of the bony pelvis and soft tissue structures in a sample of African-American and white women. This study used data from 234 participants in the Childbirth and Pelvic Symptoms Imaging Study, a cohort study of 104 primiparous women with an obstetric anal sphincter tear, 94 who delivered vaginally without a recognized anal sphincter tear and 36 who underwent by cesarean delivery without labor. Race was self-reported. At 6-12 months postpartum, rapid acquisition T2-weighted pelvic MRIs were obtained. Bony and soft tissue dimensions were measured and compared between white and African-American participants using analysis of variance, while controlling for delivery type and age. The pelvic inlet was wider among 178 white women than 56 African-American women (10.7+/-0.7 cm compared with 10.0.+0.7 cm, P<.001). The outlet was also wider (mean intertuberous diameter 12.3+/-1.0 cm compared with 11.8+/-0.9 cm, P<.001). There were no significant differences between racial groups in interspinous diameter, angle of the subpubic arch, anteroposterior conjugate, levator thickness, or levator hiatus. In addition, among women who delivered vaginally without a sphincter tear, African-American women had more pelvic floor mobility than white women. This difference was not observed among women who had sustained an obstetric sphincter tear. White women have a wider pelvic inlet, wider outlet, and shallower anteroposterior outlet than African-American women. In addition, after vaginal delivery, white women demonstrate less pelvic floor mobility. These differences may contribute to observed racial differences in obstetric outcomes and to the development of pelvic floor disorders.

Obstetric outcomes of elderly primiparous singleton pregnancies conceived by in vitro fertilization compared with those conceived spontaneously

Aim: To examine the obstetric outcomes of elderly primiparous singleton pregnancies conceived by in vitro fertilization (IVF) compared with those conceived spontaneously. Methods: Data were collected from primiparous women aged 35years and older with a singleton pregnancy conceived by IVF (n=89) or spontaneously (n=849). Data included antenatal data, gestational age at delivery, obstetric complications, such as pregnancy-induced hypertension, gestational diabetes, placental previa and placental abruption, mode of delivery, birth weight, fetal demise and the Apgar score at 1min. Results: The elective Cesarean rate in pregnancies following IVF was significantly higher than that in the control group (P=0.014). However, there were no significant differences in obstetric outcomes between the two groups. Conclusions: The current results did not support the IVF-related risks of elderly primiparous singleton pregnancies. (Reprod Med Biol 2007; 6: 219-222).

Laparotomy versus laparoscopy for antenatal appendectomy

YAIR BLUMENFELD, MEREDITH ROCHON, KEITH EDDLEMAN, JEFFREY FREED, Mount Sinai School of Medicine, Obstetrics, Gynecology and Reproductive Science, New York, New York, Mount Sinai School of Medicine, Surgery, New York, New York OBJECTIVE: To compare intra-operative and post-operative differences between laparotomy and laparoscopy for antenatal appendectomy, and to determine differences in obstetrical outcomes between patients whose final pathology showed acute appendicitis to those with normal appendices. STUDY DESIGN: Retrospective cohort study of all antenatal appendectomies performed at a single institution from 1/1993 to 12/2004. Medical records were reviewed to ascertain maternal demographics, procedure details, and pregnancy outcomes. RESULTS: Sixty patients had appendectomies during the study period, 32 (53%) by laparoscopy (Lsc) and 28 by laparotomy (X-lap). Baseline demographics were similar between the two groups. Lsc was performed more frequently in the second half of the study period (44% v. 76%, p=.024). Those undergoing Lsc had their procedures performed at a significantly earlier gestational age (16.8 range 3-30 wks vs. 22.2 range 9-36 wks, p=.005), had longer procedures (61G25 min v 49G16 min, p=.024) and had a significantly shorter median hospital stay (2 range 1-36 days v 3 range 1-15 days, p=.004). Two patients required reoperation and transfusion for bleedingboth in the Lsc group (procedures at 20 and 30 wks). There was no difference in pregnancy outcome between the groups, though there was a trend toward higher rates of PTL in the X-lap group (48% v 10%, p=.07). Overall, 29% of patients had PTL, 18% PTD, 12% PPROM, and 23% of babies were admitted to the NICU. Despite this, mean GA at delivery was 38.5 wks with a mean birthweight of 3101G648g. Twenty-five percent of patients undergoing surgery had a normal appendix. There was no difference in outcome between those with appendicitis and those with a normal appendix. CONCLUSION: Shorter hospital stay and a trend towards a decreased rate of preterm labor suggest that laparoscopy should be the preferred approach for antenatal appendectomy whenever technically feasible. Increased experience with laparascopy in the future may further improve pregnancy outcome.

Comparison of obstetric outcome following the introduction of patient-controlled epidural analgesia with background infusion compared with continuous epidural infusion technique

PATIENT-CONTROLLED EPIDURAL ANALGESIA WITH BACKGROUND INFUSION COMPARED WITH CONTINUOUS EPIDURAL INFUSION TECHNIQUE AOIFE O’NEILL, NIAMH HAYES, EVE GAUGHAN, JOHN LOUGHREY, MICHAEL GEARY, Rotunda Hospital, Dublin, Ireland OBJECTIVE: Patient controlled epidural analgesia (PCEA) with low-dose background infusion has been shown in one study to result in fewer epidural rescue interventions, but this has not been a universal finding.PCEA techniques have been associated with reduced analgesic requirements, which may decrease instrumental delivery rates. We compared the effect of PCEA (5 ml bolus every 15 min/as required) with background infusion (6 ml/hour), versus continuous infusion epidural analgesia (CIEA) at 10 mls/hr with the same solution (bupivacaine 0.1% and fentanyl 2 mcg/ml) for nulliparous women. Our outcome measures were instrumental delivery rates, analgesic consumption and the frequency of rescue epidural reinforcement. STUDY DESIGN: A retrospective review of the hospital database prior to and after the introduction of PCEA with background infusion was conducted to assess major obstetric outcomes. A chart review for a sample of parturients in each group was also conducted to examine analgesic consumption and rates of rescue intervention between PCEA with background infusion and CIEA. RESULTS: The groups were demographically similar. There was no statistically significant difference in obstetric outcome between PCEA and CIEA (table). There was a reduction in the frequency of rescue reinforcement by anaesthetic and midwifery staff and a trend towards reduction in the average hourly dose of bupivacaine. CONCLUSION: Decreasing the number of rescue interventions reduces anaesthetic and midwifery workload in maintaining acceptable epidural analgesia on a busy labour ward. However, this technique has not reduced instrumental delivery rates in nulliparous women at our hospital. We conclude that PCEA with background infusion is an acceptable method of epidural analgesia maintenance.

Birth outcomes in teenage pregnancies

To evaluate and characterize the racial/ethnic differences in obstetric outcomes of early and late teenagers in California. A data-set linking birth and death certificates with maternal and neonatal hospital discharge records in California was utilized to identify nulliparous women (11 to 29 years of age) who delivered between January 1,1992 and December 31,1997. Pregnancy outcomes of early (11-15 year) and late (16-19 year) teenagers were compared to those of a control group of women aged 20-29. Early (n = 31 232) and late teens (n = 271 470) demonstrated greater neonatal and infant mortality and major neonatal morbidities (delivery < 37 weeks of gestation and birthweight < 2500 g) when compared to pregnancies in the older control women (n = 662 752). Ethnicity adversely affected outcome with African-Americans of all ages having worse outcomes than whites. The higher rate of adverse obstetric outcomes among the teenage pregnancies occurred despite a lower cesarean section rate and was consistent across all ethnic groups. When compared to women aged 20-29, all teen pregnancies were associated with higher rates of poor obstetric outcomes. Other factors besides teen pregnancy appear to be responsible for poor outcomes in certain ethnic groups.

Birth outcomes in teenage pregnancies

Objective: To evaluate and characterize the racial/ethnic differences in obstetric outcomes of early and late teenagers in California. Methods: A data-set linking birth and death certificates with maternal and neonatal hospital discharge records in California was utilized to identify nulliparous women (11 to 29 years of age) who delivered between January 1,1992 and December 31,1997. Pregnancy outcomes of early (11-15 year) and late (16-19 year) teenagers were compared to those of a control group of women aged 20-29. Results: Early (n = 31 232) and late teens (n = 271 470) demonstrated greater neonatal and infant mortality and major neonatal morbidities (delivery < 37 weeks of gestation and birthweight < 2500 g) when compared to pregnancies in the older control women (n = 662 752). Ethnicity adversely affected outcome with African-Americans of all ages having worse outcomes than whites. The higher rate of adverse obstetric outcomes among the teenage pregnancies occurred despite a lower cesarean section rate and was consistent across all ethnic groups. Conclusions: When compared to women aged 20-29, all teen pregnancies were associated with higher rates of poor obstetric outcomes. Other factors besides teen pregnancy appear to be responsible for poor outcomes in certain ethnic groups.

Is a speculum examination sufficient for excluding the diagnosis of ruptured fetal membranes?

To determine the false negative rate of a sterile speculum examination for the diagnosis of rupture of the membranes in women not in labor and without visible amniotic fluid at speculum examination. Furthermore, possible risks to the mother and the baby after suspected rupture of the membranes were analyzed. In women not in labor with suspected rupture of the membranes between gestational weeks 34 and 42, a sterile speculum examination was performed. If no amniotic fluid was visible, a test for Diamine oxidase was carried out. The results of tests were not known to the obstetricians or the women. The women were allowed to return home with no further controls if no amniotic fluid was visible at the speculum examination. Neonatal and obstetric outcome was recorded prospectively. Of 27,502 deliveries, 2,099 women not in labor attended the delivery ward for suspected rupture of the membranes after week 34. Amniotic fluid was visualized in 1,580 women. In 519 women in whom no amniotic fluid was seen at the speculum examination, the Diamine oxidase test was negative in 456 and positive in 63. Antibiotics were given to eleven children (2.4%) in the group with a negative Diamine oxidase and to one infant (1.6%) in the positive Diamine oxidase group (p>0.05). No differences in obstetric outcome were recorded. The false negative rate of a speculum examination for the diagnosis of rupture of the membranes in women without amniotic fluid visible at a speculum examination was 12% when Diamine oxidase was used as the standard for the diagnosis of rupture of the membranes. This study did not show any disadvantages for mothers and infants if the women were sent home after a false negative speculum examination. The value of biochemical methods in the management of women not in labor with rupture of the membranes after thirty-four weeks of gestation could be questioned.

Obstetric outcomes and infant birthweights for Vietnamese-born and Australian-born women in southwestern Sydney.

The southwestern Sydney area has the highest population of Vietnamese immigrants in New South Wales. The purpose of this study was to identify differences in obstetric outcomes and birthweights of infants of Vietnamese-born women and Australian-born women in southwestern Sydney during 1991. There was a higher incidence of gestational diabetes and a lower incidence of pre-eclampsia in Vietnamese-born women. The rate of induction of labour for Australian-born women (23.7 per cent) was almost double the rate for Vietnamese-born women (12.9 per cent). Birthweights of infants of vietnamese-born women were significantly lower at the 10th, 50th and 90th percentile. The use of racially appropriate growth charts will reduce overdiagnosis of growth-restricted infants and therefore unnecessary treatment. These findings highlight the need to take ethnic differences into account when planning health care.