Higher Rates Of Cesarean Delivery Research Articles

Cerebral Aneurysms in Pregnancy and Delivery

It is not known what effect pregnancy or delivery has on the risk of rupture of an intracranial aneurysm, and, consequently, the optimal management of unruptured aneurysms in pregnancy is unclear. To study the effect of pregnancy and delivery on the risk of rupture of intracranial aneurysms and to delineate trends in neurosurgical and obstetric management of pregnant women with intracranial aneurysms. The Nationwide Inpatient Sample data were analyzed for years 1988 to 2009 to estimate the risk of aneurysm rupture during pregnancies and deliveries. We calculated the risk by dividing the observed number of patients with ruptured aneurysm during pregnancy and delivery by the expected number based on the incidence among women of pregnancy age. There were 714 and 172 hospitalizations involving ruptured aneurysms with pregnancy and delivery, respectively. Assuming 1.8% prevalence of unruptured aneurysms among all women of pregnancy age, we estimated that 48,873 women hospitalized for pregnancy and 312,128 women hospitalized for delivery had unruptured aneurysms. The risks of rupture during pregnancy and deliveries were 1.4% (95% confidence interval [CI] = [1.35, 1.57]) and 0.05% (95% CI = [0.0468, 0.0634]), respectively. Of 218 deliveries performed with unruptured aneurysm, 153 were cesarean deliveries (70.18%, 95% CI = [64.06, 76.30%]), suggesting that the rate of cesarean deliveries in patients with unruptured aneurysms is significantly higher than in the general population (P < .001). We were not able to find an increased association between pregnancy or delivery and the risk of rupture of cerebral aneurysms. The significantly higher rate of cesarean deliveries performed in patients with unruptured aneurysms may not be necessary.

Estimated Fetal Weight by Ultrasound

Use of prenatal ultrasonography (US) has risen concomitantly with the increase in cesarean delivery (CD) rates. Sonographic overestimation of fetal macrosomia may be associated with a lower threshold for CD for labor arrest. If obtaining the US estimated fetal weight (US-EFW) near term increases the risk of CD, this could be a modifiable risk factor. This retrospective cohort study was undertaken to determine whether women with a US-EFW within 1 month of delivery are more likely to undergo CD compared with women without a US-EFW. The women had singleton live births; their demographic and delivery data were obtained from medical records, and the date, indication, and EFW were recorded. Patients were divided into those with a US-EFW within 1 month of delivery and women with no US-EFW. Logistic regression was used to analyze whether US-EFW was an independent risk factor for CD. The mode of delivery was the outcome variable. The statistical software package SPSS version 12.0 was used for all data analyses. Subsets created were groups at low risk, those with EFWs of less than 3000 g, those with EFWs greater than 3500 g, and those with actual birth weights of greater than 4000 g. This cohort included 2329 women with term pregnancies who met the inclusion and exclusion criteria, of whom 1168 (50.2%) had a US-EFW within 1 month of delivery. Of those with a US-EFW, 540 (46%), 276 (24%), 179 (15%), and 173 women (15%) had the US within 1 week of delivery and 1 to 2 weeks, 2 to 3 weeks, and 3 weeks to 1 month before delivery, respectively. The most common indications were “postdates” (19%), uterine size less than dates (17%), uterine size greater than dates (14%), and older maternal age (16%). Women with a US-EFW within 1 month of delivery were significantly older and more likely to be white, be cared for by a physician rather than a midwife, be obese, undergo labor induction, and deliver at slightly later gestational ages. No differences in parity, previous CD, or actual birth weight were found between the 2 groups. The unadjusted CD rates showed that women with a US-EFW were 55% more likely to have a CD (15.7% vs 10.2%; P < 0.01). The timing of US within the 1-month period before delivery had little impact. The CD rates were 16% with a US within 1 month of delivery and 16%, 15.5%, and 12% for a US within 3, 2, and 1 week(s) of delivery, respectively. The main indications for CD were failure to progress and nonreassuring fetal heart tracings in both groups. Of 17 CDs performed for presumed macrosomia, all in the US-EFW group, only 3 deliveries had an EFW of greater than 5000 g. When controlling for birth weight, maternal age, race, body mass index, previous CD, parity, gestational age, induction versus spontaneous labor, and provider group, US-EFW was a statistically significant independent risk factor for CD. Women with a US-EFW within 1 month of delivery were 44% more likely to have a CD. Other independent predictors of CD were birth weight, advanced maternal age, black or Hispanic race, nulliparity, obesity, previous CD, and faculty provider group. In the entire cohort, US-EFW was associated with increased odds of CD (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.1–1.9). For those with fetuses of less than 3000 g, US-EFW was not associated with an increased risk of CD (OR, 0.97; 95% CI, 0.45–2.1). With EFW greater than 3500 g, the OR was greater and statistically significant (OR, 1.8; 95% CI, 1.3–2.7) and was stronger still for the population with an actual birth weight greater than 4000 g (OR, 3.1; 95% CI, 1.2–8.3). For women with a US-EFW within 1 month of delivery, the association between the US and CD seems to be due to provider concern over larger US-EFWs because the risk of CD was not increased if the US-EFW was less than 3000 g. However, for women with a US-EFW of greater than 3500 g, an 85% increased risk of CD was apparent with US-EFW determination. The rising CD rate is a great concern, but many of the known reasons contributing to the rise are not readily modifiable. These results indicate that provider knowledge of larger US-EFW may be associated with a higher rate of CD. Limiting the use of US to determine fetal weight near term may help to reduce the CD rate in the United States.

Liver diseases in pregnancy: Liver transplantation in pregnancy

Pregnancy in patients with advanced liver disease is uncommon as most women with decompensated cirrhosis are infertile and have high rate of anovulation. However, if gestation ensued; it is very challenging and carries high risks for both the mother and the baby such as higher rates of spontaneous abortion, prematurity, pulmonary hypertension, splenic artery aneurysm rupture, postpartum hemorrhage, and a potential for life-threatening variceal hemorrhage and hepatic decompensation. In contrary, with orthotopic liver transplantation, menstruation resumes and most women of childbearing age are able to conceive, give birth and lead a better quality of life. Women with orthotopic liver transplantation seeking pregnancy should be managed carefully by a team consultation with transplant hepatologist, maternal-fetal medicine specialist and other specialists. Pregnant liver transplant recipients need to stay on immunosuppression medication to prevent allograft rejection. Furthermore, these medications need to be monitored carefully and continued throughout pregnancy to avoid potential adverse effects to mother and baby. Thus delaying pregnancy 1 to 2 years after transplantation minimizes fetal exposure to high doses of immunosuppressants. Pregnant female liver transplant patients have a high rate of cesarean delivery likely due to the high rate of prematurity in this population. Recent reports suggest that with close monitoring and multidisciplinary team approach, most female liver transplant recipient of childbearing age will lead a successful pregnancy.

Complications during cesarean delivery in a patient with two previous myomectomies

Myomas are associted with numerous pregnancy-related maternal and fetal complications, including high rate of cesarean deliveries. We present a woman with huge posterior myoma who had two previous myomectomies. During the cesarean section, the anatomy was found to be grossly distorted. Thus it was necessary to make an inverted T-incision on the uterus, which facilitated delivery of the fetus. The patients postoperative recovery was uneventful. This case illustrates the difficulties that may arise during cesarean section in the presence of uterine myomas in women with previous myomectomies. Clinicians should be prepared to manage those difficulties with inverted T-incision in order to prevent fetal injuries. Such operations should be performed by an experienced obstetrician.

Cesarean delivery rates in Down syndrome pregnancies

Data on rates of cesarean delivery among pregnancies diagnosed with genetic syndromes remains limited. We examined the cesarean delivery rates for Down syndrome pregnancies over a 10-year period in the US. We used data from the 1995-2004 US delivery data files to examine cesarean delivery rates in singleton pregnancies (at ≥20 weeks' gestation) with and without Down syndrome. We further examined if the rates of cesarean deliveries in primary and repeat cesarean deliveries among Down syndrome pregnancies differed based on the presence or absence of major structural abnormalities or stillbirth or gestational age at delivery. There were 35 million singleton deliveries of which 19186 were diagnosed at birth with Down syndrome (1 in 2000 births after 20 weeks gestation). The primary cesarean delivery rates were higher among Down syndrome pregnancies (17.5% in 1995 and 21.5% in 2004) compared to non-Down syndrome pregnancies (12.3% in 1995 and 16.6% in 2004). Temporal trends for cesarean deliveries were steeper among Down syndrome pregnancies with gastrointestinal and heart abnormalities than in Down syndrome cases without abnormalities. Higher cesarean delivery rates were also noted among Down syndrome pregnancies ending in third trimester live born than in control. In the US, cesarean deliveries in Down syndrome pregnancies increases over time and is greater when Down syndrome is associated with structural abnormalities and delivered during the third trimester of pregnancy.

Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery

Cesarean delivery rates in California and the United States rose by 50% between 1998 and 2008 and vary widely among states, regions, hospitals, and health care providers. The leading driver of both the rise and the variation is first-birth cesarean deliveries performed during labor. With the large increase in primary cesarean deliveries, repeat cesarean delivery now has emerged as the largest single indication. The economic costs, health risks, and negligible benefits for most mothers and newborns of these higher rates point to the urgent need for a new approach to working with women in labor. This commentary analyzes the high rates and wide variations and presents evidence of costs and risks associated with cesarean deliveries (complete discussion provided in the California Maternal Quality Care Collaborative White Paper at www.cmqcc.org/white_paper). All stakeholders need to ask whether society can afford the costs and complications of this high cesarean delivery rate and whether they can work together toward solutions. The factors involved in the rise in cesarean deliveries point to the need for a multistrategy approach, because no single strategy is likely to be effective or lead to sustained change. We outline complementary strategies for reducing the rates and offer recommendations including clinical improvement strategies with careful examination of labor management practices; payment reform to eliminate negative or perverse incentives; education to recognize the value of vaginal birth; and full transparency through public reporting and continued public engagement.

Pregnancy Outcomes in Women With and Without Gestational Diabetes Mellitus According to The International Association of the Diabetes and Pregnancy Study Groups Criteria

To estimate the incidence of gestational diabetes mellitus (GDM) according to The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria and the pregnancy complications in women fulfilling these criteria but who are not considered diabetic according to the Canadian Diabetes Association criteria. We estimated the rate of GDM according to the IADPSG criteria from November 2008 to October 2010. Then, we conducted a chart review to compare maternal and neonatal outcomes between women classified as GDM according to the IADPSG criteria but not by the Canadian Diabetes Association criteria (group 1; n=186) and nondiabetic women according to both criteria (group 2; n=372). Results were expressed as crude (odds ratio [OR]) or adjusted OR and 95% confidence interval (CI). The study has a statistical power of 80% to detect a difference between 16% and 8% in large for gestational age newborns (α level of 0.05; two-tailed). The rate of GDM using the IADPSG criteria was 27.51% (95% CI 25.92-29.11). Group 1 presented similar rates of large-for-gestational-age newborns (9.1% compared with 5.9%, adjusted OR 1.58, 95% CI 0.79-3.13; P=.19), delivery complications (37.1% compared with 30.1%, OR 1.37, 95% CI 0.95-1.98; P=.10), preeclampsia (6.5% compared with 2.7%, adjusted OR 2.40, 95% CI 0.92-6.27; P=.07), prematurity (6.5% compared with 2.7%, OR 1.10, 95% CI 0.53-2.27; P=.85), neonatal complications at delivery (13.4% compared with 9.7%, OR 1.45, 95% CI 0.84-2.49; P=.20), and metabolic complications (10.8% compared with 14.2%, OR 0.73, 95% CI 0.42-1.26; P=.29) compared with group 2. Women classified as nondiabetic by the Canadian Diabetes Association Criteria but considered GDM according to the IADPSG criteria have similar pregnancy outcomes as women without GDM. More randomized studies with cost-effectiveness analyses are needed before implementation of these criteria. II.

Incidence and obstetrical outcomes of cervical intraepithelial neoplasia and cervical cancer in pregnancy

To estimate the incidence and outcomes of cervical intraepithelial neoplasia (CIN) and cervical cancer in pregnancy. We conducted a population-based cohort study using the United States Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 1999 to 2008. The incidence of CIN and cervical cancer was measured and logistic regression analysis used to estimate the adjusted effect of CIN and cervical cancer on obstetrical outcomes. There were 8,826,137 births over a 10-year period of which 11,755 were among women with CIN and 294 among women with cervical cancer. Compared with controls, women with CIN were younger, had lower annual incomes, and more likely to be on Medicaid while women with cancer were more likely to be older. Women with CIN had lower rates of cesarean delivery but higher rates of transfusions and cesarean hysterectomies, while women with cancer had higher rates of cesarean deliveries, transfusions and cesarean hysterectomies. There were no significant increase of thrombosis; maternal death, instrumental delivery, IUGR, PPROM or intrauterine death was found. CIN and cervical cancer are rare in pregnancy. Although there is a greater risk of transfusion/hysterectomy, overall major maternal and neonatal morbidity does not appear to be increased.

Value of Doppler sonography near term: can umbilical and uterine artery indices in low-risk pregnancies predict perinatal outcome?

The goal of this study was to evaluate the umbilical and uterine Doppler velocimetry waveforms for predicting the perinatal outcome of low-risk pregnancies at term. We prospectively recruited 514 women with low risk pregnancies and performed umbilical and uterine artery Doppler assessments between 37 and 41 weeks of gestation. Ultrasound measurements (completed in 365 patients) were correlated with the perinatal outcome. The velocimetry waveforms of the umbilical artery were significantly associated with birthweight, placental weight, and postpartal umbilical artery pH. Low pH, placental weight, and birthweight were correlated with increasing pulsatility index (PI) and resistance index (RI). An umbilical artery PI > 1.2 and a uterine artery RI > 0.5 were associated with statistically higher rates of infants that were small for gestational age (SGA). Also, high cesarean delivery rates were correlated with an umbilical artery PI > 1.2. In our low-risk pregnancies population, the elevated umbilical artery indices at term appeared to be associated with the higher rates of infants that were SGA and cesarean deliveries. The Doppler waveforms at term had low prognostic value for predicting neonatal acidosis or decreased Apgar scores.

Maternal “isolated” obesity and obstetric complications

Objective: To investigate pregnancy outcomes, particularly cesarean delivery (CD), among women with “isolated” obesity (i.e. without additional comorbidities). Study design: We conducted a retrospective population-based study between the years 1988–2010. The pregnancy outcomes of obese (prepregnancy BMI ≥30 kg/m2) and nonobese patients were compared. Patients with chronic hypertension, pregestational diabetes mellitus, other preexisting chronic morbidities, multiple gestations, age above 40 years, grand multiparity (above 5 deliveries), lack of prenatal care, and following fertility treatments were excluded from the analysis. Stratified analyses, using multiple logistic regression models, were performed to control for confounders. Results: During the study period, a total of 173,628 deliveries met the inclusion criteria; 1605 (0.9%) occurred in patients with “isolated” obesity. Higher rates of CD were found among patients with “isolated” obesity (30.7% vs. 12.3%; odds ration [OR] = 3.2; p < 0.001). When controlling for possible confounders, using a multivariable model with CD as the outcome variable, the association between “isolated” obesity and CD remained significant (adjusted OR = 2.6; p < 0.001). No significant differences were found in the risks of perinatal complications including perinatal mortality, shoulder dystocia, congenital malformations, and low 5-min Apgar score. Conclusion: “Isolated” obesity, although not a risk factor for adverse perinatal outcomes, is an independent risk factor for CD.

Can angle of progression in pregnant women before onset of labor predict mode of delivery?

The angle of progression (AOP), measured by transperineal ultrasound, has been used to assess fetal head descent during labor. Our aim was to assess whether, before onset of labor, parous women have a narrower AOP than do nulliparous women and if a narrow AOP is associated with a higher rate of Cesarean delivery. In this prospective, observational study, we performed transperineal ultrasound in pregnant women not yet in labor at ≥ 39 weeks' gestation who delivered within 1 week of sonography. The AOP was compared as follows: in nulliparous women, between those who had a Cesarean section and those who delivered vaginally; and among women who delivered vaginally, between those who were nulliparous and those who were parous. Included in the study were 100 nulliparous and 71 parous women. Among those who delivered vaginally (n = 161), the median AOP before onset of labor was narrower in parous than in nulliparous women (98° (interquartile range (IQR)), 90-107° vs 104° (IQR, 97-113°), P < 0.001). Among the 100 nulliparous women, (1) the median AOP before onset of labor was narrower in those who went on to deliver by Cesarean section (n = 9) than in those delivered vaginally (n = 91) (90° (IQR, 85.5-93.5°) vs 104° (IQR, 97-113°), P < 0.001); (2) an AOP ≥ 95° (derived from the receiver-operating characteristics curve) was associated with vaginal delivery in 99% of women; and (3) 89% (8/9) of women who delivered by Cesarean section had an AOP < 95°. Among the 71 parous women, only one delivered by Cesarean section and all of those with an AOP < 95° delivered vaginally. A narrow AOP (< 95°) in non-laboring nulliparous women at term is associated with a high rate of Cesarean delivery. Parous women have a narrower AOP than do nulliparous women before the onset of labor; however, unlike in nulliparous women, a narrow AOP in parous women does not appear to be associated with Cesarean delivery and most parous women with such an angle go on to deliver vaginally.

PS2-13: Trends in Elective Labor Induction at 7 US Health Plans, 2001-2007

Sascha Dublin1, Karin Johnson1, Rod Walker1, Darios Getahun2, Susan Andrade3, Lyndsay Avalos2, Sarah Beaton4, Robert Davis5, Lisa Herrinton6, Pamala Pawloski7, Marsha Raebel8, David Smith9, Darren Toh10 and Aaron Caughey11 1Group Health Cooperative 2Kaiser Permanente Southern California 3Fallon Community Health Plan, Meyers Primary Care Institute 4Lovelace Health System 5Kaiser Permanente Southeast 6Kaiser Permanente Northern California 7HealthPartners 8Kaiser Permanente Colorado 9Kaiser Permanente Northwest 10Harvard Pilgrim Health Care Institute, Harvard Medical School 11Oregon Health and Science University

Delivery method choice in the South African private sector

The high caesarean rate in South Africa is five times higher than the World Health Organisation recommended rate. This is a matter of concern and urgently needs to be investigated. Therefore, this study aimed to find out why South Africans have such a high caesarean section delivery rate by exploring decisions made with regard to the choice of mode of birth. This study found that in South Africa, the advice comes from the obstetrician not the midwife. The pregnant women in this study did not have antenatal health education related to the available different modes of delivery and were denied the opportunity to make an informed decision despite them having attended the antenatal care clinic, being well educated and able to understand concepts explained to them. It was found that the private doctors were still in the forefront of the patient pathway and that the midwife was often left to prepare the woman for the caesarean section even though they perhaps did not agree.

The Effect of Maternal Obesity on Pregnancy Outcomes of Women with Gestational Diabetes Controlled with Diet Only, Glyburide, or Insulin

To examine the effect of obesity on maternal and neonatal outcomes in women diagnosed with gestational diabetes mellitus (GDM) and managed with diet only, glyburide, or insulin. Women with singleton gestations enrolled for outpatient services diagnosed with GDM and without history of pregnancy-related hypertension at enrollment or in a prior pregnancy were identified in a database. Women with GDM controlled by diet only (n = 3918), glyburide (n = 873), or insulin without prior exposure to oral hypoglycemic agents (n = 2229) were included. Pregnancy outcomes were compared for obese versus nonobese women within each treatment group and also compared across treatment groups within the obese and nonobese populations. Within each treatment group, obesity was associated with higher rates of cesarean delivery, pregnancy-related hypertension, macrosomia, and hyperbilirubinemia (all p < 0.05). Higher rates of pregnancy-related hypertension and hyperbilirubinemia were observed in women receiving glyburide. Obesity adversely affects pregnancy outcome in women with GDM. Higher rates of pregnancy-related hypertension and hyperbilirubinemia were observed in pregnant women receiving glyburide.

Estimating the impact of pelvic immaturity and young maternal age on fetal malposition

Fetal malposition, specifically occiput posterior and transverse (OP/OT), is associated with higher intra-partum morbidity. We tested the hypothesis that young maternal age and pelvic immaturity are risk factors for fetal malposition. In a cohort study of all nulliparous teen (≤18years) deliveries over a 4-year period at one institution, fetal head position at time of delivery was collected and correlated with maternal characteristics and outcome data. Using Risser staging observations, pelvic maturity age was set at 16, and accordingly, the women were divided into two groups (younger vs. older teens). Analysis was performed using Fisher's exact, student t test, and logistic regression modeling. Older teen mothers (16-18years, n=609) had higher rates of malposition (22 vs. 12%, p=0.02) when compared with younger teens (≤15years, n=98). Among all women with a malpositioned fetus, older teens had a higher body mass index (BMI: 32.6±6.7 vs. 28.5±3.5, p=0.04) and subsequent need for cesarean delivery (69 vs. 33%, p=0.02) when compared with their younger counterparts. Although younger teens were more successful in having a vaginal delivery (67%) with an OP/OT position, it was at the expense of a 25% rate of severe perineal laceration (third/fourth degree). Obesity, and not young maternal age or pelvic immaturity, is associated with fetal malposition. The direct association with increasing pre-pregnancy BMI and the long-term impacts of the high rates of cesarean delivery in this young population underscores the need for more public health focus.

The effects of adjuvant insulin therapy among pregnant women with IGT who failed to achieve the desired glycemia levels by diet and moderate physical activity

Objective: Evaluation of adjuvant insulin therapy effects on glycemic control, perinatal outcome and postpuerperal glucose tolerance in impaired glucose tolerance (IGT) pregnant women who failed to achieve desired glycemic control by dietary regime. Methods: A total of 280 participants were classified in two groups: Group A patients continued with dietary regime and Group B patients were treated with adjuvant insulin therapy. Glycemic control was assessed by laboratory and ultrasonograph means. Pregnancy outcomes were evaluated by prevalence of pregnancy induced hypertension (PIH), high birth weight, neonatal hypoglycemia and caesarean section rates. Postpuerperal glucose tolerance was assessed by oral glucose tolerance test (oGTT). Results: All laboratory and ultrasound indicators of glycemic control had significantly lower values in Group B. Group A women were more likely to develop the EPH (Edema, Proteinuria, Hypertension) syndrome, 20% versus 7.86% (p = 0.003). High birth weight occurred more frequently in Group A, but the difference was not significant (p = 0.197). Higher rate of caesarean delivery was in Group A than in Group B, 16.43% versus 26.43% (p = 0.041). The difference in neonatal hypoglycemia was not significant (p = 0.478). Pathological oGTT results were observed in 73 Group A patients and in 15 Group B patients. Conclusion: Lower caesarean section rates and the EPH syndrome incidence are the benefits of adjuvant insulin therapy in IGT patients.

Temporal trends of latency period and perinatal survival after very early preterm premature rupture of fetal membranes

This paper shows temporal trends of latency period and perinatal survival after preterm premature rupture of membranes at or before 28 weeks (very early PPROM). We have studied retrospectively medical records of all cases of very early PPROM attended in our Obstetric Department from January 1, 2000 to December 31, 2010. A total of 327 cases of very early PPROM were attended, representing 0.4 % of all deliveries, 3.68 % of all preterm births and 15 % of cases all of PPROM. The mean gestational age at delivery was 27 weeks (range 20-34). The mean duration of latency period for the total of 327 cases was 12.1 days (range 0-83, SD 13.3), with a clear trend to its increase from 2005 (p < 0.05). The mean duration of latency period was largest in 2010 (p < 0.05). For the whole period 2000-2010, perinatal deaths reached 30.6 % of all cases, with a clear trend to decrease as gestational age at diagnosis increased, and over the years of study. We have also found a high rate of obstetric complications and a high rate of cesarean deliveries. The upward trend in the duration of latency period in all groups over the years of study and the encouraging perinatal survival observed, even in previable PPROM, are incentives to follow expectant/conservative management in these cases.

Pregnancy outcome in a Spanish population of women beyond age 40 delivered above 32 weeks’ gestation

Objective: To investigate the effect of age and parity on obstetric outcome in a Spanish population of pregnants aged 40 years or older delivered above 32 weeks’gestation. Methods: A retrospective cohort of 16764 singleton pregnancies delivered above 32 weeks’gestation between 2000 and 2007 in a nontertiary community hospital was studied. Obstetric outcomes in women aged 40 years or above (n = 335) were compared to women aged 20–29 years (n = 347) delivered at the same period. Results: During the study period, the prevalence of mothers aged 40 or above increased from 1.6% to 3%. Older pregnants were more likely to be multiparous and to have used assisted reproductive techniques. They were more likely to develop gestational diabetes (OR 7.77, 3.50–17.94) and preeclampsia (OR 2.60, 1.13–6.16) and to have a higher rate of cesarean delivery (OR 2.95, 1.98–4.42). Elective was the most frequent cause of cesarean delivery in this group. Newborns were at higher risk to suffer diabetes-related complications but no differences neither in 5-min Apgar score of <7 nor in the need for admission into special care baby unit were found. No perinatal deaths were registered. Conclusion: Our Spanish population of older mothers showed a higher risk for being delivered by cesarean section and for developing either preeclampsia or gestational diabetes. The overall neonatal outcome was unaffected. These data may be helpfull to counsel patients about their pregnancy expectations and possible outcomes.

Fetal sex and perinatal outcomes

To evaluate the relationship of fetal sex with obstetric risk factors and perinatal outcomes. Retrospective study of deliveries during 2003-2009 at a tertiary hospital based on the analysis of obstetric and neonatal risk variables according to neonatal sex. Of the 29,530 deliveries studied, the neonate was a boy in 15,038 (50.92%) and a girl in 14,492 (49.08%). The rates of gestational diabetes, prematurity, true umbilical cord knot and nuchal cord were higher for male newborns, whereas the rate of echographic diagnosis of intrauterine fetal growth retardation was higher for female newborns. Mothers of male fetuses had higher rates of cesarean delivery and instrumental vaginal delivery. The indication for ending labor due to the non-reassuring fetal heart rate was also more frequent among male newborns. This group had higher rates of acidemia, although there were no significant differences between sexes in other short-term neonatal outcomes. In all subgroups analyzed here, fetal weight was higher in male newborns. Male sex is an independent risk factor for unfavorable outcomes of pregnancy and delivery.

Jejunoileal atresia: Factors affecting the outcome and long-term sequelae

Context:Jejunoileal atresia (JIA) is a common abnormality. The outcome is conditioned by several variables. Nutritional problems, and long-term sequelae are described among those who survive.Aim:To correlate the type of JIA and its management to the outcome and long-term quality of life.Settings and Design:Forty-three cases over a 17-year period (1992–2009). Perinatal data, management, and outcome were extracted from the clinical notes. The cases that had survived were contacted to get information about their present condition.Materials and Methods:Morbidity and mortality were matched to maturity, birth weight, mode of diagnosis, type of JIA, associated anomalies, and management and duration of parenteral nutrition. Growth and quality of life in 34 cases were evaluated via a telephone interview at a minimum of one year from surgery.Statistical analysis:Fisher test, Linear regression test, Kruskal-Wallis test, Dunn's comparison test.Results:Male/Female ratio was 25/18 and median birth weight was 2.644 g. Prenatal diagnosis was recorded in 34%. Six patients (14%) had associated anomalies. Primary surgery was resection and anastomosis in 88% and temporary stoma in 12%. Length of the resected bowel ranged from 3 to 65 cm. Whenever multiple atresia was found, the bowel length was saved by multiple anastomosis. Three dehiscences and three adhesive obstructions required a reoperation. Two patients (4%) died due to a central catheter–related sepsis. Prenatal diagnosis did not influence the outcome and was associated with a higher rate of Cesarean deliveries. Interview, at a median of nine years, showed normal growth in 85%. One case of short bowel syndrome is still on parenteral support at 22 months.Conclusions:Preserving bowel length and reducing the recourse to stoma is the key to good outcome and growth. Sequelae are correlated with the type of atresia and length of residual bowel; however, they decrease their severity with time.