Composite Maternal Outcome Research Articles

Maternal outcomes according to cesarean uterine incision between 23 and 27 weeks’ gestation

Objective Cesarean delivery between 23 and 27 weeks’ gestation is a risk factor for performing classical and inverted T uterine incisions. When attempting cesarean delivery via a low transverse incision at a very preterm gestational age, having difficulty in delivery of the fetus may require conversion to an inverted T-incision. We sought to examine maternal short-term outcomes according to the type of attempted uterine incisions in preterm deliveries. Study design This was a multihospital retrospective cohort study of women undergoing cesarean delivery between 23 0/7 and 27 6/7 week’ gestation from 2005 through 2014. Cases were classified as attempting low transverse incision if the uterine incision was a low transverse or an inverted T incision. Composite maternal outcome (postpartum hemorrhage, transfusion, endometritis, sepsis, wound infection, deep venous thrombosis/pulmonary embolism, hysterectomy, respiratory complications, and intensive care unit admission) was compared between cases where a low transverse incision was attempted and those with a classical uterine incision. We also examined operative time and Apgar score at 5 minutes. Multivariable logistic regression or linear regression was used to obtain adjusted p-value or adjusted odds ratios (aOR) with 95% confidence interval (95%CI), controlling for maternal age, gestational age, body mass index (kg/m2), and preterm premature rupture of membranes. Results Of 311 women undergoing cesarean delivery between 23 0/7 and 27 6/7 week’ gestation, attempting low transverse incision occurred in 127 (41%). Of these, conversion to an inverted T or J uterine incision occurred in 14 (11%). There was no difference in the composite outcome between cases with attempting low transverse incision and those with classical incision (17.3 versus 23.4%, respectively; aOR 0.58 [95%CI 0.30–1.11]). Cases in which a low transverse uterine incision was attempted had shorter median operative time (46 versus 55 minutes; adjusted p-value < 0.01). No differences were seen in the Apgar score at 5 minutes (adjusted p-value = .81). Conclusion The incidence of conversion from a low transverse to an inverted T uterine incision in very preterm cesarean deliveries was low. Attempting a low transverse compared to a classical uterine incision was associated with similar odds of the primary outcome and shorter operative time.

Safety and success rate of vaginal birth after two cesarean sections: retrospective cohort study.

Cesarean section is a lifesaving procedure with short and long-term consequences. Growing rates of cesareansections worldwide arise problems for subsequent birth. The aim of this study was to compare safety of vaginal birthafter two cesarean sections with repeat third cesarean section to help healthcare providers and patients make well informeddecisions about mode of subsequent delivery. This was a retrospective cohort study conducted in a tertiary reference hospital. Database of alldeliveries (2010-2017) after two previous cesarean sections was created from electronic and paper medical records. Pretermdeliveries, abnormal karyotype and neonates with congenital anomalies were excluded from the study. The final analysisincluded 412 cases for maternal outcome analysis and 406 cases for neonatal outcome analysis. Trial of labor after two cesareans in comparison to repeat cesarean section increases the risk of hemorrhage(OR: 10.84) and unfavorable composite maternal outcome (OR: 2.58). Failed trial of labor increases this risk of hemorrhage(OR: 15.27) and unfavorable composite maternal outcome (OR: 4.59) even further. There were no significant differences in neonataloutcomes. 22 out of 35 trials of labor ended in successful delivery giving a success rate of 62.85%. 5 of 7 labor inductionsended in repeat cesarean section giving 28.6% success rate. There were no maternal deaths and emergency hysterectomies. Trial of labor, especially failed trial of labor, is associated with an increased risk of perinatal complications.

Mediterranean-style diet in pregnant women with metabolic risk factors (ESTEEM): A pragmatic multicentre randomised trial.

BackgroundPregnant women with metabolic risk factors are at high risk of complications. We aimed to assess whether a Mediterranean-style diet reduces adverse pregnancy outcomes in high-risk women.Methods and findingsWe conducted a multicentre randomised trial in 5 maternity units (4 in London and 1 in Birmingham) between 12 September 2014 and 29 February 2016. We randomised inner-city pregnant women with metabolic risk factors (obesity, chronic hypertension, or hypertriglyceridaemia) to a Mediterranean-style diet with high intake of nuts, extra virgin olive oil, fruits, vegetables, nonrefined grains, and legumes; moderate to high consumption of fish; low to moderate intake of poultry and dairy products; low intake of red and processed meat; and avoidance of sugary drinks, fast food, and food rich in animal fat versus usual care. Participants received individualised dietary advice at 18, 20, and 28 weeks’ gestation. The primary endpoints were composite maternal (gestational diabetes or preeclampsia) and composite offspring (stillbirth, small for gestational age, or admission to neonatal care unit) outcomes prioritised by a Delphi survey. We used an intention-to-treat (ITT) analysis with multivariable models and identified the stratification variables and prognostic factors a priori.We screened 7,950 and randomised 1,252 women. Baseline data were available for 593 women in the intervention (93.3% follow-up, 553/593) and 612 in the control (95.6% follow-up, 585/612) groups. Over a quarter of randomised women were primigravida (330/1,205; 27%), 60% (729/1,205) were of Black or Asian ethnicity, and 69% (836/1,205) were obese. Women in the intervention arm consumed more nuts (70.1% versus 22.9%; adjusted odds ratio [aOR] 6.8, 95% confidence interval [CI] 4.3–10.6, p ≤ 0.001) and extra virgin olive oil (93.2% versus 49.0%; aOR 32.2, 95% CI 16.0–64.6, p ≤ 0.001) than controls; increased their intake of fish (p < 0.001), white meat (p < 0.001), and pulses (p = 0.05); and reduced their intake of red meat (p < 0.001), butter, margarine, and cream (p < 0.001). There was no significant reduction in the composite maternal (22.8% versus 28.6%; aOR 0.76, 95% CI 0.56–1.03, p = 0.08) or composite offspring (17.3% versus 20.9%; aOR 0.79, 95% CI 0.58–1.08, p = 0.14) outcomes. There was an apparent reduction in the odds of gestational diabetes by 35% (aOR 0.65, 95% CI 0.47–0.91, p = 0.01) but not in other individual components of the composite outcomes. Mothers gained less gestational weight (mean 6.8 versus 8.3 kg; adjusted difference −1.2 Kg, 95% CI −2.2 to −0.2, p = 0.03) with intervention versus control. There was no difference in any of the other maternal and offspring complications between both groups. When we pooled findings from the Effect of Simple, Targeted Diet in Pregnant Women With Metabolic Risk Factors on Pregnancy Outcomes (ESTEEM) trial with similar trials using random effects meta-analysis, we observed a significant reduction in gestational diabetes (odds ratio [OR] 0.67, 95% CI 0.53–0.84, I2 = 0%), with no heterogeneity (2 trials, 2,397 women). The study’s limitations include the use of participant reported tools for adherence to the intervention instead of objective biomarkers.ConclusionsA simple, individualised, Mediterranean-style diet in pregnancy did not reduce the overall risk of adverse maternal and offspring complications but has the potential to reduce gestational weight gain and the risk of gestational diabetes.Trial registrationClinicalTrials.gov NCT02218931.

Thresholds for Ambulatory Blood Pressure Monitoring Based on Maternal and Neonatal Outcomes in Late Pregnancy in a Southern Chinese Population.

BackgroundIn contrast to the general population, outcome‐derived thresholds for diagnosing ambulatory hypertension in pregnancy are not yet available. We aimed to identify and compare outcome‐derived ambulatory blood pressure (BP) monitoring thresholds for adverse perinatal outcomes by using approaches related and not related to clinic BP in a southern Chinese population.Methods and ResultsAmbulatory BP monitoring was performed in a cohort of 1768 high‐risk participants in late pregnancy who were not taking antihypertensive medications. Participants were followed for composite maternal (severe complications) and neonatal (pregnancy loss, advanced neonatal care, and small for gestational age) outcomes. Modeling of clinic BP–unrelated approaches revealed a nonlinear threshold effect of ambulatory diastolic BP on the composite outcome, with increased risk for daytime ≥79 mm Hg and 24‐hour measurement ≥76 mm Hg. For other ambulatory BP components showing linear associations with outcome, the following thresholds were identified: 131 mm Hg for daytime systolic, 121 mm Hg for nighttime systolic, 130 mm Hg for 24‐hour systolic, and 73 mm Hg for night‐time diastolic BP. These thresholds unrelated to clinic BP were lower than the equivalents yielding a similar probability of outcome to clinic BP of 140/90 mm Hg and were comparable with equivalents to clinic BP of 130/80 mm Hg.ConclusionsUsing an outcome‐derived approach unrelated to clinic BP, we identified rounded thresholds to define ambulatory hypertension in at‐risk women in late pregnancy in a southern Chinese population as follows: 130/80 mm Hg for daytime, 120/75 mm Hg for nighttime, and 130/75 mm Hg for 24‐hour measurement. For wider clinical applicability and to align both nonpregnancy and pregnancy ambulatory BP monitoring with an outcomes‐based approach, prospective, multiethnic, international studies from early pregnancy onward will be required.

Perinatal outcome following induction of labor in patients with good glycemic controlled gestational diabetes: does timing matter?

To compare maternal and neonatal outcomes in women with good glycemic controlled gestational diabetes mellitus (GDM) undergoing induction of labor at early and late term. A retrospective cohort study of all women with singleton pregnancies and well-controlled GDM undergoing induction of labor for non-GDM indications in the early (37 + 0-38 + 6 gestational weeks) and late term (39 + 0-40 + 6weeks), in a single university-affiliated medical center (2014-2016). Exclusion criteria included: pre-gestational diabetes, multiple gestations and elective cesarean delivery. Maternal and neonatal outcomes were compared between groups. Composite maternal outcome included: post-partum hemorrhage, blood products transfusion, and cesarean or instrumental delivery. Composite neonatal outcome included: neonatal intensive care unit admission, respiratory distress syndrome, hypoglycemia and jaundice. Overall, 430 women met inclusion criteria. Amongst them, 193 (44.88%) were induced at early term and 237 (55.11%) were induced at late term. There were higher rates of hypertensive complications of any kind and pre-eclampsia, in women induced at early term (11.04% vs. 4.26%, p = 0.021, and 5.92% vs. 1.60%, p = 0.04, respectively). There were no differences in maternal and neonatal outcomes between groups. Rates of composite maternal outcome and composite neonatal outcome did not differ between groups (OR 0.92, 95% CI 0.59-1.44, p = 0.73 and OR 0.78, 95% CI 0.47-1.3, p = 0.36, respectively). Women with good glycemic controlled GDM may be safely induced at early term, when other indications exist, without an increased risk for adverse maternal or neonatal outcomes.

Variation in Outcome Reporting in Studies on Obesity in Pregnancy—A Systematic Review [20S

INTRODUCTION: Improving outcomes in women with obesity (BMI>30 kg/m2) in pregnancy is limited by the heterogeneous outcomes between clinical trials. This systematic review of antepartum and peripartum interventions/exposures aimed to determine outcomes and their definitions reported thus far, as a preliminary step towards the standardization of outcomes. METHODS: MEDLINE, Embase, CENTRAL and www.clinicalTrials.gov were searched for trials, secondary analyses and systematic reviews in English between 01 January 2000 and 20 November 2017. Grey literature and reference lists of included studies were searched. Title/abstracts and full-texts were screened in duplicate. The following data were extracted: study characteristics, primary, secondary maternal, fetal and neonatal outcomes (including composites), their definitions or measurements and outcome reporting quality (MOMENT criteria). The proportion of studies reporting each outcome, a primary outcome and variations in definitions and components of composite outcomes were determined. RESULTS: Of 4916 results screened, 218 full-texts were assessed and 70 included. 173 maternal/obstetric outcomes and 86 neonatal/fetal outcomes were reported. 49 of the 58 trials/registrations reported a primary outcome, 21 of which were not in a reproducible way. The most frequent maternal outcome was gestational weight gain (24 studies) with inconsistent definitions between studies. The most frequent fetal/neonatal outcome was birthweight (17 studies). There were three maternal composite outcomes, one fetal/neonatal and one combined. No maternal composite comprised the same components. CONCLUSION: The high number of outcomes prevents the reporting of relevant outcomes in all obesity in pregnancy studies. Further, inconsistencies and variations between outcome choices and definitions identified present challenges for study comparability and data aggregation.

Operative Vaginal Delivery Is a Safe Option in Women Undergoing a Trial of Labor after Cesarean.

Objective To compare outcomes of operative intervention in the second stage of labor during trial of labor after cesarean (TOLAC). Study Design A secondary analysis of the Maternal-Fetal Medicine Units Network cesarean section registry was conducted. Analysis was by first attempted mode of delivery. Results A total of 1,837 met inclusion criteria. Subjects in the operative vaginal groups (OVDs) were more likely to have a prior vaginal delivery (vacuum 34.2%; forceps 34.3%) than the repeat cesarean delivery (RCD) group (22.6%; p < 0.0001). Most OVD attempts were successful (forceps 90.4%; vacuum 92.6%). Neonatal morbidity was not different (12.1% forceps vs. 14.6% vacuum; 14.8% RCD). Maternal morbidity was highest among forceps deliveries (32.3 vs. 24.3% vacuum; 22.0% RCD, p = 0.0001). RCD was associated with surgical injury (2.7 vs. 0.7% forceps; 0% vacuum; p < 0.0001), endometritis (8.4 vs. 3.2% forceps, 1.2% vacuum; p < 0.0001), and wound complications (1.9 vs. 0.4% forceps; 0.3% vacuum; p = 0.006). OVD was associated with anal sphincter laceration (22.7% forceps, 15.5% vacuum; 0% RCD; p = 0.01). Conclusion The success rate of OVD is high in TOLAC with similar outcomes to RCD. Maternal composite outcomes were highest with forceps-assisted vaginal deliveries. However, considering overall morbidity, OVD in the second stage of labor in TOLAC is a reasonable, safe option in selected cases.

A double blind, randomised, placebo-controlled trial to evaluate the efficacy of metformin to treat preterm pre-eclampsia (PI2 Trial): study protocol

IntroductionPre-eclampsia is a major complication of pregnancy, globally responsible for 60 000 maternal deaths per year, and far more fetal losses. There is no definitive treatment other than delivery. A...

Maternal and perinatal outcomes in women undergoing expectant management of early-onset pre-eclampsia: A retrospective cohort study

Background. Expectant management of early-onset pre-eclampsia, with the aim of improving perinatal outcomes, may increase the risk of maternal morbidity. Objective. To study the maternal and perinatal outcomes and their association with various risk factors in women undergoing expectant management for early-onset pre-eclampsia. Methods. A retrospective cohort study was carried out in a tertiary centre in south India between April 2014 and June 2015. We studied 201 women with singleton pregnancies with pre-eclampsia diagnosed between 28 and 34 weeks’ gestation. Demographic data, medication and treatment details, and delivery data were extracted from maternal charts. The primary outcomes were: (i) composite maternal outcomes, defined as the development of any of eclampsia, abruptio placentae, pulmonary oedema or renal failure; and (ii) perinatal mortality. Logistic regression was used to assess the independent association risk factors with primary outcomes, after adjusting for other variables. Results. Sixty-nine women (34.3%) had one or more of the composite adverse maternal outcomes, and there were 74 (36.8%) cases of perinatal mortality. The presence of imminent symptoms (odds ratio (OR)=2.35) and multiparity (OR=2.31) were associated with composite adverse maternal outcomes, whereas low birth weight and breech vaginal delivery were associated with perinatal mortality. Perinatal mortality was higher in women with pre-eclampsia diagnosed between 28 and 30 weeks. Gestational age at diagnosis was not found to be associated with composite adverse maternal outcomes or perinatal morbidity. Conclusion. Expectant management in early-onset pre-eclampsia can be safely considered without increasing maternal risk, after thorough counselling about outcomes, based on the available neonatal facilities in low-resource settings.

Cholecystectomy During the Third Trimester of Pregnancy: Proceed or Delay?

Current guidelines suggest that cholecystectomy during the third trimester of pregnancy is safe for both the woman and the fetus. However, no population-based study has examined this issue. The aim of this analysis was to compare the results of cholecystectomy during the third trimester of pregnancy with outcomes in women operated on in the early postpartum period in a large population. The California Office of Statewide Health Planning and Development database was queried from 2005 to 2014. Women undergoing cholecystectomy during the third trimester of pregnancy (n= 403) were compared with those having this procedure in the 3 months post partum (n= 17,490). Patient demographics as well as maternal delivery and cholecystectomy-related outcomes were compared by standard statistics as well as after adjustments for age, race, comorbidities, insurance status, and hospital setting. Women who underwent cholecystectomy during the third trimester were older (27 vs 25 years; p < 0.001), but did not differ in race or insurance status. Cholecystectomy during pregnancy was more likely to require hospitalization (85% vs 63%; p < 0.001) and more likely to be performed open (13% vs 2%; p < 0.001). Composite maternal outcomes (odds ratio 1.88; p < 0.001), including preterm delivery (odds ratio 2.05; p < 0.001) as well as length of hospital stay (+0.83 days; p < 0.001) and readmissions (odds ratio 2.05; p= 0.002), were all significantly increased when cholecystectomy was performed during pregnancy. Maternal delivery and procedure-related outcomes were worse when cholecystectomy was performed during the third trimester of pregnancy. Preterm delivery, which is associated with multiple adverse infant outcomes, was increased in third-trimester women. Whenever possible, cholecystectomy should be delayed until the postpartum period.

308: Relationship between number of prior cesareans and early preterm delivery in women with abnormal placentation

To balance perinatal and maternal risks and benefits, delivery timing at 34-36 weeks is recommended for pregnancies complicated by abnormal placentation such as morbidly adherent placenta (MAP). However, it has recently been suggested that those with ≥2 prior cesarean deliveries (CD) and MAP should be delivered earlier than 34 weeks because of a higher risk of complications. We sought to determine the relationship between number of prior CD in women with MAP and early preterm delivery (PTD <34weeks). Additionally, we evaluated the same relationship in a broader group with placenta previa (with or without MAP). This is a secondary analysis of a prospective, multicenter, observational study that included women with prior CD (MFMU Cesarean Registry). Two groups of patients from the registry were studied: patients with MAP and patients with placenta previa regardless of MAP (PP). The exposure of interest was the number of prior CD: ≥2 CD compared to ≤1 CD. The primary outcome was PTD <34 weeks. Secondary outcomes included transfusion of blood products, preterm labor requiring hospitalization/tocolysis, NICU admission, and a composite of maternal and neonatal complications. Balance of maternal demographics in the two groups was assessed using two sample t-tests and chi- square tests, and potential confounders were included in multivariable logistic regression models. Backward selection was used to identify parsimonious models. The MAP analysis included 194 women, 97 (50%) of whom had ≤ 1 prior CD and 97 (50%) of whom had ≥2 prior CD. There was no increased risk of PTD <34 weeks in women with ≥2 prior CD in the setting of MAP (23.7% vs. 29.9%, p=0.27). Only need for plasma transfusion was associated with ≥2 prior CD (29.9% vs. 17.5%, p=0.04) (Table 1). There were 776 women with PP, 667 (86%) with ≤ 1 prior CD and 109 (14%) with ≥2 prior CD. Similarly, there was no increased risk of PTD <34 weeks with ≥2 CD in the setting of PP (27.5% vs. 22.6%, p=0.08). However, it was associated with a higher odds of need for transfusion and the maternal composite outcome (Table 2). Women with MAP or PP who have had ≥2 prior CD did not appear to have a higher risk of complications or PTD<34 weeks. Those with ≥2 prior CD may have a higher risk of maternal complications including need for transfusion products that may be independent of timing of delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

455: American College of Cardiology/American Heart Association Stage 1 Hypertension Before Delivery and Adverse Pregnancy Outcomes

The American College of Cardiology/American Heart Association (ACA/AHA) recently revised their definitions of hypertension (HTN) with the addition of stage 1 HTN (either systolic (SBP) 130-139 or diastolic (DBP) 80-89 mmHg). Because the implications of this new definition in pregnancy are not known, we aimed to determine the frequency of adverse maternal and neonatal outcomes in stage 1 HTN at the last clinic visit before delivery. Secondary analysis of a multicenter randomized trial of antioxidants to prevent preeclampsia (PE) in singleton nulliparous low-risk women. BP was measured by trained staff and outcomes were adjudicated. For this analysis, we included women who delivered ≥ 36 weeks gestation and abstracted their most recent BP in clinic, within 30 days prior to delivery. The higher of systolic (SBP) and diastolic (DBP) was used for classification into: Group 1, those who were never diagnosed with pregnancy associated hypertension (PAH, defined as either SBP >140 or DBP >90 mmHg on two occasions at least 4 hours apart) and their last clinic BP was <130/80 mmHg; Group 2, women without PAH but last clinic BP was consistent with stage 1 HTN by the new classification; and Group 3, those later diagnosed with PAH or had SBP at least 140 or DBP at least 90 mm Hg at their last clinic visit (stage 2 HTN). The primary outcome was a composite of adverse neonatal outcomes. Univariable and multivariable analyses were performed. 8,778 women were included in the analysis with 1,114 (12.7%) who would have been re-labeled as stage I hypertension by the recent guideline (Group 2). Groups differed on baseline and demographic characteristics (table 1). After adjusting for these differences, women in Group 2 did not have higher primary composite maternal (aOR 0.86, 95% CI 0.69-1.07) or neonatal (aOR 0.94, 95% CI 0.74-1.18) adverse outcomes, or other outcomes compared with Group 1 (Table 2). As expected, women in Group 3 had higher odds of developing the composite maternal outcome (aOR 1.35, 95% CI 1.17-1.56) and various adverse maternal outcomes and their infants had higher odds of developing the primary (aOR 1.47, 95% CI 1.26-1.72) and various secondary outcomes, compared with those from Group 1 (Table 2). Stage 1 HTN as defined by the new ACC/AHA at the last visit before delivery is not associated with adverse maternal or neonatal outcomes. Findings do not justify reclassifying PAH to include stage 1 BP levels.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

301: The impact of mode of delivery on subsequent pregnancy outcomes after periviable birth

A pregnancy at risk of delivery in the periviable period presents a clinical and ethical challenge, requiring in-depth counseling and complex decision-making. While it is generally known that cesarean delivery (CD) increases maternal morbidity compared to vaginal delivery (VD), there is limited information regarding the implications of periviable mode of delivery on subsequent pregnancy outcomes. Our study assesses whether women who undergo a periviable CD (index CD) have increased rates of severe maternal morbidity in subsequent pregnancies as compared to those with a prior periviable VD (index VD). This is a retrospective cohort study of all pregnant women who had live born deliveries between 22- 26 weeks gestation and a subsequent pregnancy during 2004-2016 at a single tertiary care center. Maternal and neonatal demographic information for both the index periviable and subsequent pregnancies were collected and analyzed using chi-square and t-test statistics. The primary outcome was a composite of severe maternal morbidity, including uterine complications, ICU admission, sepsis, venous thromboembolism and transfusion. Secondary maternal obstetric complications and neonatal morbidity parameters were also analyzed. Multivariable logistic regression modeling was performed to determine the impact of index mode of delivery on composite maternal and neonatal morbidity outcomes. One hundred and thirty-four women and 161 neonates met inclusion criteria. Maternal and neonatal demographics of the index VD (n=60) versus index CD (n=74) groups were similar. There was no statistically significant difference in the maternal morbidity composite in the unadjusted (OR 1.69, 95%CI 0.36 - 7.87) or adjusted models (aOR 0.25, 95%CI 0.02 - 3.85). There were no hysterectomies or maternal deaths in either group. Only one uterine rupture case was noted in the index CD group. Analyzed secondary maternal outcomes and subsequent neonatal outcomes were not significantly different between groups. In our cohort, women who undergo a periviable CD do not have higher odds of severe maternal morbidity in subsequent pregnancies when compared to those with a prior periviable VD. Pooled multi-institutional data is necessary to further define the lifetime maternal risks of periviable birth for use in patient counseling.

Does prenatal identification of fetal macrosomia change management and outcome?

To assess whether there is an association between predicted fetal macrosomia and adverse outcomes in macrosomic newborns (> 4000g), based on a sonographic evaluation up to 2weeks prior to delivery. A retrospective cohort study of 3098 mothers of macrosomic babies who were delivered at our institution (2000-2015). We compared the management and outcomes of women with predicted fetal macrosomia with that of women with unknown fetal macrosomia. The primary outcomes were cesarean section (CS) rate and postpartum hemorrhage. Secondary outcomes were composite maternal and neonatal outcomes and birth injuries. In 601 (19.4%) women fetal macrosomia was predicted, and in 2497 (80.6%) women, fetal macrosomia was unknown. CS rate was more than 3.5 times higher in the group of predicted macrosomia (47.2% vs. 12.7%, P < 0.001) than those with unpredicted macrosomia; not only due to non-progressive labor, but for non-reassuring heart rate as well. However, predicted fetal macrosomia reduced the risk of postpartum hemorrhage (aOR 0.5, 95% CI 0.2-1.0), maternal (aOR 0.3, 95% CI 0.2-0.5) and neonatal composite adverse outcomes (aOR 0.7 95% CI 0.6-0.9). It was also associated with increased risk for induction of labor, episiotomy, 3rd- or 4th-degree tears and a longer maternal hospitalization. Birth injuries and shoulder dystocia were not different between the groups. Antepartum CS was found to be associated with predicted fetal macrosomia. Moreover, a planned CS due to macrosomia was associated with reduced risk for postpartum hemorrhage, maternal and neonatal outcome, even for babies with a mean birth weight < 4500g.

Induction of labor versus expectant management among women with macrosomic neonates: a retrospective study

Background: The macrosomic fetus predisposes a variety of adverse maternal and perinatal outcomes. Although older studies have shown no benefit in inducing women of suspected macrosomic fetuses, more updated studies show different information.Objectives: The aim of our study was to compare induction of labor versus expectant management among women with macrosomic neonates weighing more than 4000 g at term (between 37°/7 and 416/7 weeks’ gestation).Study design: This was a retrospective cohort study of all live-born singleton pregnancies with macrosomic newborns who were delivered at our institution between 1 January 2000 and 1 June 2015. We compared the outcomes of induction of labor, at each gestational age (GA), between 37 and 41 weeks (study group) with ongoing pregnancy. The primary outcome was cesarean section (CS) rate. Secondary outcomes were composite maternal and neonatal outcome and birth injuries.Results: Overall, out of 3095 patients with macrosomic newborns who were included in the study, 795 women (25.7%) underwent induction of labor. The cesarean section rate was not found to be significantly different between the groups at all gestational ages, nor was the vaginal delivery rate. After adjusting for confounders, induction of labor at 40 and 41 weeks’ gestation was associated with composite maternal outcome (adjusted odds ratio (aOR) 1.6, 95% confidence interval (CI): 1.3–2.1; aOR 1.7, 95% CI: 1.3–2.2, respectively) and composite neonatal outcome (aOR 1.6, 95% CI: 1.1–2.4; aOR 1.8, 95% CI: 1.1–2.9). Induction of labor at 40 weeks’ gestation was also associated with increased risk of birth injuries (aOR 2.9, 95% CI: 1.4–6).Conclusions: Compared with ongoing pregnancy, induction of labor of women with macrosomic neonates between 37 and 41 weeks of gestation does not reduce the CS rate, nor does it increase the vaginal delivery rate. Moreover, induction of labor of those women beyond 39 weeks’ gestation is associated with composite adverse maternal/neonatal outcome, specifically birth injuries.

Birthweight thresholds for increased risk for maternal and neonatal morbidity following vaginal delivery: a retrospective study.

To determine neonatal birthweight (BW) thresholds for adverse maternal and neonatal outcome following vaginal delivery. A retrospective cohort study of all women with singleton pregnancies who underwent vaginal delivery in a university-affiliated tertiary hospital (1996-2015). The association between BW and adverse outcome in neonates with BW ≥ 3500g (> 90th centile BW at 37weeks' gestation) with 100g-increment groups was explored. Pregnancies complicated by diabetes mellitus, fetal anomalies or cesarean deliveries were excluded. The composite neonatal outcome was defined as shoulder dystocia or brachial plexus injury. The composite maternal outcome was defined as postpartum hemorrhage or third- or fourth-degree perineal tears. Of the 121,728 deliveries during the study period, 26,920 (22.1%) met inclusion criteria. Of these, 1024 (3.8%) had a composite adverse maternal outcome and 947 (3.5%) had a composite adverse neonatal outcome. The rates of composite maternal outcomes increased significantly only at a BW of 4800g and above. The composite neonatal outcomes increased significantly only at a BW of 4400g and above. In multivariate analysis, after subcategorizing our cohort into 3 BW groups [3500-3999g (control, n = 23,030); 4000-4399g (n = 3494); ≥ 4400g (n = 396)], BW was associated with adverse neonatal outcomes in a dose-dependent manner. In the BW ≥ 4400g group, to prevent one case of shoulder dystocia or Erb's palsy, 12 cesarean deliveries needed to be performed. For non-diabetic mothers who deliver vaginally, neonatal BW ≥ 4400g was associated with a significant increase in adverse neonatal outcomes, whereas neonatal BW ≥ 4800g was associated with a significant increase in adverse maternal outcomes.

Effect of Diet and Physical Activity–based Interventions in Pregnancy on Gestational Weight Gain and Pregnancy Outcomes: Meta-Analysis of Individual Participant Data from Randomized Trials

(BMJ. 2017;358:j3991) Obesity and excessive gestational weight gain are major risk factors for adverse maternal and neonatal outcomes. Worldwide ∼50% of women of childbearing age are obese or overweight. Interventions during pregnancy to improve diet and physical activity have shown positive effects for limiting excessive gestational weight gain. The effects of these interventions on maternal and neonatal outcomes are unclear, however. This meta-analysis of individual participant data (IPD) was undertaken to assess the effects of diet and physical activity–based interventions in pregnancy on gestational weight gain and composite maternal and neonatal outcomes in specific subgroups based on body mass index, age, parity, ethnicity, and preexisting medical condition. Effects of these interventions on important individual complications were also analyzed.

Labor induction versus expectant management at early term in pregnancies with second trimester elevated human chorionic gonadotropin or alpha fetoprotein

Elevated human chorionic gonadotropin (HCG) and alpha fetoprotein (AFP) have been linked to placental dysfunction and associated morbidities. We aimed to compare the induction of labor with expectant management at term in those pregnancies for the prevention of neonatal and maternal morbidities. Women with second trimester HCG ≥ 2 and/or AFP ≥ 2 multiples of the median, without additional maternal or fetal complications, from their 38th gestational week were offered the choice of labor induction or expectant management. The primary outcomes were maternal composite outcome (composed of cesarean deliveries, pre-eclampsia or placental abruption) and neonatal composite outcome (composed of antenatal or neonatal death, Apgar score at 5 min < 7, admission to the neonatal intensive care unit, need for phototherapy, respiratory abnormalities, birth trauma or neonatal infection). Of 305 women, 124 women chose to undergo labor induction, and 181 women chose expectant management. The composite maternal outcome in the expectant management group was twice the rate of the labor induction group, although it did not reach statistical significance (18 [10%] vs 6 [5%]; P = 0.1; relative risk [expectant/induced] 2.04; 95% confidence interval 0.8-5.0). Increased rate of phototherapy led to increased neonatal composite outcomes in the labor induction group compared with the expectant management group (34 [27%] vs 27 [15%], respectively = 0.007). In pregnancies with elevated AFP and/or HCG, early term labor induction initiated a trend towards improvement in maternal outcome but increased the rate of mild neonatal morbidity. The statistical insignificance of the large effect on the maternal outcome might reflect the lack of statistical power. Further research is needed to address this limitation.

329: Excess complement activation is associated with adverse outcomes in women with hypertensive disorders of pregnancy

Complement activation occurs in normal pregnancy, but excess activation is associated with preeclampsia. Terminal complement activation generates C5b-9, the lytic membrane attack complex, which mediates organ damage. We hypothesize that activation of C5b-9 is increased in women with hypertensive disorders of pregnancy and adverse outcomes We assessed urine and plasma C5b-9 levels in hypertensive subjects from project COPA (COmplement and Preeclampsia in the Americas), an IRB approved, multi-center observational study, which enrolled subjects from 6 centers and 3 cities in Colombia (Bogotá, Cartagena and Medellín; Nov 15-Jul 16). Hypertensive subjects enrolled in blocks by gestational age ( ≤ or ≥ 34 weeks) and diagnosis (ACOG criteria): 1. chronic hypertension (CHTN); 2. gestational hypertension (GHTN); 3. preeclampsia (PE) and; 4. PE with severe features (PE-SF). COPA was powered for PE-SF (n=100). Clinical data, urine and plasma were collected by trained coordinators, with C5b-9 measured by enzyme linked immunosorbent assays (Human C5b-9 ELISA, BD Biosciences). Maternal and neonatal outcomes were assessed individually and as composite outcomes. Data were analyzed by Chi-square, t-test and logistic regression 293 subjects were evaluated [CHTN (n=42), GHTN (n=92), PE (n=58), PE-SF (n=101)]. Adverse maternal and neonatal outcomes, by plasma C5b-9 quartiles 1-4 (pC5b9, Q1-4), are shown in Table 1. Composite maternal outcomes were increased with low pC5b9 (Q1, ≤1443 ng/ml), particularly for those ≥ 34wks (OR 2.93, 95% CI 1.0-8.6, p=0.05). For neonates, preterm birth (PTB) was increased with lower pC5b9 levels (PTB, 2870 ± 1904 vs. term, 3572 ± 2262 ng/ml, p=0.006). Adverse outcomes, by urine C5b-9 (uC5b9) quartiles, are shown in Table 2. They were more common with high uC5b9 levels (Q4, ≥8.49 ng/ml), predominantly due to increased kidney injury (OR 3.0, 95%CI 1.1-8.4, p=0.036) and PTB (OR 2.0, 95% CI 1.2-3.5, p=0.01) We describe a novel pattern of complement activation (low plasma / high urine C5b-9), which associates with adverse maternal and neonatal outcomes in women with hypertensive disorders of pregnancy. We postulate that excess complement activation results in kidney injury and depletion of complement factors in plasma, with resultant pregnancy complications.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Adverse Maternal and Neonatal Outcomes in Indicated Compared with Spontaneous Preterm Birth in Healthy Nulliparas: A Secondary Analysis of a Randomized Trial.

To compare the risks of adverse maternal and neonatal outcomes associated with spontaneous (SPTB) versus indicated preterm births (IPTB). A secondary analysis of a multicenter trial of vitamin C and E supplementation in healthy low-risk nulliparous women. Outcomes were compared between women with SPTB (due to spontaneous membrane rupture or labor) and those with IPTB (due to medical or obstetric complications). A primary maternal composite outcome included: death, pulmonary edema, blood transfusion, adult respiratory distress syndrome (RDS), cerebrovascular accident, acute tubular necrosis, disseminated intravascular coagulopathy, or liver rupture. A neonatal composite outcome included: neonatal death, RDS, grades III or IV intraventricular hemorrhage (IVH), sepsis, necrotizing enterocolitis (NEC), or retinopathy of prematurity. Of 9,867 women, 10.4% (N = 1,038) were PTBs; 32.7% (n = 340) IPTBs and 67.3% (n = 698) SPTBs. Compared with SPTB, the composite maternal outcome was more frequent in IPTB-4.4% versus 0.9% (adjusted odds ratio [aOR], 4.0; 95% confidence interval [CI], 1.4-11.8), as were blood transfusion and prolonged hospital stay (3.2 and 3.7 times, respectively). The frequency of composite neonatal outcome was higher in IPTBs (aOR, 1.8; 95% CI, 1.1-3.0), as were RDS (1.7 times), small for gestational age (SGA) < 5th percentile (7.9 times), and neonatal intensive care unit (NICU) admission (1.8 times). Adverse maternal and neonatal outcomes were significantly more likely with IPTB than with SPTB.