Nonreassuring Fetal Heart Tracing Research Articles

Unplanned Cesarean for Abnormal or Indeterminate Fetal Heart Tracing Varies Significantly by Race and Ethnicity.

The US maternity care system achieves worse outcomes for birthing people identifying as Black versus White. Assessment of fetal well-being in labor is an area of perinatal care subject to significant interobserver variability and therefore may be at particular risk of medical racism influencing care. Statewide collaborative quality initiative data, focused on decreasing the nulliparous, term, singleton, vertex (NTSV) cesarean birth rate, were used to conduct a retrospective cohort study to assess differences in cesarean birth for nonreassuring fetal status between birthing people identifying as Black compared with White. Generalized linear mixed modeling with hospital as a random intercept was used for multivariate analyses accounting for birthing people clustering within hospitals. Between March 1, 2020, and December 31, 2022, 69,622 births were identified, 8291 (11.9%) of which were an unplanned cesarean with a primary indication of nonreassuring fetal heart tracing (cesarean for FHT). Race and ethnicity were significantly associated with a higher risk, after controlling for covariates: compared with White birthing people, birthing people of unknown race or ethnicity had 1.23 (95% CI 1.13-1.35) and Asian Pacific Islander birthing people had 1.55 times the odds (95% CI 1.37-1.76), whereas Black birthing people had 1.71 times the odds (95% CI 1.59-1.83) of birthing via unplanned cesarean for FHT. In adjusted analysis, prepregnancy diabetes, positive COVID-19 status at admission, elevated body mass index, and birthing in the Detroit Metro area were associated with cesarean for FHT. In an unplanned subgroup analysis of births within the Detroit Metro region, Black individuals remained significantly more likely to have an unplanned cesarean for FHT (aOR 1.63, 95% CI 1.48-1.79). After controlling for individual and hospital-level factors, cesarean for FHT was more common among non-Hispanic Black vs non-Hispanic White birthing people in this statewide cohort of NTSV births.

Neonatal Alloimmune Thrombocytopenia with HLA and HPA-3a Antibodies in a Down Syndrome Neonate

Abstract Introduction/Objective Neonatal Alloimmune Thrombocytopenia (NAIT) is a rare cause of thrombocytopenia seen in 1 in 11,000 neonates with lethal risks such as intracranial hemorrhage. This is caused by maternal antibodies against fetal platelets and the most common culprits are antibodies to Human Platelet Antigen-1b (HPA-1b) but rarely to Human Leukocyte Antigen (HLA) antibodies. We describe a rare case of a newborn with Down syndrome with maternal antibodies against HLA and presumed antibodies against HPA-3a. Down syndrome causes hematologic abnormalities with mild thrombocytopenia. Methods/Case Report A preterm male with Down syndrome was born via Cesarean delivery due to non-reassuring fetal heart tracing at a gestational age of 35 weeks. He was admitted for low birth weight and his hospital course was complicated by severe thrombocytopenia of 37 x 10^9/L without bleeding symptoms. Initially attributed to his trisomy 21 but due to his suboptimal response to platelet transfusion, NAIT was suspected. The mother had antibodies against HLA on initial screen and was presumed to have HPA-3a antibodies since she was homozygous for HPA-3b antigen. The neonate was managed with multiple transfusions of platelets and Intravenous Immunoglobulin (IVIG). The platelet count stabilized to 325 x 10^9/L on his 25th day of life. Results (if a Case Study enter NA) n/a Conclusion To our knowledge, this is the only published case of NAIT with both HPA-3a and HLA antibodies in a Down syndrome neonate. It is unclear whether the primary reason for thrombocytopenia is due to NAIT caused by HPA-3a antibodies or HLA antibodies or his existing Down syndrome. This case contributes to understanding the complexity between immune-related diseases such as NAIT and genetic conditions such as Down syndrome. Although NAIT occurs rarely, timely diagnosis and treatment is of utmost importance to prevent lethal complications.

Presence and Size of Placental Lakes on 20-Week Fetal Anatomy Ultrasound and Obstetrical Outcomes

Our objective was to determine if placental lake presence or size is associated with adverse pregnancy outcomes. This was a retrospective cohort of patients who had fetal anatomy ultrasounds at 18–22 weeks and delivered between 2018 and 2022. Placental lakes were classified as small (>2.0 to 3.9 cm) or large (≥4 cm). Multiple gestations, placenta previas, and placenta accretas were excluded. Outcomes included low birthweight, cesarean delivery, primary cesarean for non-reassuring fetal heart tracing, fetal growth restriction, preterm birth, and severe preeclampsia. A total of 1052 patients were included; 294 had placental lakes (204 small, 90 large). No differences in pregnancy outcomes were observed.

History of Cholestasis Is Not Associated with Worsening Outcomes in Subsequent Pregnancy with Cholestasis.

Intrahepatic cholestasis of pregnancy is associated with adverse pregnancy outcomes including intrauterine fetal demise, spontaneous preterm labor, and meconium-stained amniotic fluid. Studies have yet to determine if patients with a history of pregnancy complicated by cholestasis had an association with more severe adverse outcomes in a subsequent pregnancy complicated by cholestasis. Retrospective cohort study of multiparous, singleton, nonanomalous live gestations complicated by cholestasis at Elmhurst Hospital Center from 2005 to 2019. We compared rates of adverse outcomes in multiparous pregnancies complicated by cholestasis with versus without prior cholestasis. Our primary outcome was rates of spontaneous preterm labor. Our secondary outcomes included rates of iatrogenic preterm birth, meconium-stained amniotic fluid, cesarean delivery for nonreassuring fetal heart tracing. Chi-square and multivariate regression tests were used to determine the strength of association. In all analyses, a p-value less than 0.05 and 95% confidence interval not crossing 1.00 indicated statistical significance. Mount Sinai Icahn School of Medicine Institutional Review Board approval was obtained for this project. Of the 795 multiparous pregnancies complicated by cholestasis, 618 (77.7%) had no prior history of cholestasis and 177 (23.3%) had prior history of cholestasis. Multiparous pregnancies with history of cholestasis had higher rates of prior preterm birth, earlier gestational age at diagnosis and delivery, and were more likely to receive ursodeoxycholic acid therapy. Pregnancies with history of cholestasis were not associated with spontaneous preterm labor in subsequent pregnancies with cholestasis, but history of cholestasis was associated with iatrogenic preterm birth and neonatal intensive care unit (NICU) admission. After adjusting for confounders, the association with iatrogenic preterm birth and NICU admission were no longer statistically significant. There was no significant association between history of cholestasis and other adverse obstetric outcomes. Findings suggests that history of prior cholestasis is not associated with worsening outcomes in subsequent pregnancies complicated by cholestasis. · Prior cholestasis may not alter risk in subsequent pregnancies.. · Unclear relationship between cholestasis and hepatobiliary disease.. · Studies needed to develop cholestasis screening protocol..

1076 Risk Factors Predictive of Cesarean Section for Non-reassuring Fetal Heart Tracing among Inductions

1076 Risk Factors Predictive of Cesarean Section for Non-reassuring Fetal Heart Tracing among Inductions

Prior History of Cholestasis Is Not Associated With Worsening Outcomes in Subsequent Pregnancy With Cholestasis [ID: 1363296

INTRODUCTION: Intrahepatic cholestasis of pregnancy (IHCP) is associated with adverse pregnancy outcomes including intrauterine fetal demise, spontaneous preterm labor, and meconium-stained amniotic fluid. Studies have yet to determine whether a prior pregnancy complicated by cholestasis is associated with more severe adverse outcomes in a subsequent pregnancy complicated by cholestasis. METHODS: This was a retrospective cohort study of multiparous, singleton, nonanomalous live gestations complicated by IHCP at Elmhurst Hospital Center from 2005 to 2019. We compared rates of adverse outcomes in multiparous pregnancies complicated by IHCP with or without history of prior IHCP. Our primary outcome of interest was rates of spontaneous preterm labor. Our secondary outcomes included rates of iatrogenic preterm birth, meconium-stained amniotic fluid, cesarean delivery (CD) for nonreassuring fetal heart tracing, umbilical artery pH less than 7.20, and neonatal intensive care unit (NICU) admission. Chi-square and multivariate regression tests were used to determine the strength of association. In all analyses, a P value less than 0.05 and 95% CI not crossing 1.00 indicated statistical significance. Mount Sinai Icahn School of Medicine IRB approval was obtained for this project. RESULTS: Of the 795 multiparous pregnancies complicated by IHCP, 618 (77.7%) had no prior history of IHCP and 177 (23.3%) had prior history of IHCP. Multiparous pregnancies with prior history of IHCP had higher rates of prior preterm birth, had earlier gestational age at diagnosis and delivery, and were more likely to receive ursodeoxycholic acid therapy. In subsequent pregnancies with IHCP, history of IHCP was associated with iatrogenic preterm birth and NICU admission. After adjusting for confounders, the association with iatrogenic preterm birth and NICU admission were no longer statistically significant. There was no significant association between history of prior IHCP and other adverse obstetric outcomes. CONCLUSION: Findings suggest that history of prior IHCP is not associated with worsening outcomes in subsequent pregnancies complicated by cholestasis.

The Association of Anesthesia Type and Neonatal Outcomes Following Category-1 Cesarean Delivery: A Retrospective Cohort Study.

Objectives Neuraxial anesthesia is the preferred anesthesia technique for cesarean delivery due to a decreased risk of adverse events. However, general anesthesia is often employed during emergent cesarean deliveries to achieve a shorter decision-to-delivery interval. The objective of this study was to determine if the conversion of epidural labor analgesia to surgical anesthesia for a category-1 cesarean delivery is associated with significant neonatal morbidity. Study design This was a retrospective cohort study of all intrapartum category-1 cesarean deliveries performed at an academic tertiary care institution between August 2016 and July 2021. The primary outcome was neonatal morbidity, defined as a composite of neonatal umbilical artery pH < 7.10 and/or 5-min Apgar score < 7, and/or neonatal intensive care unit admission. A multivariate regression analysis was performed to control for the presence of covariates and examine the degree to which they influenced the outcome. Results A total of 185 mother-neonate pairs qualified for inclusion, of which 23 had cesarean delivery under general anesthesia and 162 under epidural anesthesia. There was no significant difference in adverse neonatal outcomes between category-1 cesarean deliveries done under general anesthesia compared to epidural anesthesia (47% vs 35%,p = 0.3). The incidence of umbilical arterial pH < 7.10 was higher in the general anesthesia group compared to the epidural anesthesia group (35% vs 12%,p = 0.018). The multivariate regression model showed that gestational age (OR = 0.63; 95% CI = 0.51-0.75, p = <0.001) and non-reassuring fetal heart trace (OR = 0.18; 95% CI = 0.05-0.58, p = 0.005) were significant predictors of adverse neonatal outcome. Conclusion Our results suggest that the conversion of epidural analgesia to surgical anesthesia for category-1 cesarean delivery in women with a functional labor epidural catheter is not associated with poorer neonatal outcomes.

Fetal doppler role in predicting non-reassuring fetal heart tracing in patients undergoing induction of labor

We sought to determine whether Doppler-flow measurements before performing induction of labor predict non reassuring fetal heart rate and cesarean section rate in pregnant women at 38-41 weeks of gestation.

Emergent prelabor cesarean delivery in solid organ transplant recipients: associated risk factors and outcomes

BackgroundPregnancies after solid organ transplant are at a higher risk of antepartum admission and pregnancy complications including cesarean delivery. Emergent prelabor cesarean delivery is associated with increased maternal and neonatal morbidity in other high-risk populations, but its incidence and impact in transplant recipients is not well-understood. ObjectiveThis study aimed to characterize the risk factors and outcomes of emergency prelabor cesarean delivery in kidney and liver transplant recipients. Study DesignThis was a retrospective cohort study of all kidney and liver transplant recipients at >20 weeks gestation enrolled in the Transplant Pregnancy Registry International between 1976 and 2019. Participants admitted antepartum who required emergency prelabor cesarean delivery were compared with those admitted antepartum who underwent nonemergent birth. The primary outcomes were severe maternal morbidity and neonatal composite morbidity. Multivariable logistic regression was conducted for neonatal composite morbidity. ResultsOf 1979 births, 181 pregnancies (188 neonates) with antepartum admission were included. 51 pregnancies (53 neonates, 28%) were delivered by emergent prelabor cesarean delivery compared with 130 pregnancies (135 neonates, 72%) admitted antepartum who subsequently did not require emergent delivery. The most common indication for emergent delivery was nonreassuring fetal heart tracing (44 pregnancies /51 emergent deliveries = 86%). Pregnant people who underwent emergent prelabor cesarean delivery were less likely to deliver at a transplant center (37.3% vs 41.5%; P=.04) and had increased rates of chronic hypertension (33.3% vs 16.2%; P=.02). There was no significant difference in severe maternal morbidity (3.9% vs 4.6%; P=.84), though there was an increase in surgical site infection in the emergent prelabor cesarean delivery cohort (3.9% vs 0%; P=.02). Among those with emergent prelabor cesarean delivery, there was a significant increase in neonatal composite morbidity (43.4% vs 19.3%; P<.001) with earlier gestational age at delivery (33.4 vs 34.7 weeks; P=.02), lower birthweight (1899 g vs 2321 g; P<.001), lower birthweight percentile (30.3% vs 40.6%; P=.03), increased neonatal intensive care unit admission (52.8% vs 35.6%; P=.03), and increased neonatal mortality (11.3% vs 1.5%; P=.002). After adjusting for year of conception, race, hypertensive disorders, and fetal malformations, there was a persistent increased risk of neonatal morbidity (adjusted odds ratio, 3.01; 95% confidence interval, 1.50–6.08; P=.002) associated with emergent prelabor cesarean delivery after transplant. ConclusionAlmost one-third of kidney and liver transplant recipients admitted antepartum had an emergency prelabor cesarean delivery, and 63% of this cohort delivered outside of a transplant center. Pregnancies after transplantation should involve multidisciplinary transplant-obstetrics collaboration to ensure optimal antepartum disease management, especially for preexisting hypertension, to prevent and mitigate obstetrical and neonatal morbidity in the setting of emergent cesarean delivery.

Beyond stillbirth: association of intrahepatic cholestasis of pregnancy severity and adverse outcomes

Intrahepatic cholestasis of pregnancy is associated with adverse pregnancy outcomes, including sudden fetal cardiac arrhythmias, resulting in stillbirth. This association has been correlated with the total bile acid levels, which are a marker for disease severity. Studies are yet to determine if intrahepatic cholestasis of pregnancy severity is also associated with increased rates of other adverse neonatal outcomes. This study aimed to determine whether pregnancies complicated by intrahepatic cholestasis of pregnancy show a bile acid severity-based relationship with other adverse obstetrical outcomes beyond stillbirth alone. This was a retrospective cohort study of singleton, nonanomalous gestations complicated by intrahepatic cholestasis of pregnancy at the Elmhurst Hospital Center from 2005 to 2019. Severity was defined by the peak total bile acid levels (μmol/L): mild (10-19), low moderate (20-39), high moderate (40-99), and severe (>100). We examined the rates of spontaneous preterm labor, fetal growth restriction, preterm prelabor rupture of membranes, iatrogenic preterm birth, meconium-stained amniotic fluid, cesarean delivery for nonreassuring fetal heart tracing, umbilical artery pH, neonatal intensive care unit admission, and neonatal birthweight. The chi-square, Fisher exact, Student t, Mann-Whitney, and multivariate regression tests were used to determine the association of intrahepatic cholestasis of pregnancy severity and adverse neonatal outcomes. In all analyses, mild severity was used as the base comparator. A P value of <.05 and 95% confidence interval not crossing 1.00 indicated statistical significance. Of the 1202 pregnancies complicated by intrahepatic cholestasis of pregnancy, 306 (25.5%) were mild, 449 were low moderate (37.4%), 327 were high moderate (27.2%), and 120 were severe (10.0%). After adjusting for confounders, progressive intrahepatic cholestasis of pregnancy severity was associated with an increased risk of spontaneous preterm labor (low moderate adjusted odds ratio, 1.60; 95% confidence interval, 0.76-3.38; high moderate adjusted odds ratio, 3.49; 95% confidence interval, 1.69-7.22; severe adjusted odds ratio, 6.58; 95% confidence interval, 2.97-14.55), iatrogenic preterm birth (low moderate adjusted odds ratio, 1.54; 95% confidence interval, 0.95-2.52; high moderate adjusted odds ratio, 3.11; 95% confidence interval, 1.91-5.06; severe adjusted odds ratio, 4.94; 95% confidence interval, 2.81-8.71), and meconium-stained amniotic fluid (low moderate adjusted odds ratio, 1.33; 95% confidence interval, 0.75-2.36; high moderate adjusted odds ratio, 2.63; 95% confidence interval, 1.48-4.65; severe adjusted odds ratio, 3.91; 95% confidence interval, 1.98-7.69). There was no significant association between intrahepatic cholestasis of pregnancy severity and other adverse outcomes. The findings suggest that intrahepatic cholestasis of pregnancy disease severity is associated with an increased risk of spontaneous preterm labor, iatrogenic preterm birth, and meconium-stained amniotic fluid. These findings provide valuable insight toward patient anticipatory counseling.

Quadruplet pregnancy with widespread Tenney-Parker changes: A case report

Introduction: The incidence of multiple pregnancies has increased tremendously over the last 3–4 decades due to the advent of assisted reproductive technology treatment. Generally, multifetal pregnancy is associated with increase in maternal and perinatal morbidity and mortality, which are directly proportional with increasing numbers of fetuses in higher order multiple pregnancies. Case Report: We present a case of a 26-year-old G1P0104 female with a 3-year history of anovulatory infertility. After the third cycle of ovarian stimulation with clomiphene citrate, she became pregnant with quadruplets. She had no significant past medical or surgical history. The pregnancy was a tetrachorionictetraamniotic quadruplet and it was relatively uncomplicated during the first and second trimesters. However, the patient had prolonged antepartum admission from 25w6d due to symptomatic preterm uterine contractions. At 31w3d, the patient underwent primary cesarean section due to non-reassuring fetal heart tracing and biophysical profile of quadruplet A. Four viable neonates were delivered, three females and one male. All four quadruplets were admitted to the Neonatal Intensive Care Unit (NICU) with varying degrees of neonatal complications due to prematurity, but they were discharged home between 8 and 9 weeks of life. The placental pathology showed Tenney-Parker changes, but it did not adversely affect the outcome of these infants. Conclusion: Higher-order multifetal pregnancies can pose serious management challenges because of increased preterm delivery. Hence, management should be in a tertiary medical center with a multi-disciplinary team that includes an Obstetrician, Perinatologist, and Neonatologist.

A Diagnosis of Choriocarcinoma in a Parturient Presenting With Intracranial Hemorrhage

Choriocarcinoma in a viable pregnancy is uncommon. The diagnosis can easily be missed when there is an explanation for the clinical symptoms that the cancer can mimic. We present the case of a primigravid patient whose choriocarcinoma was initially missed as a result of seemingly obvious explanations for her atypical history and disease manifestation. The patient is a Caucasian female at 30 weeks and 5 days of gestation who presented with persistent headaches and new-onset tonic-clonic seizures found on brain magnetic resonance imaging (MRI) to have a left intracranial hematoma, a 5 mm midline shift, and multiple foci of restricted diffusion. Cerebral angiogram demonstrated arteriovenous malformations (AVMs). The fetus was emergently delivered 1 week into hospitalization for non-reassuring fetal heart tracings in the setting of maternal lethargy secondary to continued AVM hemorrhage. The patient’s hospital course was complicated by four episodes of intracranial bleeding and edema requiring neurosurgical intervention. Three weeks after hospitalization she was discharged to a rehabilitation center, shortly after which placental biopsy demonstrated choriocarcinoma. MRI after readmission demonstrated extensive metastatic disease and human chorionic gonadotropin (hCG) levels were greater than 225,000 mIU/mL. Despite two additional neurosurgical procedures and extensive chemotherapy the patient died 3 months after initial presentation. Choriocarcinoma is extremely rare in viable pregnancies, but it should be considered when a parturient presents with intracranial bleeding. A high level of suspicion and serial serum hCG levels may lead to early and potentially life-saving multidrug chemotherapy. With a broader differential, earlier hCG measurement, and earlier treatment, our patient may have survived.

Prostaglandins for induction in pregnancies with fetal growth restriction

The data on safety of prostaglandin agents for induction of pregnancies with fetal growth restriction is limited. To compare the rates of adverse outcomes among pregnancies with fetal growth restriction undergoing induction of labor with and without prostaglandins STUDY DESIGN: We performed a propensity-score-based secondary analysis of the Consortium on Safe Labor database. We included term, singleton, and nonanomalous pregnancies with fetal growth restriction (estimated fetal weight <10th percentile for gestational age). We excluded previous cesarean deliveries. The primary exposure was induction using prostaglandins (prostaglandin E1 or prostaglandin E2) compared with other methods. The primary outcome was a composite of adverse neonatal outcomes. The secondary outcomes included all cesarean deliveries and cesarean deliveries for nonreassuring fetal heart tracings. A subgroup analysis comparing the type of prostaglandin was planned a priori. The results are expressed as adjusted odds ratios with 95% confidence intervals. Of 756 (0.3%) inductions, 212 (28%) used prostaglandins (108 prostaglandin E1, 94 prostaglandin E2), and 553 (72%) used nonprostaglandin methods, including oxytocin (348, 63%), amniotomy (211, 38%), and/or mechanical dilation (9, 1%). There were no differences in the composite of adverse neonatal outcomes between the prostaglandin (10.4%) and the nonprostaglandin group (6.7%), adjusted odds ratio, 1.39 (0.64-3.03). The rate of cesarean delivery was higher in the inductions that received prostaglandins than those that did not (25.5% vs 14.8%, adjusted odds ratio, 1.80; 1.07-3.02). The rate of cesarean delivery for nonreassuring fetal heart tracings was higher for those that received prostaglandins than those that did not (16.0% vs 8.7%, adjusted odds ratio, 2.37; 1.28-4.41). When prostaglandin E1 and prostaglandin E2 were examined independently, there were similar increases in the composite of adverse neonatal outcomes and cesarean delivery rates for both prostaglandin E1 and prostaglandin E2 compared with nonprostaglandin controls. There were no differences in the composite of adverse neonatal outcomes when prostaglandins were used for induction in pregnancies with fetal growth restriction compared with other methods. However, there was a higher rate of cesarean delivery and cesarean delivery indicated for nonreassuring fetal heart tracings when prostaglandins (both prostaglandin E1 and prostaglandin E2) were used, compared with nonprostaglandin methods.

A Cross-Sectional Study Examining Differences in Indication for Cesarean Delivery by Race/Ethnicity.

(1) Background: There are persistent racial/ethnic disparities in cesarean delivery in the United States (U.S.), yet the causes remain unknown. One factor could be provider bias. We examined medical indications for cesarean delivery that involve a greater degree of physician discretion (more subjective) versus medical indications that involve less physician discretion (more objective) to better understand factors contributing to the higher rate among Micronesian, one of the most recent migrant groups in the state, compared to White women in Hawai‘i. (2) Methods: A retrospective chart review was conducted to collect data on 620 cesarean deliveries (N = 296 White and N = 324 Micronesian) at the state’s largest maternity hospital. Multivariate regression models were used to examine associations between maternal and obstetric characteristics and (1) subjective indication defined as non-reassuring fetal heart tracing (NRFHT) and arrest of labor disorders, and (2) objective indication defined as all other indications (e.g., malpresentation). (3) Results: We found that Micronesian women had significantly higher odds of cesarean delivery due to a subjective indication compared to White women (aOR: 4.17; CI: 2.52-6.88; P < 0.001; N = 619) after adjusting for multiple covariates. (4) Conclusion: These findings suggest unmeasured factors, possibly provider bias, may influence cesarean delivery recommendations for Micronesian women in Hawai‘i.

311 Development of a prediction model for cesarean delivery among term women with presumed intraamniotic infection

To identify factors associated with cesarean delivery (CD) among term laboring women who develop an intrapartum fever due to presumed intraamniotic infection and to develop a predictive model for CD to assist in patient counseling. We performed a multi-center, retrospective cohort study among febrile, term laboring women between January 1, 2015 and December 31, 2017. We excluded women who had a documented non-obstetric source of infection, received antibiotics on admission for other indications, used immunosuppressant medication chronically, or had an intrauterine fetal demise. The medical record was reviewed, and sociodemographic, labor, and clinical characteristics were extracted. We identified the factors associated with CD and built our predictive model using backward stepwise regression. The final model was shown through the area under the receiver operating characteristic curve (AUC). The cohort consisted of 850 febrile laboring women, of whom 295 (34.7%) had a CD. Indications for Cesarean delivery included 34.6% for failure to progress, 33.6% for non-reassuring fetal heart tracing, 29.8% for arrest of descent, and 2.0% for failed operative delivery due to maternal exhaustion. The final model included stage of labor stratified by cervical exam dilation (less than 6 cm of dilation in latent labor, 6 cm to 9.5 cm in active first stage of labor, and 10 cm dilation in second stage of labor), duration of rupture of membranes (in hours), and if labor was induced. Our final model had an AUC of 0.74 (95% CI 0.71-0.78) with a Hosmer-Lemeshow test P=0.07. Using a predicted probability cutoff of 0.47, the model’s sensitivity was 54.7%, specificity was 80.7% with a positive predictive value of 60.1% and negative predictive value of 77.0% to predict CD. Information available at the time of development of an intrapartum fever may be used to counsel patients regarding the likelihood of CD. Our study was limited by unavailable electronic fetal monitoring data which also heavily influences CD risk.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Facteurs de risque de césarienne en cours de travail pour la nullipare avec une obésité morbide

ObjectivesObesity is a well-known caesarean and obstetrical risk factor. However, the number of obese nulliparous women is increasing worldwide, creating an urgent need for research into the impact of obesity on the mode of delivery. Our objective was to identify caesarean risk factors in obese nulliparous women with a BMI (body mass index) greater than 40kg/m2. MethodsA literature review was conducted on PubMed; including articles published between 2009 and 2019 in French and English, on caesarean risk during labor among class III obese nulliparous women. ResultsOne prospective study, and 6 retrospective analyses were included. Their results suggest that the rate of caesarean delivery increases with the BMI. Maternal age, particularly after 35 years, as well as induced labor and the use of oxytocin during labor, were positively associated with cesarean delivery. Moreover, maternal BMI was linked to an increased risk of non-elective caesarean section due to non-reassuring fetal heart tracing. ConclusionExtreme BMI, age, induced labor and oxytocin use are associated with caesarean delivery in nulliparous women with BMI≥40kg/m2. Further research are needed to estimate the best candidates for elective cesarean delivery.

Risk factors for Cesarean delivery in pregnancy with small-for-gestational-age fetus undergoing induction of labor.

To identify risk factors for Cesarean delivery and non-reassuring fetal heart tracing (NRFHT) in pregnancies with a small-for-gestational-age (SGA) fetus undergoing induction of labor and to design and validate a prediction model, combining antenatal and intrapartum variables known at the time of labor induction, to identify pregnancies at increased risk of Cesarean delivery. This was a retrospective cohort study of non-anomalous, singleton gestations with a SGA fetus that underwent induction of labor, delivered in a single tertiary referral center between January 2011 and December 2016. SGA was defined as estimated fetal weight (EFW) < 10th percentile. The primary outcome was to identify risk factors associated with Cesarean delivery. The secondary outcome was to identify risk factors associated with NRFHT. Univariate and multivariate analyses were used to determine which clinical characteristics, available at the time of admission, had the strongest association with Cesarean delivery and NRFHT during labor induction. The predictive value of the final models was assessed by the area under the receiver-operating-characteristics curve (AUC). Sensitivity and specificity of the models were also assessed. Internal validation of the models was performed using 10 000 bootstrap replicates of the original cohort. The adequacy of the models was evaluated using the Hosmer-Lemeshow goodness-of-fit test. A total of 594 pregnancies were included. Cesarean delivery was performed in 243 (40.9%) pregnancies. Significant risk factors associated with Cesarean delivery, and included in the final model, were maternal age, gestational age at delivery and initial method of labor induction. The bootstrap estimate of the AUC of the final prediction model for Cesarean delivery was 0.82 (95% CI, 0.78-0.86). The model had sensitivity of 64.2%, specificity of 86.9%, positive likelihood ratio (LR) of 4.9 and negative LR of 0.41. The model had good fit (P = 0.617). NRFHT complicated 117 (19.7%) pregnancies. Significant risk factors for NRFHT included EFW < 5th percentile, abnormal umbilical artery Doppler studies (pulsatility index > 95th percentile or absent/reversed end-diastolic flow) and gestational age at delivery. The final prediction model for NRFHT had an AUC of 0.69 (95% CI, 0.63-0.75) and specificity of 97.0%. We identified several significant risk factors for Cesarean delivery and NRFHT among SGA pregnancies undergoing induction of labor. Clinicians may use these risk factors to guide patient counseling and to help anticipate the potential need for operative delivery. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Fetal Growth Restriction and Cesarean Delivery for Nonreassuring Fetal Heart Rate Tracing in the Late Preterm Period [15K

INTRODUCTION: Women with fetal growth restriction (FGR) are often counseled about the fetus being unable to tolerate induction of labor and the risk for cesarean delivery (CD) for non-reassuring fetal heart tracing (NRFHT), especially in the late preterm period (between 34.0 and 36.6 weeks, LPP). The purpose of our study was to determine the association between FGR and CD for NRFHT in the LPP. METHODS: We performed a single-center case control study of women undergoing induction of labor (IOL) in the LPP between January 2010 and January 2017. Women were included if they underwent IOL between 34.0 and 36.6 weeks gestation of pregnancy with a non-anomalous, vertex, singleton gestation. Women with a previous CD and contraindications to IOL were excluded. Rates of FGR in women undergoing CD for NRFHT were compared to those undergoing CD for other indication or vaginal delivery. RESULTS: The odds of FGR were statistically significant for women who underwent a CD for NRFHT as compared to those having a vaginal delivery or CD for other indication (AOR 4.0; 95% CI 1.97-8.08) and (AOR 3.08; 95% CI 1.13-8.43). African American women had higher odds of IUGR than their white counterparts (AOR 2.65; 95% CI 1.46-4.82). CONCLUSION: Women with a diagnosis of FGR are significantly more likely to have a CD for NRFHT than a CD for other indication or VD in the LPP. This information should be included in counseling women who are undergoing an IOL and have a diagnosis of FGR in the LPP regardless of their indication for induction.

Declining Insulin Requirements in Late Pregnancy: A Cause for Concern? [07D

INTRODUCTION: There is conflicting data on whether diminishing insulin requirement at the end of pregnancy is a sign of placental insufficiency. This study gathered descriptive data on women with diminishing insulin requirement and their obstetric and neonatal outcomes. METHODS: This was a retrospective cohort study of women who received antenatal care between November 2017 and May 2019 in a clinic of endocrinologists and obstetricians. We hypothesized that women with a declining insulin requirement would have increased rates of placental dysfunction-related complications (oligohydramnios, IUGR, abnormal dopplers, non-reassuring antepartum testing, or a cesarean delivery for non-reassuring fetal heart tracing). RESULTS: Our cohort consisted of 157 women: 30 Type 1, 43 Type 2 and 84 gestational diabetics. Twenty-one (13%) experienced a drop in insulin with an average decline of 28% starting at 34 weeks. There was no significant difference in complications related to placental dysfunction (33% vs 24%; P=.37). There was a significantly increased rate of polyhydramnios (43% vs. 9%; P&lt;.01). Women who experienced a decline in insulin delivered one week earlier (median 36w4d vs. 37w4d; P&lt;.01). NICU admissions rates were higher (62% vs. 33%; P&lt;.01) independent of gestational age, and were secondary to respiratory distress (52% vs. 24%; P&lt;.01) as there were no differences in rates of treated hypoglycemia. CONCLUSION: We found no relationship between a decline in insulin requirement and placental function-related complications. Interestingly, we found higher rates of polyhydramnios and NICU admissions for respiratory distress regardless of gestational age, suggesting a decline in insulin requirement has a greater impact on the neonate after delivery.

Association between long interpregnancy intervals and cesarean delivery due to arrest disorders

It is hypothesized that pregnancy causes time-limited physiologic adaptations of the reproductive system, such as increased blood flow to the uterus. With long interpregnancy intervals, those adaptations may regress, and maternal physiologic characteristics may revert to those of primigravid women. Therefore, it is plausible that long interpregnancy interval is associated with cesarean delivery, especially due to arrest disorders (failed induction of labor, arrest of dilation, or arrest of descent). To examine the association between interpregnancy interval and cesarean delivery due to arrest disorders in multiparous women without a history of cesarean delivery. This was a retrospective cohort study of all women who had more than 1 singleton pregnancy at 23 weeks' gestation or greater at MedStar Washington Hospital Center from January 2009 to June 2018. We defined the interpregnancy interval as the duration from the birth of the preceding offspring to the date of conception of the index offspring. We a priori decided to categorize women based on the interpregnancy interval (less than 18 months, 18-59 months, and 60 months or greater). Our primary outcome was cesarean delivery due to arrest disorders. We also examined overall cesarean delivery and cesarean delivery due to nonreassuring fetal heart tracing. Multivariable logistic regression was performed to calculate adjusted odds ratios and 95% confidence intervals, controlling for predefined covariates. Of 2741 women, 1143 (41.7%), 1369 (49.9%), and 229 (8.4%) had an interpregnancy interval of less than 18 months, 18-59 months, and 60 months or more, respectively. After adjusting for confounders, an interpregnancy interval of 60 months or more compared to an interpregnancy interval of 18-59 months was associated with increased odds of cesarean delivery due to arrest disorders (4.8% vs 1.3%; adjusted odds ratio, 3.06; 95% confidence interval, 1.34-6.97) and cesarean delivery due to arrest of dilation (3.1% vs 0.7%; adjusted odds ratio, 3.24; 95% confidence interval, 1.10-9.59). An interpregnancy interval of less than 18 months compared to an interpregnancy interval of 18-59 months was associated with decreased odds of cesarean delivery due to nonreassuring fetal heart tracing (2.4% vs 4.1%; adjusted odds ratio, 0.55; 95% confidence interval, 0.32-0.92). An interpregnancy interval of 60 months or greater compared to an interpregnancy interval of 18-59 months was associated with increased odds of cesarean delivery due to arrest disorders. Beneficial effects on postpartum adaptations in the reproductive system may regress as interpregnancy interval increases.