Term Maternal Outcomes Research Articles

Indications for late preterm birth, and factors associated with short term maternal and neonatal outcomes at a tertiary care institution.

The preterm birth rate is rising mainly because of the marked increase in late preterm deliveries. To evaluate the indications for LPTB and the factors associated with the short term maternal and neonatal outcomes. This retrospective study was conducted at a tertiary health care institution. The study sample included 191 women who delivered between October 2019 to November 2020. The majority (81%) were medically indicated LPTB, and mainly for maternal indications (77%). The most common maternal indication for LPTB was for hypertensive disease of pregnancy (HDP) (82.5%). There was a significant increase in the high care/ ICU admission for maternal indication of LPTB, maternal age < 20 years, and patients with HDP. There was 1 maternal death and 1 neonatal death. 48% of the neonates were admitted to NICU and 53% had neonatal complications. Neonates born by caesarean delivery were more likely to have respiratory complications and be admitted to NICU. These maternal/ neonatal factors should be used to identify patients at risk of adverse maternal and neonatal outcomes.

The Maternal factors and short term outcomes associated with episiotomy during vaginal delivery at Women and Newborn Hospital , Lusaka, Zambia

Background: An episiotomy is a surgically planned incision on the posterior vaginal wall and perineum performed during the second stage of labour to facilitate the delivery of the neonate. The practice has been used for many decades in the belief that it offers benefit to the mother and the neonate. With the objective of protecting the pelvic floor and preventing fetal trauma, during the birth, its routine use was widely accepted in the past, principally in woman in her first delivery. However, it is not free from complications which include iatrogenic injury to the anal canal, perineal pain and excess bleeding. This study was therefore conducted to explore the short term maternal outcomes and factors associated with episiotomy.&#x0D; &#x0D; Methodology: An unmatched case control study was conducted in postnatal wards of Women and New-born hospital in Lusaka, Zambia between November 2019 and April 2020 with convenient sample for the cases and systematic sample for the controls. A semi-structured interviewer administered questionnaire was used and 102 participants (cases) who had episiotomy performed were recruited while 204(controls) were without episiotomies.&#x0D; &#x0D; Results: A total of 306 (102 are cases and 204 are control) were included. Age was found to be a good predictor of episiotomy in that those younger than 18 years were more than seven times likely to have an episiotomy (AOR=7.65; 95%CI 1.36-18.21; p=0.035). It was also found out that primi gravidas were five times likely to have an episiotomy performed compared to parous women (OR=4.96; 95%CI 2.58-9.52; p&lt;0.001). Out of those delivered by a midwife, 73(28.3%) participants had an episiotomy performed compared to 29(60.4%) delivered by a medical officer. Multivariate regression it was shown that being delivered by a midwife was protective against an episiotomy (OR=0.260; 95%CI 0.14-0.49; p=0.001). Out of the 102 participants who had an episiotomy, only two had third degree tear extension. It was also noted that 99 out of 102 (97%) participants who had an episiotomy experienced post-delivery perineal pain compared to 94 out of 204(46%) of those who had no episiotomies. In univariate analysis, it was found that post-delivery perineal pain was associated with episiotomy (p&lt;0.001). It was further found that those who had an episiotomy performed were about 4 times likely to experience perineal pain post- delivery (OR=3.8; 95%CI 1.2-12.3). The mean blood loss among those who has had no episiotomy was 230mls compared to 270mls among those who had an episiotomy. However, post-delivery blood loss was found to be a poor predictor of an episiotomy (OR=0.998; 95%CI 0.991-1.006; p=0.670).&#x0D; &#x0D; Conclusion: Maternal factors associated with episiotomy included age, parity, method of induction, and the personnel conducting the delivery Short term maternal outcomes of episiotomy were perineal tear extension, excess blood loss and post-delivery perineal pain. It was found that 8.5% of women had undergone an episiotomy done on them. Health professional conducting deliveries should be educated on indications of episiotomy, patient selection during episiotomy and trained on surgical skills to repair episiotomy to reduce morbidity associated the procedure.

The Maternal factors and short term outcomes associated with episiotomy during vaginal delivery at Women and Newborn Hospital , Lusaka, Zambia

Background: An episiotomy is a surgically planned incision on the posterior vaginal wall and perineum performed during the second stage of labour to facilitate the delivery of the neonate. The practice has been used for many decades in the belief that it offers benefit to the mother and the neonate. With the objective of protecting the pelvic floor and preventing fetal trauma, during the birth, its routine use was widely accepted in the past, principally in woman in her first delivery. However, it is not free from complications which include iatrogenic injury to the anal canal, perineal pain and excess bleeding. This study was therefore conducted to explore the short term maternal outcomes and factors associated with episiotomy.&#x0D; Methodology: An unmatched case control study was conducted in postnatal wards of Women and New-born hospital in Lusaka, Zambia between November 2019 and April 2020 with convenient sample for the cases and systematic sample for the controls. A semi-structured interviewer administered questionnaire was used and 102 participants (cases) who had episiotomy performed were recruited while 204(controls) were without episiotomies.&#x0D; Results: A total of 306 (102 are cases and 204 are control) were included. Age was found to be a good predictor of episiotomy in that those younger than 18 years were more than seven times likely to have an episiotomy (AOR=7.65; 95%CI 1.36-18.21; p=0.035). It was also found out that primi gravidas were five times likely to have an episiotomy performed compared to parous women (OR=4.96; 95%CI 2.58-9.52; p&lt;0.001). Out of those delivered by a midwife, 73(28.3%) participants had an episiotomy performed compared to 29(60.4%) delivered by a medical officer. Multivariate regression it was shown that being delivered by a midwife was protective against an episiotomy (OR=0.260; 95%CI 0.14-0.49; p=0.001). Out of the 102 participants who had an episiotomy, only two had third degree tear extension. It was also noted that 99 out of 102 (97%) participants who had an episiotomy experienced post-delivery perineal pain compared to 94 out of 204(46%) of those who had no episiotomies. In univariate analysis, it was found that post-delivery perineal pain was associated with episiotomy (p&lt;0.001). It was further found that those who had an episiotomy performed were about 4 times likely to experience perineal pain post- delivery (OR=3.8; 95%CI 1.2-12.3). The mean blood loss among those who has had no episiotomy was 230mls compared to 270mls among those who had an episiotomy. However, post-delivery blood loss was found to be a poor predictor of an episiotomy (OR=0.998; 95%CI 0.991-1.006; p=0.670).&#x0D; Conclusion: Maternal factors associated with episiotomy included age, parity, method of induction, and the personnel conducting the delivery Short term maternal outcomes of episiotomy were perineal tear extension, excess blood loss and post-delivery perineal pain. It was found that 8.5% of women had undergone an episiotomy done on them. Health professional conducting deliveries should be educated on indications of episiotomy, patient selection during episiotomy and trained on surgical skills to repair episiotomy to reduce morbidity associated the procedure.

Immediate and long-term outcomes of balloon mitral valvotomy in pregnancy

ObjectivesTo study the immediate maternal and fetal outcomes and long term maternal outcomes in pregnant women undergoing balloon mitral valvotomy. MethodsWe retrospectively analyzed balloon mitral valvotomy during pregnancy performed between January 2008 and July 2018. ResultsBMV was carried out in 97 pregnant women with mean age of 26.1 ± 4.5 years, at mean gestational age of 23.1 ± 4.6 weeks. The procedure was successful in 95 patients (97.9%). There was one maternal death post procedure due to intra-uterine death and disseminated intravascular coagulation. Adverse immediate fetal outcome was seen in 2 cases with one intra-uterine fetal demise and one preterm labour. Mitral valve area increased from mean of 0.82 ± 0.12 cm to 1.66 ± 0.14 cm (p < 0.001). Mean trans-mitral diastolic gradient decreased from 19.7 ± 5.6 mm Hg to 7.5 ± 2 mm Hg. Right ventricular systolic pressure decreased significantly from mean of 56.7 ± 16.2 mm Hg to mean of 35.6 ± 11 mm Hg. Survival analysis showed cumulative event free survival of 89% at 5 years and 65% at 10 years, considering a composite endpoint of clinical restenosis, repeat BMV or MVR or cardiovascular death. ConclusionsBalloon mitral valvotomy is a safe and effective treatment for severe mitral stenosis during pregnancy. Long term maternal outcomes after BMV done during pregnancy are good and comparable to that of BMV done in non-pregnant patients.

Elective repeat cesarean delivery compared with trial of labor after a prior cesarean delivery: a propensity score analysis

ObjectiveTo determine neonatal and short term maternal outcomes according to intentional mode of delivery following a cesarean delivery (CD). Study designWomen pregnant after CD between January 2000 and December 2007 were categorized according to whether they had an elective repeat CD (ERCD) or a Trial of Labor (TOL). Prognostically equal ERCD and TOL groups were created using the propensity score matching technique. Conditional logistic regression was performed to assess differences in neonatal and maternal outcomes. PopulationWomen in their second ongoing pregnancy with a history of CD. ResultsAfter ERCD the rates of low 5min Apgar score (OR 0.3, 95%CI 0.2–0.5, p<0.001), meconium aspiration (OR 0.0, 95%CI 0–0.7, p=0.02) and birth trauma (OR 0.08, 95%CI 0.002–0.5, p<0.001) were lower compared to TOL. The rate of transient tachypnoea of the newborn (TTN) appears higher in the ERCD group (OR 1.7, 95%CI 1.0–2.8, p=0.04). Uterine rupture (OR 0.1, 95%CI 0.003–0.8, p=0.02) and hemorrhage (OR 0.6, 95%CI 0.5–0.8, p<0.001) occurred less in the ERCD group. ConclusionNeonatal and short term maternal morbidity appears to be lower after ERCD than after TOL. Only TTN was seen more often after ERCD.

Longitudinal perspective is needed to improve postpartum health

Our attention in maternity care research and practice is focused primarily on short-term outcomes. A systematic review of randomised controlled trials evaluating perinatal interventions concluded that only a minority of trials reported offspring outcomes following hospital discharge (Teune et al. BJOG 2013;120:15–22). A parallel analysis would perhaps yield an even lower proportion of studies measuring medium to longer term maternal outcomes. This is troubling, as frameworks such as epigenetics, developmental origins of health and disease, life-course health development, and the human microbiome highlight the importance of long-term impacts of exposures during early sensitive windows of most rapid human development, with long-term impacts on childbearing women increasingly identified as well. When we shine the light on just a small area, what are we missing out there in the dark? McDonald and colleagues' Maternal Health Study investigated first-time mothers' experience of postpartum dyspareunia and the results are illuminating. Experiences of dyspareunia soared above baseline prepregnancy levels, with more than one in four participants reporting persistent dyspareunia. In the adjusted analysis emergency caesarean section was associated with persistent dyspareunia. Professional recognition of the overuse of caesarean section, calls for safely preventing such procedures, and identification of well-supported ways to do so point to opportunities to prevent persistent dyspareunia (American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine Obstet Gynecol 2014;123:693–711). Mothers and babies have the rest of their lives ahead of them, and high performing healthcare systems cannot rely primarily on myopic knowledge. With a longer view, notable proportions of women experience a range of new-onset morbidities in the weeks after giving birth, persisting in many to 6 months and beyond (Declercq et al. Listening to Mothers III: New Mothers Speak Out. New York: Childbirth Connection; 2013). We need long-term follow up in randomised controlled trials and complementary well-conducted observational studies. It is important to monitor and treat postpartum morbidity in clinical practice. In a national survey in the USA, excluding infection, more than seven out of ten participants did not seek help from a health professional for various new-onset postpartum problems (Declercq et al. Listening to Mothers; Report of the First National U.S. Survey of Women's Childbearing Experiences. New York: Maternity Center Association, 2002). A high-quality patient-reported outcome measure of composite maternal morbidity captured 4–8 weeks postpartum could improve maternal health in several ways. It could engender discussion, counselling and treatment during postpartum care. Relevant information would be captured in the health record for continued attention within primary care in settings with the capacity to share health records from other providers. More generally, such a measure could inform professionals and the public regarding maternity-care outcomes, fostering quality improvement and patient choice. Better research, measurement, prevention and treatment are needed to address issues of great interest and consequence to women during a phase of maternity care and the life cycle that have received incommensurate attention. I am a co-investigator of the Listening to Mothers surveys. I have no financial interests in matters discussed in this commentary.

385: Etiology and management of acute pulmonary edema in pregnancy-postpartum: Role of echocardiography

POSTPARTUM: ROLE OF ECHOCARDIOGRAPHY MOUNIRA HABLI, ANNETTE BOMBRYS, JOHN R. BARTON, HELEN HOW, BAHA SIBAI, University of Cincinnati, Cincinnati, Ohio, Central Baptist Hospital, Lexington, Kentucky OBJECTIVE: To evaluate the role of echocardiography (ECHO)in the etiology and management of acute pulmonary edema in pregnancy. STUDY DESIGN: 59 pregnant women with acute pulmonary edema were evaluated with ECHO between 2000-2006.Women with known functional or structural heart disease were excluded. Maternal outcomes are: ECHO parameters(left ventricular end diastolic[LVED] and systolic dimension[LVES],ejection fraction[EF], % shortening and evidence of systolic diastolic dysfunction), risk factors, acute and discharge medications and major morbidities. 47(80%) patients had a follow up of 1-5 years. Data were analyzed using T-test, Chi square and Fisher exact test. RESULTS: Based on ECHO findings, patients(pts) were classified as having cardiogenic (n 36) or non-cardiogenic (n 23) etiology. There were no differences between groups regarding race, age, rate of hypertensive disorders (67% vs 58%) and admission with preterm labor (11%vs 17%). Mean gestational age at delivery was 36.4 3.25 wks. Among the cardiogenic group, 21 (58%) had peripartum cardiomyopathy, 6 (17%) had isolated systolic dysfunction, 8 (22%) had newly diagnosed valvular disease and one had pulmonary hypertension. These pts had significant impairment in left ventricular performance as compared to non-cardiogenic group (table). All pts received diuretics and oxygen.There was a difference in use of antihypertensive medications(66%,cardiogenic vs 39%,p 0.04). At discharge 28 (77%) women in the cardiogenic group received targeted medications based on ECHO findings as compared to none in the non-cardiogenic group. There were no maternal deaths. CONCLUSION: Echocardiography should be an integral part of the initial evaluation of the etiology and management of acute pulmonary edema in pregnancy. Information obtained by ECHO will assist in improvement of short and long term maternal outcomes.