Search

Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrial-myometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. Maternal morbidity and mortality can occur because of severe and sometimes life-threatening hemorrhage, which often requires blood transfusion. Although ultrasound evaluation is important, the absence of ultrasound findings does not preclude a diagnosis of placenta accreta spectrum; thus, clinical risk factors remain equally important as predictors of placenta accreta spectrum by ultrasound findings. There are several risk factors for placenta accreta spectrum. The most common is a previous cesarean delivery, with the incidence of placenta accreta spectrum increasing with the number of prior cesarean deliveries. Antenatal diagnosis of placenta accreta spectrum is highly desirable because outcomes are optimized when delivery occurs at a level III or IV maternal care facility before the onset of labor or bleeding and with avoidance of placental disruption. The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). Optimal management involves a standardized approach with a comprehensive multidisciplinary care team accustomed to management of placenta accreta spectrum. In addition, established infrastructure and strong nursing leadership accustomed to managing high-level postpartum hemorrhage should be in place, and access to a blood bank capable of employing massive transfusion protocols should help guide decisions about delivery location. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to determine the effectiveness of treatment over time for bacterial vaginosis in pregnancy and the probability of spontaneous resolution with placebo. Study design: Women with asymptomatic bacterial vaginosis on Gram stain were assigned randomly at 16 to 23 weeks of gestation to receive two 2-g doses of metronidazole or placebo 48 hours apart and were re-evaluated for changes in Gram stain score on one occasion ≥2 weeks later. Results: Of 658 women who underwent metronidazole therapy, treatment was successful (score, <7) in 78% of those women who were seen at 2 to 3.9 weeks of gestation, which was similar to women seen ≥10 weeks after treatment. In 683 women who underwent placebo therapy, spontaneous resolution increased significantly from 13% at 2 to 3.9 weeks of gesttion to 36% at ≥10 weeks of gestation. Spontaneous resolution was more common with lower vaginal pH or lactobacilli on Gram stain at the time of random assignment. Conclusion: The effectiveness of metronidazole therapy of bacterial vaginosis persists for ≥ 10 weeks. Women who underwent placebo therapy had significant remission of bacterial vaginosis over ≥ 10 weeks. Remission was more common when the initial vaginal microbiologic disturbances were less severe. [ABSTRACT FROM AUTHOR]

Objective: Our purpose was to determine whether maternal plasma levels of neutrophil granule products are elevated in patients with chorioamnionitis after preterm premature rupture of membranes (PROM).Study Design: Fifty-two patients between 24 and 34 weeks' gestation with preterm PROM were included. Plasma samples for defensins and lactoferrin were collected throughout latency. Fifty-two control subjects between 26 and 30 weeks' gestation were recruited for baseline levels.Results: Mean control defensin levels were compared with mean defensin levels on admission (668 ng/mL vs 5665 ng/mL, P<.01). Mean defensin levels on admission in patients without chorioamnionitis were compared with those of patients in whom histologic chorioamnionitis developed (520 ng/mL vs 9163 ng/mL, P<.01). The same relationships were not demonstrated for lactoferrin. With use a defensin value of 1500 ng/mL on admission, the sensitivity is 76% and specificity is 94% in predicting histologic chorioamnionitis.Conclusions: Maternal plasma levels of defensins are markers of histologic chorioamnionitis in patients after preterm PROM. [ABSTRACT FROM AUTHOR]

The use of trial of labor after cesarean delivery calculators in the prediction of successful vaginal birth after cesarean delivery gives physicians an evidence-based tool to assist with patient counseling and risk stratification. Before deployment of prediction models for routine care at an institutional level, it is recommended to test their performance initially in the institution's target population. This allows the institution to understand not only the overall accuracy of the model for the intended population but also to comprehend where the accuracy of the model is most limited when predicting across the range of predictions (calibration). The purpose of this study was to compare 3 models that predict successful vaginal birth after cesarean delivery with the use of a single tertiary referral cohort before continuous model deployment in the electronic medical record. All cesarean births for failed trial of labor after cesarean delivery and successful vaginal birth after cesarean delivery at an academic health system between May 2013 and March 2016 were reviewed. Women with a history of 1 previous cesarean birth who underwent a trial of labor with a term (≥37 weeks gestation), cephalic, and singleton gestation were included. Women with antepartum intrauterine fetal death or fetal anomalies were excluded. The probability of successful vaginal birth after cesarean delivery was calculated with the use of 3 prediction models: Grobman 2007, Grobman 2009, and Metz 2013 and compared with actual vaginal birth after cesarean delivery success. Each model's performance was measured with the use of concordance indices, Brier scores, and calibration plots. Decision curve analysis identified the range of threshold probabilities for which the best prediction model would be of clinical value. Four hundred four women met the eligibility criteria. The observed rate of successful vaginal birth after cesarean delivery was 75% (305/404). Concordance indices were 0.717 (95% confidence interval, 0.659–0.778), 0.703 (95% confidence interval, 0.647–0.758), and 0.727 (95% confidence interval, 0.669–0.779), respectively. Brier scores were 0.172, 0.205, and 0.179, respectively. Calibration demonstrated that Grobman 2007 and Metz vaginal birth after cesarean delivery models were most accurate when predicted probabilities were >60% and were beneficial for counseling women who did not desire to have vaginal birth after cesarean delivery but had a predicted success rates of 60–90%. The models underpredicted actual probabilities when predicting success at <60%. The Grobman 2007 and Metz vaginal birth after cesarean delivery models provided greatest net benefit between threshold probabilities of 60–90% but did not provide a net benefit with lower predicted probabilities of success compared with a strategy of recommending vaginal birth after cesarean delivery for all women. When 3 commonly used vaginal birth after cesarean delivery prediction models are compared in the same population, there are differences in performance that may affect an institution's choice of which model to use. [ABSTRACT FROM AUTHOR]

Pelvic examination was performed on 65 asymptomatic pregnant women at 7-22 weeks' gestation with vaginal pH > 4.4. Median concentrations of vaginal fluid neutrophil defensins and cervical interleukin-8 were significantly greater among women with asymptomatic trichomoniasis than in uninfected counterparts. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to estimate the nationwide prevalence of cystic fibrosis (CF) in pregnancy and determine what medical complications exist at delivery among pregnant women with CF. Study Design The Nationwide Inpatient Sample (NIS) was queried for all delivery-related discharges. Women with CF were identified by International Classification of Diseases, 9th revision, Clinical Modifications codes and compared with women without CF. The prevalence of selected severe medical complications was compared between the 2 groups (NIS years 2008-2010) using multivariable logistic regression and the linear change in prevalence of CF at delivery determined (NIS years 2000-2010). Results From 2000 to 2010, there was a significant linear increase in the prevalence of CF at delivery from 3.0 to 9.8 per 100,000 deliveries, in 2000 and 2010, respectively (R 2 = 0.92, P < .0001). From 2008-2010, there were 1119 deliveries to women with CF and 12,627,627 to women without CF. Women with CF were more likely to be white ( P < .0001) and have diabetes (odds ratio [OR], 14.0; 95% confidence interval [CI], 11.8–16.7) or asthma (OR, 5.1; 95% CI, 4.3–6.1). Multivariable logistic regression demonstrated that women with CF were more likely to die (adjusted OR [aOR], 76.0; 95% CI, 31.6–183), require mechanical ventilation (aOR, 18.3; 95% CI, 10.8–31.2), or have pneumonia (aOR, 56.5; 95% CI, 43.2−74.1), acute renal failure (aOR, 17.3; 95% CI, 9.1–32.6), preterm labor (aOR, 2.2; 95% CI, 1.9–2.6), or an adverse composite CF outcome (aOR, 28.1; 95% CI, 21.8–36.3). Conclusion Pregnant women with CF are more likely to die, require mechanical ventilation, and have infectious complications compared with women without CF, although the absolute risks are low and these events are relatively rare. [ABSTRACT FROM AUTHOR]

Despite evidence regarding the benefits of influenza immunization during pregnancy for both the pregnant woman and her infant, as well as reassuring safety data, influenza vaccination rates in pregnancy have lagged. The 2009 influenza pandemic was accompanied by increased maternal vaccination rates. In this article, we review programmatic and research priorities with regard to overcoming barriers to influenza immunization of pregnant women. [ABSTRACT FROM AUTHOR]

Abstract Objective Tetanus toxoid, reduced diphtheria toxoid, and acellular pertusiss (Tdap) vaccine is recommended during each pregnancy, regardless of prior receipt. Data on reactogenicity and immunogenicity, particularly after repeated Tdap, are limited. We compared local injection-site and systemic reactions and serologic response following Tdap in (1) pregnant and nonpregnant women and (2) pregnant women by self-reported prior Tdap receipt. Study design Pregnant women (gestational age 20–34 weeks) and nonpregnant women receiving Tdap were enrolled in this observational study. Injection-site and systemic reactions were assessed for one week post-vaccination. Pertussis toxin, filamentous hemagglutinin, pertactin, fimbriae, tetanus and diphtheria specific IgG antibody titers were determined by standardized enzyme-linked immunosorbent assay at baseline and 28 days post-vaccination. Reactogenicity and serologic responses were compared by pregnancy status, and within pregnant women by self-reported prior Tdap receipt. Results 374 pregnant and 225 nonpregnant women were vaccinated. Severe local or systemic reactions or "any" fever were uncommon (≤3% for both groups). Moderate/severe injection-site pain was significantly higher in pregnant (17.9%) versus nonpregnant (11.1%) women, but did not prompt a healthcare visit. Proportions of other moderate/severe or any severe reactions were not significantly higher in pregnant compared to nonpregnant women. Moderate/severe (including pain) and severe reactions were not significantly higher in pregnant women receiving repeat versus first-time Tdap. Antibody titers increased from baseline to post-vaccination for all vaccine antigens in pregnant and nonpregnant women; post-vaccination titers against pertussis toxin and filamentous hemagglutinin were significantly higher in nonpregnant versus pregnant women (p < 0.01). Conclusion Tdap was well-tolerated in pregnant and nonpregnant women. Pregnant women were more likely to report moderate/severe pain at the Tdap injection-site compared with nonpregnant women, but did not necessitate medical visits. Prior Tdap receipt did not increase occurrence of moderate/severe local or systemic reactions in pregnant women. Serologic responses to all vaccine antigens were robust. Clinical Trial Registration@ClinicalTrials.gov. NCT02209623. https://clinicaltrials.gov/ct2/show/NCT02209623. [ABSTRACT FROM AUTHOR]

Highlights: [•] A toxicity grading scale is defined for adverse event reporting in pregnancy. [•] Vital sign changes in pregnancy are discussed and toxicity grading developed for each trimester. [•] Normal laboratory values are listed and a toxicity grade is assigned based on value and trimester of pregnancy. [ABSTRACT FROM AUTHOR]

Background: This study examines whether adding nicotine replacement therapy (NRT) to cognitive-behavioral therapy (CBT) for pregnant smokers increases rates of smoking cessation.Methods: An open-label randomized trial (Baby Steps, n=181) of CBT-only versus CBT+NRT (choice of patch, gum, or lozenge; 1:2 randomization) was used. Data were collected from 2003 through 2005; analyses were conducted in 2006 and 2007. Outcomes were biochemically validated self-reported smoking status at 7 weeks post-randomization, 38 weeks gestation, and 3 months postpartum.Results: Women in the CBT+NRT arm were almost three times more likely than women in the CBT-only arm to have biochemically validated cessation at both pregnancy time points (after 7 weeks: 24% vs 8%, p=0.02; at 38 weeks gestation: 18% vs 7%, p=0.04), but not at 3 months postpartum (20% vs 14%, p=0.55). Recruitment was suspended early by an Independent Data and Safety Monitoring Board when an interim analysis found a higher rate of negative birth outcomes in the CBT+NRT arm than in the CBT-only arm. In the final analysis, the difference between the arms in rate of negative birth outcomes was 0.09 (p=0.26), when adjusted for previous history of preterm birth.Conclusions: The addition of NRT to CBT promoted smoking cessation in pregnant women. This effect did not persist postpartum. More data are needed to determine safety parameters and to confirm the efficacy of NRT use during pregnancy. [ABSTRACT FROM AUTHOR]