Blood type and postpartum hemorrhage by mode of delivery: A retrospective cohort study
OBJECTIVE:To assess the relationship between postpartum hemorrhage and ABO blood type for vaginal delivery and cesarean delivery. STUDY DESIGN/METHODS:This is a retrospective cohort study of data abstracted from the PeriBank database regarding demographics and delivery outcomes. All live singleton deliveries from January 2011 until March 2018 were included in this study. Exclusion criteria were sickle cell disease and multiple gestations. Analyses were conducted separately for cesarean delivery and vaginal delivery. Quantitative variables were analyzed with analysis of variance testing and categorical variables with chi square testing. Significant demographic differences between groups were controlled for using multivariate logistical regression. The primary outcome was the rate of postpartum hemorrhage by blood type (A, B, AB, and O), defined as blood loss >500â€‰mL in vaginal delivery and >1000â€‰mL in cesarean delivery. 43,437 patients were screened and 32,023 women met inclusion criteria (22,484 vaginal deliveries (70.2%) and 9539 cesarean deliveries (29.8%)). RESULTS:In the vaginal delivery group there were differences in age, parity, race, use of regional anesthesia, rate of induction of labor, and thrombocytopenia between blood types. In the cesarean delivery group, age, parity, and race were significantly different between blood types. There was no observed difference in the rate of postpartum hemorrhage by blood type for those who delivered via vaginal delivery when controlling for demographic differences (pâ€‰=â€‰0.2). In the cesarean delivery group, there was a significantly higher rate of postpartum hemorrhage in women with type O blood (5.2% type O vs 3.8% type A vs 4.4% type B vs 4.2% type AB, pâ€‰=â€‰0.035), including when controlling for demographic differences (pâ€‰=â€‰0.02). In both vaginal and cesarean delivery groups, there was no difference in rates of any of the secondary outcomes, including blood transfusion, hysterectomy, intrapartum dilation and curettage, and intensive care unit admission. CONCLUSION/CONCLUSIONS:Although this study found no statistically significant difference in clinical outcomes between blood types, type O blood may be an additional risk factor to consider for postpartum hemorrhage at the time of cesarean delivery.
Severe acute respiratory distress syndrome in coronavirus disease 2019-infected pregnancy: obstetric and intensive care considerations [Case Report]
Since the emergence of a novel coronavirus (severe acute respiratory syndrome coronavirus 2) in Wuhan, China, at the end of December 2019, coronavirus disease 2019 has been associated with severe morbidity and mortality and has left world governments, healthcare systems, and providers caring for vulnerable populations, such as pregnant women, wrestling with the optimal management strategy. Unique physiologic and ethical considerations negate a one-size-fits-all approach when caring for critically ill pregnant women with coronavirus disease 2019, and few resources exist to guide the multidisciplinary team through decisions regarding optimal maternal-fetal surveillance, intensive care procedures, and delivery timing. We present a case of rapid clinical decompensation and development of severe acute respiratory distress syndrome in a woman at 31 weeks' gestation to highlight these unique considerations and present an algorithmic approach to the diagnosis and management of the disease.
Clinical course of severe and critical COVID-19 in hospitalized pregnancies: a US cohort study
Background/UNASSIGNED:The COVID-19 pandemic has had an impact on healthcare systems around the world with 3.0 million infected and 208,000 resultant mortalities as of this writing. Information regarding infection in pregnancy is still limited. Objectives/UNASSIGNED:To describe the clinical course of severe and critical infection in hospitalized pregnant women with positive laboratory testing for SARS-CoV2. Study Design/UNASSIGNED:This is a cohort study of pregnant women with severe or critical COVID-19 infection hospitalized at 12 US institutions between March 5, 2020 and April 20, 2020. Severe infection was defined according to published criteria by patient reported dyspnea, respiratory rate > 30 per minute, blood oxygen saturation â‰¤ 93% on room air, partial pressure of arterial oxygen to fraction of inspired oxygen <300 and/or lung infiltrates >50% within 24 to 48 hours on chest imaging. Critical disease was defined by respiratory failure, septic shock, and/or multiple organ dysfunction or failure. Women were excluded if they had presumed COVID-19 infection but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported. Results/UNASSIGNED:=0.01). For those who required it, intubation usually occurred around day 9, and peak respiratory support for women with severe disease occurred on day 8. In women with critical disease, prone positioning was performed in 20% of cases, the rate of ARDS was 70%, and re-intubation was necessary in 20%. There was one case of maternal cardiac arrest, but no cases of cardiomyopathy and no maternal deaths. Thirty-two (50%) women in this cohort delivered during their COVID-19 hospitalization (34% of severe and 85% of critical women). Eighty-eight percent (15/17) of pregnant women with critical COVID-19 who delivered during their disease course were delivered preterm, 94% of them via cesarean; in all, 75% (15/20) of critically ill women delivered preterm. There were no stillbirths or neonatal deaths, or cases of vertical transmission. Conclusion/UNASSIGNED:In hospitalized pregnant women with severe or critical COVID-19 infection, admission typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 severe versus 12 critical). Critically ill women had a high rate of ARDS, and there was one case of cardiac arrest, but there were no cases of cardiomyopathy, or maternal mortality. Hospitalization for severe or critical COVID-19 infection resulted in delivery during the course of infection in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.
Pregnancy and Lactation in a 67-Year-Old Elderly Gravida following Donor Oocyte In Vitro Fertilization [Case Report]
There is limited data on the anticipated perinatal course among gravidae in their sixth and seventh decades. Our objective was to describe the relatively uncomplicated prenatal, intrapartum, and postpartum course of a 67-year-old essential primigravida. Briefly, our patient conceived a singleton pregnancy via IVF with donor oocytes, then presented at 13 6/7 weeks of gestation to initiate prenatal care. Her medical history was significant for chronic hypertension, hyperlipidemia, and obesity. Her cardiac function was monitored throughout pregnancy, and she delivered at 36 1/7 weeks by cesarean for a decline in left ventricular function with mitral regurgitation. Her intrapartum and postpartum course was uncomplicated, and she was able to successfully breastfeed for six months and resume prepregnancy activity. For comparison, we analyzed deliveries among gravidae > 45 years of age from our institutional obstetrical database (2011-2018). This case represents the eldest gravidae identified in the literature and illustrates the potential for a relatively uncomplicated perinatal course with successful lactation. This case may enable other providers to counsel elderly patients on anticipated outcomes inclusive of ability to breastfeed.
What's new in the multiple gestations literature? [Editorial]
Second-trimester cervical length and outcomes of induction of labor at term
OBJECTIVE:To evaluate whether second-trimester cervical length (CL) is associated with induction of labor (IOL) outcomes. METHODS:Retrospective cohort study of nulliparous singletons undergoing CL screening at 18Â 0/7-23Â 6/7Â weeks from 1/1/2012 to 12/31/2013. Women induced at term (â‰¥37Â weeks) were included. Primary outcome was vaginal delivery (VD) within 24â€‰h. The effect of CL on outcomes was assessed by incidence across CL quartiles and a receiver operating characteristics (ROC) curve. Odds ratios (OR) were adjusted (aOR) for confounders. RESULTS:Two-hundred-and-sixty-eight women were included. Aside from a difference in incidence of prior cervical surgery between CL quartiles (pâ€‰<.â€‰02), other characteristics were similar. Ninety-two women (35%) had a VD within 24â€‰h (versus a CD or VD >24â€‰h). A longer a CL was associated with a decreased likelihood of a VD within 24â€‰h with aORs of the third and fourth quartiles of 0.35 (0.16-0.75) and 0.43 (0.21-0.90), respectively, compared to the first quartile. A CL >40â€‰mm was predictive of not having a VD within 24â€‰h with a sensitivity of 56%, specificity of 58% and a positive predictive value of 72%. CONCLUSION/CONCLUSIONS:A second-trimester CL >40â€‰mm is associated with a decreased likelihood of VD within 24â€‰h in an IOL.
Second trimester cervical length and prolonged pregnancy (.)
OBJECTIVE:To determine whether second trimester transvaginal ultrasound cervical length (CL) is associated with prolonged pregnancy (â‰¥41 0/7 weeks) in nulliparous women who reach term (â‰¥37 weeks) with a planned vaginal delivery. METHODS:Retrospective cohort of nulliparous singletons 18 0/7-23 6/7 weeks gestation undergoing CL screening from 1/1/12 to 12/31/13. Women who delivered at term with spontaneous labor or reached 41 weeks were included. Primary outcome was incidence of prolonged pregnancy. Risk of prolonged pregnancy was assessed by CL quartile using odds ratio, adjusted for confounders (aOR) and a receiver operating characteristic (ROC) curve. RESULTS:722 women were included, among them 171 (24%) had a prolonged pregnancy. There was a significant difference in BMI and race across CL quartiles. The aOR of having a prolonged pregnancy with CL in quartiles 2, 3, and 4 versus quartile 1 were 2.14(1.27-3.62), 2.72(1.59-4.65), and 1.69(1.02-3.03), respectively. CLâ€‰â‰¥â€‰37â€‰mm (beyond first quartile) was associated with a two-fold increased risk of prolonged pregnancy versus CLâ€‰<â€‰37â€‰mm, (27% vs 15%, pâ€‰<â€‰0.01, aOR 2.17 (1.38-3.41)). ROC curve did not identify a CL cutoff that was predictive of prolonged pregnancy (AUC 0.544, pâ€‰=â€‰0.079). CONCLUSIONS:Although a longer second trimester CL is associated with an increased risk for prolonged pregnancy, it is not predictive.
Overview of Cervical Insufficiency: Diagnosis, Etiologies, and Risk Factors
The diagnosis of cervical insufficiency can be made in women with or without prior pregnancy losses. Cervical insufficiency has been defined by transvaginal ultrasound cervical length <25 mm before 24 weeks in women with prior pregnancy losses or preterm births at 14 to 36 weeks, or by cervical changes detected on physical examination before 24 weeks of gestation.
Cerclage: Indications and Patient Counseling
Cervical cerclage is a surgical procedure to prevent preterm birth. There are currently 3 main indications, based on either history, ultrasound, or physical exam changes.
Pessary versus cerclage versus expectant management for cervical dilation with visible membranes in the second trimester
OBJECTIVE: We evaluated pessary for dilated cervix and exposed membranes for prolonging pregnancy compared to cerclage or expectant management. METHODS: Multicenter retrospective cohort study of women, 15-24 weeks, singleton pregnancies, dilated cervix >/=2 cm and exposed membranes. Women received pessary, cerclage or expectant management. Primary outcome was gestational age (GA) at delivery. Secondary outcomes were time until delivery, preterm premature rupture of membranes (PPROM) and neonatal survival. RESULTS: About 112 women met study criteria; 9 - pessary, 85 - cerclage and 18 - expectant management. Mean GA at delivery was 22.9 +/- 4.5 weeks with pessary, 29.2 +/- 7.5 weeks with cerclage and 25.6 +/- 6.7 weeks with expectant management (p = 0.015). Time until delivery was 16.1 +/- 18.9 days in the pessary group, 61.7 +/- 48.2 days in the cerclage group and 26.8 +/- 33.4 days in the expectant group (p < 0.001). PPROM occurred less frequently and neonatal survival increased in women with cerclage. There was a significant difference in all the perinatal outcomes with cerclage compared with either pessary or expectant management. CONCLUSIONS: Perinatal outcomes with pessary were not superior to expectant management in women with dilated cervix with exposed membranes in the second trimester in this small retrospective cohort.