Objective To determine the risk of wound complications by skin incision type in obese women undergoing cesarean delivery. Data sources:Electronic databases (MEDLINE, Scopus, and Ovid) were searched from their inception through August 2018. Methods of study selection:We included all randomized controlled trials and cohort studies reporting the placement of skin incision during cesarean section in obese women, defined as those with BMI >= 30 kg/m(2). Studies were included if they compared one placement of skin incision with a different one as comparison group. The primary outcome was incidence of wound complications, while secondary outcomes included wound infection, hematoma, seroma, postpartum hemorrhage, and endometritis. Demographics and outcomes for each individual study identified were reported as part of the review. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference (MD) or relative risk (RR) with 95% confidence interval (CI). Sub-group analyses (vertical versus Pfannenstiel) were also reported. Tabulation, integration and results:Seventeen studies (including 3 RCTs; 8960 participants among the 15 non-overlapping studies) were included in the systematic review. Vertical incisions were associated with a relative risk of 2.07 (95% CI1.61-2.67) for wound complications compared to transverse incisions, however significant possible confounders were present. Studies were mildly-moderately heterogeneous (I(2)44.81%, 95% CI 0.00-71.85%) with varying definitions of obesity and wound complications. High transverse incisions (3 studies, 218 participants) trend toward a lower risk of wound complications compared to low transverse incisions (RR 0.338, 95% CI 0.114-1.004). Conclusions Vertical incisions may be associated with an increased risk for wound complications compared to transverse incisions for cesarean delivery in obese women. Randomized controlled trials are needed to evaluate optimal cesarean skin incisions for these women.

Recent population-based studies defining the frequency of and risk factors for diabetic ketoacidosis (DKA) in pregnancy are lacking. We aimed to identify sociodemographic and clinical factors associated with DKA in pregnancy. Repeated cross-sectional study with case-control analysis of women in the National Inpatient Sample (2012-Q3 2015) with pregestational diabetes (DM) admitted to the hospital during pregnancy. The primary outcome was DKA (ICD-9 codes 250.1, 250.10, 250.12, 250.13). DKA was compared over time using a test of trend. Demographic, hospital, and clinical characteristics were compared between women with and without DKA using chi-square and student's t-test. Multivariable logistic regression assessed what characteristics were independently associated with DKA. Variables were included in the initial model if p < 0.20 in bivariable analysis and sequentially removed using likelihood ratio testing with p < 0.05 considered significant. Of 44,159 deliveries complicated by pregestational DM, there were 1,263 cases of DKA, or 286 cases per 10,000 DM deliveries. DKA increased from 2012 to 2015 (Figure). In addition to time, factors associated with higher adjusted odds of DKA included non-Hispanic Black (vs White) race, public (vs private) insurance, urban (vs rural) hospital, larger size hospital, anemia, substance use disorder, and antenatal depression (Table). Factors associated with a lower adjusted odds of DKA included older age, Hispanic or other race (vs White), and obesity (Table). Among these, the factors with the strongest associations were obesity (aOR 0.22, 95%CI 0.18-0.28) and time (aOR 3.40, 95%CI 2.67-4.32 for 2013; aOR 3.53, 95%CI 2.78-4.48 for 2014; aOR 3.87, 95%CI 3.03-4.94 for 2015 Q1-3; referent=2012). Hypertension, renal disease and US region were not associated with DKA. In a contemporary, nationwide US sample, DKA increased over time with sociodemographic and clinical disparities. Further investigation is needed to confirm the rise in DKA after 2012 and identify how to address the identified disparities to prevent DKA in the future.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Given the burden of maternal morbidity due to postpartum hemorrhage (PPH), a prediction model is needed. Our objective was to construct and validate models using machine learning that predict a woman's risk of PPH using clinical data available at the time of admission for labor. Estimated blood loss was reported on births from 10 of 12 hospitals in the U.S. Consortium for Safe Labor Study from 2002-2008. PPH was defined as an EBL ≥1000 mL. Fifty-five risk factors were considered. Logistic and lasso regression, random forest, and Extreme Gradient Boosting models were derived to predict PPH. Temporal external validation was performed from the first phase (2002-2006) for model derivation and the second phase (2007-2008) for model validation. Hospital-specific (geographic) and temporal validation were combined by using each hospital once as a validation sample, with the remaining hospitals used for model derivation during the first phase. Model performance was measured by c-statistics, calibration, and decision curves. Of the 152,279 births, 7,279 (4.8%, 95% CI 4.7, 4.9) had a PPH. All models had good to excellent discrimination during temporal validation (c-statistic [95% CI]: logistic regression 0.87 [0.86,0.87], lasso 0.87 [0.86,0.88], random forest 0.92 [0.91,0.92], Extreme Gradient Boosting 0.93 [0.92,0.93]) and hospital with temporal validation (c-statistic: logistic regression 0.87 [0.86,0.87], lasso 0.87 [0.86,0.88], random forest 0.92 [0.91,0.92] and Extreme Gradient Boosting 0.93 [0.92,0.94]). The Extreme Gradient Boosting model (Figure 1) had the best performance across time and hospitals (Figure 2a). All models provided superior net benefit when clinical decision thresholds were between 0 to 80% predicted risk with the boosting model providing the largest net benefit (Figure 2b). These prediction models using machine leaning had excellent discrimination ability to predict PPH. Clinical application of these models could allow providers to be clinically prepared and facilitate triage of women at high-risk of PPH to the appropriate level of maternity care.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Study objective: Our study sought to determine whether or not nitrous oxide analgesia decreases pain compared to oxygen placebo during external cephalic version for breech presentation. Procedural success may be limited by pain and anxiety. Although neuraxial anesthesia has been studied extensively for these procedures, many centers lack resources for routine use. Nitrous oxide is noninvasive, has minimal side effects and requires limited facilities. We hypothesized that its analgesic properties would decrease pain compared to oxygen placebo during external cephalic version. Design: Double-blinded randomized placebo-controlled trial. Setting: Labor and delivery triage room. Patients: Forty-eight patients, >= 18 years of age, 37-weeks' gestation or beyond, singleton pregnancy, breech presentation, and American Society of Anesthesiology physical status I-III, having an external cephalic version. Interventions: Patients undergoing external cephalic version were randomized to receive self-administered 50% nitrous oxide/50% oxygen versus 100% oxygen placebo. Measurements: The primary outcome measured was intra-procedural pain. Secondary outcomes were intraprocedural anxiety, patient satisfaction, and procedure difficulty. Main results: Forty-eight patients were enrolled; 23 received nitrous oxide and 25 received oxygen. No difference was noted in mean pain scores (nitrous oxide 5.5 +/- 2.3, placebo 5.4 +/- 2.7, [CI95% = -1.40, 1.51]; P = 0.943) or anxiety scores (nitrous oxide 1.6 +/- 2.0, placebo 1.2 +/- 1.8, [CI95% = - 0.74, 1.45]; P = 0.515). Procedural difficulty (1-10 scale, 1 = very easy, 10 = extremely difficult) was not different between groups (nitrous oxide 6.1 +/- 2.2, placebo 6.1 +/- 3.2, [CI95% = -1.54, 1.66]; P = 0.944). There was a significant increase in the number of version attempts in the nitrous oxide group (nitrous oxide 3.9 +/- 1.9, placebo 2.8 +/- 1.4, [CI95% = 0.05, 2]; P = 0.046). Patient satisfaction was significantly lower in the nitrous oxide group (nitrous oxide 4.3 +/- 4.0, placebo 6.9 +/- 3.6, [CI95% = -4.93, - 0.34]; P = 0.025). Conclusion: Despite the desirable properties of nitrous oxide, there was no analgesic benefit over oxygen for external cephalic version. Its routine use for these procedures was not supported.

Objective: To investigate the association between maternal obesity as measured by prepregnancy body mass index (BMI) and group B streptococcus (GBS) colonization. Methods: We conducted a secondary analysis from the Consortium on Safe Labor Study (CSL) in the United States cohort study (2002-2008). Pregnant women with deliveries at ≥37 weeks of gestation who attempted labor were included (115,070 assessed deliveries). The association between maternal prepregnancy BMI, categorized as normal weight or below (<25 kg/m2), overweight (25 to <30 kg/m2), class I obesity (30 to <35 kg/m2), class II obesity (35 to <40 kg/m2), and class III obesity (≥40 kg/m2), and GBS colonization was modeled using logistic regression with generalized estimating equations. Models adjusted for maternal age, parity, race, pregestational diabetes, insurance status, study site/region, and year of delivery. Results: The overall prevalence of GBS colonization was 20.5% (23,625/115,070), which increased with rising maternal BMI, normal weight 19.3% (13,543/70,098), overweight 20.8% (5,353/25,733), class I obesity 23.0% (2,596/11,275), class II obesity 26.1% (1,270/4,850), and class III obesity 27.7% (863/3,114). In multivariable analysis, increasing maternal obesity severity was associated with higher odds of GBS colonization, namely overweight (adjusted odds ratio [AOR]: 1.09, 95% confidence interval [CI]: 1.05-1.13), class I obesity (AOR: 1.20, 95% CI: 1.15-1.26), class II obesity (AOR: 1.42, 95% CI: 1.33-1.51), and class III obesity (AOR: 1.50; 95% CI: 1.38-1.62) compared with normal weight. In secondary analyses, these associations persisted when stratified by maternal race. Conclusions: In a national U.S. sample, increasing maternal obesity severity as assessed by prepregnancy BMI was associated with a higher likelihood of maternal GBS colonization during pregnancy.

To assess whether colonization with group B streptococcus (GBS) is associated with chorioamnionitis in an era of routine intrapartum antibiotic prophylaxis.

INTRODUCTION: Uterine tamponade balloons(UTB) reduce the need for invasive procedures in the setting of PPH; but subsequent pregnancy outcomes are unknown. We sought to examine subsequent pregnancy outcomes among women with PPH treated by UTB. METHODS: Retrospective cohort of women with diagnosis of PPH at a tertiary referral center, (1/2010-6/2016). Women with an EBL ≥1000 mL who required use of uterotonic medications, and who had at least one subsequent pregnancy were considered for inclusion. Cases defined as women whose PPH was treated with UTB; the woman immediate preceding and following each case were selected as controls. Simple statistics were used as appropriate. RESULTS: 8 women had a subsequent pregnancy after an index pregnancy requiring UTB, and were matched to 16 controls. During the index pregnancy, cases had lower median prepregnancy BMI (22.4 vs 33.1,p=0.01), but antenatal characteristics were otherwise similar. No difference between the intrapartum characteristics of cases and controls was noted, except that the EBL was higher for cases (2000 vs 1200 mL, p=0.004), and cases were more likely to require transfusion (88% vs 31%,p=0.027). Interpregnancy intervals were similar. In subsequent pregnancy, 75% of the UTB group had documented counseling regarding risk of recurrent PPH, compared with 31% of controls(p=0.082). PPH was similar between groups(38% vs 31%,p>0.99). No woman required UTB, hysterectomy, ICU admission, or had morbidly adherent placenta in subsequent delivery. CONCLUSION: Use of UTB for PPH does not appear to increase risk for recurrent PPH or abnormal placentation. Until larger studies can be performed, this information offers some reassurance regarding the use UTB.

Aims: To develop a predictive model for assessing the risk of developing neonatal respiratory morbidity using lamellar body counts (LBCs) and gestational age (GA) to provide a more patient-specific assessment.Methods: Retrospective cohort study of patients' >= 32 weeks' gestation who received amniocentesis with LBC analysis over a 9-year period. Respiratory morbidity was defined as respiratory distress syndrome, transient tachypnea of the newborn or oxygen requirement for >24 h. Logistic regression analyses were used to predict the absolute risk and odds of respiratory morbidity as a function of GA and lamellar body count.Results: Two hundred and sixty-seven mother-infant pairs included in the analysis with 32 cases (12.0%) of respiratory morbidity. When compared to those without respiratory morbidity, neonates with respiratory morbidity had amniocentesis performed at an earlier median GA, had lower mean birthweight and had lower median LBC (P < 0.01). The GA specific absolute risks and odds ratios for the presence of respiratory morbidity were calculated. The predicted absolute risks of neonatal respiratory morbidity ranged from 38% at 32 weeks to 6% at 40 weeks when LBC were 35,000/mu L.Conclusion: GA specific predicted risk of neonatal respiratory morbidity using LBC provides a statistical model, which can aid clinicians in individually counseling patients regarding the absolute risk of their neonate developing respiratory morbidity.

OBJECTIVE:The purpose of this study was to estimate the association of uterine rupture and previous incision type, either unknown or low transverse, among women who attempt a trial of labor after 1 previous cesarean delivery.STUDY DESIGN:We conducted a secondary analysis of a prospective multicenter observational study of 15,519 women with term singletons who attempted a trial of labor after 1 previous cesarean delivery. Odds ratios for the association between uterine incision location, either unknown or low transverse, and uterine rupture were estimated with the use of multivariable logistic regression.RESULTS:Between 1999 and 2002, 99 of the 15,519 women (0.64%) who attempted a trial of labor after 1 previous cesarean delivery experienced a uterine rupture. Pregnant women with an unknown scar had lower odds of uterine rupture (adjusted odds ratio, 0.71; 95% confidence interval, 0.37-1.37) compared with women with a known low transverse scar. Other adverse maternal outcomes did not differ between the 2 groups of women.CONCLUSION:Among this cohort, women with an unknown uterine incision who attempted a trial of labor were not at increased risk of uterine rupture compared with women with a known low transverse incision.

Both preeclampsia and regional anesthesia can alter placental perfusion, potentially affecting the neonatal status. We hypothesized that the more rapid hypotension induced by spinal anesthesia would decrease placental perfusion and increase short-term neonatal morbidity, compared with epidural or combined spinal-epidural anesthesia (CSE) in women with preeclampsia. We performed a secondary analysis of the Maternal Fetal Medicine Units Network Cesarean registry, a 3-year (1999-2001) observational cohort study. Singleton gestations with a diagnosis of preeclampsia and underwent primary or repeat cesarean delivery with regional anesthetic were included in the analysis. We used logistic regression to adjust for confounding variables when comparing neonatal outcomes between the groups. 4100 patients were included in the analysis. 1696 (41.4%) received a spinal 1848 (45.1%), received an epidural and 556 (13.5%) received a CSE. Gestational age at delivery, maternal age, number of previous cesareans, and indication for cesarean delivery significantly differed between the groups (p< 0.01). Intrapartum characteristics including treatment with magnesium, indication of cesarean delivery, abruption, chorioamnionitis, type of delivery, attempted labor, emergent delivery and interval from incision to delivery also differed between the groups (p≤0.02). With adjustment for these variables, infants were less likely to be admitted to the NICU if the mother received a spinal compared with an epidural or CSE (OR; 95% CI: 0.79; 0.63-0.98, 0.71; 0.53-0.94, respectively) (Table 1). Infants were less likely to have a 5 minute APGAR <7 if mother received a spinal compared with an epidural (OR 0.59; 0.43-0.83) (Table 1). We found no differences in arterial cord pH ≤7.2 (Table 1). Contrary to our hypothesis, we found that spinal anesthesia was associated with reduced short-term neonatal morbidity, compared with epidural or CSE, in a multicenter sample of women with preeclampsia delivering via cesarean.Tabled 1Neonatal outcomes by type of regional anesthesia*Adjusted for maternal age, birthweight, gestational age at delivery, number of prior cesareans, time between incision and delivery, type of delivery, magnesium treatment, race, abruption, attempted labor, chorioamnionitis, emergency delivery and indication for cesarean. Open table in a new tab

ObjectiveUniversal transvaginal cervical length (TVCL) measurement has been recommended by some experts in light of recent evidence supporting interventions to reduce preterm birth in asymptomatic women with a shortened cervix. The sensitivity of transabdominal cervical length (TACL) to detect a shortened cervix remains largely unknown. The purpose of this study was to assess the ability of TACL to detect a TVCL ≤25mm.Study DesignWe performed a prospective evaluation of universal TA and TVCL screening. During a three month period, all women presenting for ultrasound at 16-24 weeks gestation at the UNC Prenatal Diagnostics Unit received both TA and TV cervical length evaluation. A standard protocol for acquisition of TA and TVCL was instituted that included measurement of TACL prior to TVCL. At the end of the three month period, all ultrasounds were reviewed. The shortest TA and TV cervical lengths obtained were used for analysis. The additional time spent acquiring the TVCL was defined as the difference in time between the last TA image and the last TV image.Results686 of 1164 women (58.9%) underwent assessment of both TACL and TVCL. Median TACL and TVCL were 38 mm (IQR 33-32) and 41 mm (IQR 36-47), respectively. Mean difference between TA and TVCL was 3.5 mm (95% CI 2.8-4.1). In our sample, 15 women (2.2%) had a TVCL ≤25 mm, among whom 7 (47%) had a TACL ≤25 mm (Table). 442 women had a TACL ≤40 mm. We found that a TACL ≤40 mm was 100% sensitive (95% CI 79.4-100%) for detection of a transvaginal CL ≤25 mm, with a number needed to screen of 28. The median additional total time required to complete the TVCL was 8.7 minutes (IQR 6.9-10.9). If all women with TACL ≤40mm underwent TVCL assessment, we estimated that it would require 4 hours of additional ultrasound time to detect an additional case of CL ≤25 mm.Tabled 1Transabdominal CL detection of transvaginal CL ≤25mmConclusionTACL ≤40 mm detected all women with a TVCL ≤25 mm in our population. TA evaluation of the cervix may reduce the number of TV scans needed to detect a clinically significant short cervix. ObjectiveUniversal transvaginal cervical length (TVCL) measurement has been recommended by some experts in light of recent evidence supporting interventions to reduce preterm birth in asymptomatic women with a shortened cervix. The sensitivity of transabdominal cervical length (TACL) to detect a shortened cervix remains largely unknown. The purpose of this study was to assess the ability of TACL to detect a TVCL ≤25mm. Universal transvaginal cervical length (TVCL) measurement has been recommended by some experts in light of recent evidence supporting interventions to reduce preterm birth in asymptomatic women with a shortened cervix. The sensitivity of transabdominal cervical length (TACL) to detect a shortened cervix remains largely unknown. The purpose of this study was to assess the ability of TACL to detect a TVCL ≤25mm. Study DesignWe performed a prospective evaluation of universal TA and TVCL screening. During a three month period, all women presenting for ultrasound at 16-24 weeks gestation at the UNC Prenatal Diagnostics Unit received both TA and TV cervical length evaluation. A standard protocol for acquisition of TA and TVCL was instituted that included measurement of TACL prior to TVCL. At the end of the three month period, all ultrasounds were reviewed. The shortest TA and TV cervical lengths obtained were used for analysis. The additional time spent acquiring the TVCL was defined as the difference in time between the last TA image and the last TV image. We performed a prospective evaluation of universal TA and TVCL screening. During a three month period, all women presenting for ultrasound at 16-24 weeks gestation at the UNC Prenatal Diagnostics Unit received both TA and TV cervical length evaluation. A standard protocol for acquisition of TA and TVCL was instituted that included measurement of TACL prior to TVCL. At the end of the three month period, all ultrasounds were reviewed. The shortest TA and TV cervical lengths obtained were used for analysis. The additional time spent acquiring the TVCL was defined as the difference in time between the last TA image and the last TV image. Results686 of 1164 women (58.9%) underwent assessment of both TACL and TVCL. Median TACL and TVCL were 38 mm (IQR 33-32) and 41 mm (IQR 36-47), respectively. Mean difference between TA and TVCL was 3.5 mm (95% CI 2.8-4.1). In our sample, 15 women (2.2%) had a TVCL ≤25 mm, among whom 7 (47%) had a TACL ≤25 mm (Table). 442 women had a TACL ≤40 mm. We found that a TACL ≤40 mm was 100% sensitive (95% CI 79.4-100%) for detection of a transvaginal CL ≤25 mm, with a number needed to screen of 28. The median additional total time required to complete the TVCL was 8.7 minutes (IQR 6.9-10.9). If all women with TACL ≤40mm underwent TVCL assessment, we estimated that it would require 4 hours of additional ultrasound time to detect an additional case of CL ≤25 mm.Tabled 1Transabdominal CL detection of transvaginal CL ≤25mm 686 of 1164 women (58.9%) underwent assessment of both TACL and TVCL. Median TACL and TVCL were 38 mm (IQR 33-32) and 41 mm (IQR 36-47), respectively. Mean difference between TA and TVCL was 3.5 mm (95% CI 2.8-4.1). In our sample, 15 women (2.2%) had a TVCL ≤25 mm, among whom 7 (47%) had a TACL ≤25 mm (Table). 442 women had a TACL ≤40 mm. We found that a TACL ≤40 mm was 100% sensitive (95% CI 79.4-100%) for detection of a transvaginal CL ≤25 mm, with a number needed to screen of 28. The median additional total time required to complete the TVCL was 8.7 minutes (IQR 6.9-10.9). If all women with TACL ≤40mm underwent TVCL assessment, we estimated that it would require 4 hours of additional ultrasound time to detect an additional case of CL ≤25 mm. ConclusionTACL ≤40 mm detected all women with a TVCL ≤25 mm in our population. TA evaluation of the cervix may reduce the number of TV scans needed to detect a clinically significant short cervix. TACL ≤40 mm detected all women with a TVCL ≤25 mm in our population. TA evaluation of the cervix may reduce the number of TV scans needed to detect a clinically significant short cervix.

Clinically useful statistical models have been published to aid clinicians in counseling patients regarding the risk of newborn development of respiratory distress syndrome (RDS) using laboratory assessments of lung maturity by gestational age. However, such models do not exist for milder forms of neonatal respiratory morbidity, such as transient tachypnea of the newborn (TTN) and prolonged oxygen requirement. We aimed to develop a predictive model to assess the risk of developing any neonatal respiratory morbidity using gestational age and lamellar body count (LBC). We performed a retrospective cohort study of patients who received a transabdominal amniocentesis with LBC analysis using the Advia 120 and 2120 hematology analyzers at UNC Hospitals between 2003 and 2012. Exclusion criteria included delivery >72 hours after amniocentesis, major fetal congenital anomaly, gestational age <32 weeks or outcome data not available. Respiratory morbidity was defined as development of RDS, TTN and/or oxygen requirement for greater than 24 hours. A standardized definition was used to define RDS and TTN using clinical laboratory and radiographic findings. Logistic regression was used to predict the probability of neonatal morbidity at each week of gestation based upon the LBC. 267 mother-infant pairs were included in the analysis. The median gestational age at the time of amniocentesis was 37 weeks (IQR 36-38) and the mean birthweight was 3094g (SD ±698). Respiratory morbidity occurred in 32 cases (12%), including 9 cases (3.4%) of RDS, 22 cases (8.2%) of TTN, and 17 cases (6.4%) requiring supplemental oxygen for >24hours. The predicted probability of neonatal respiratory morbidity by gestational age is summarized in Table 1. Gestational age-specific predicted risk of neonatal respiratory morbidity using LBC can aid clinicians in counseling patients regarding the absolute risk of their newborn developing respiratory morbidity.Tabled 1Absolute risk (%) of neonatal respiratory morbidity based on LBC and GA using predicted probabilities Open table in a new tab

Objective To compare the safety and tolerability of metformin to insulin for glycemic control among women with preexisting type 2 and early A2 gestational diabetes.Study Design Women with preexisting type 2 diabetes and those diagnosed with gestational diabetes who required medical management prior to 20 weeks were randomly assigned to metformin or insulin. Glycemic control, defined as >50% capillary blood glucose within target range, was compared between groups. Other outcomes included patient tolerance, neonatal and obstetric complications, maternal weight gain, neonatal cord blood C-peptide, and patient satisfaction with therapy.Results Twenty-eight women completed the study, with 14 in each group. Of the 15 women assigned to metformin, 100% continued to receive metformin until delivery, although 43% required supplemental insulin to achieve glycemic control. Glucose measures did not differ between the groups, and the proportion who met fasting and postprandial glycemic target values did not differ between the groups. Women treated with metformin had significantly fewer subjective episodes of hypoglycemia compared with those using insulin (0% versus 36%; p = 0.04) as well as reported glucose values < 60 mg/dL (7.1% versus 50%; p = 0.03).Conclusion Metformin should be considered for treatment of overt diabetes and early A2 gestational diabetes in pregnancy.

ObjectiveThe Generation R Study Group recently reported a reduced risk of preeclampsia in pregnant women reporting 180-260 mg/day of caffeine intake compared with women reporting <180 mg/day. No studies have measured the association between paraxanthine, the primary caffeine metabolite, and preeclampsia risk. Our objective was to assess the relationship between midgestation maternal serum paraxanthine and the risk of subsequent severe preeclampsia.Study DesignWe conducted a nested case-control study of 33 women carrying singleton gestations with no chronic medical illnesses who subsequently developed severe preeclampsia, matched by age and race to 99 healthy controls. High-performance liquid chromatography was used to measure maternal paraxanthine from banked serum samples drawn at 16-20 weeks gestational age. We used multivariate logistic regression to measure the association between serum paraxanthine and odds of severe preeclampsia.ResultsThe median paraxanthine level in our cohort was 91 ng/mL (IQR 22-206). We identified serum paraxanthine levels above the lower limit of quantification (10 ng/mL) in 25/33 cases (76%) and 88/99 controls (89%), Fishers Exact p=0.08. There was a trend towards lower paraxanthine levels in women who subsequently developed severe preeclampsia as compared to controls (geometric mean 52.46 vs. 83.10) but this did not reach statistical significance (p=0.11). Higher serum paraxanthine was associated with lower odds of severe preeclampsia (OR 0.72, 95% CI 0.48-1.08 per log paraxanthine standard deviation).ConclusionConsistent with previous reports, we found an inverse association between maternal caffeine intake, indexed by serum paraxanthine level, and severe preeclampsia, although our findings did not reach statistical significance. Larger studies are needed to confirm this association. ObjectiveThe Generation R Study Group recently reported a reduced risk of preeclampsia in pregnant women reporting 180-260 mg/day of caffeine intake compared with women reporting <180 mg/day. No studies have measured the association between paraxanthine, the primary caffeine metabolite, and preeclampsia risk. Our objective was to assess the relationship between midgestation maternal serum paraxanthine and the risk of subsequent severe preeclampsia. The Generation R Study Group recently reported a reduced risk of preeclampsia in pregnant women reporting 180-260 mg/day of caffeine intake compared with women reporting <180 mg/day. No studies have measured the association between paraxanthine, the primary caffeine metabolite, and preeclampsia risk. Our objective was to assess the relationship between midgestation maternal serum paraxanthine and the risk of subsequent severe preeclampsia. Study DesignWe conducted a nested case-control study of 33 women carrying singleton gestations with no chronic medical illnesses who subsequently developed severe preeclampsia, matched by age and race to 99 healthy controls. High-performance liquid chromatography was used to measure maternal paraxanthine from banked serum samples drawn at 16-20 weeks gestational age. We used multivariate logistic regression to measure the association between serum paraxanthine and odds of severe preeclampsia. We conducted a nested case-control study of 33 women carrying singleton gestations with no chronic medical illnesses who subsequently developed severe preeclampsia, matched by age and race to 99 healthy controls. High-performance liquid chromatography was used to measure maternal paraxanthine from banked serum samples drawn at 16-20 weeks gestational age. We used multivariate logistic regression to measure the association between serum paraxanthine and odds of severe preeclampsia. ResultsThe median paraxanthine level in our cohort was 91 ng/mL (IQR 22-206). We identified serum paraxanthine levels above the lower limit of quantification (10 ng/mL) in 25/33 cases (76%) and 88/99 controls (89%), Fishers Exact p=0.08. There was a trend towards lower paraxanthine levels in women who subsequently developed severe preeclampsia as compared to controls (geometric mean 52.46 vs. 83.10) but this did not reach statistical significance (p=0.11). Higher serum paraxanthine was associated with lower odds of severe preeclampsia (OR 0.72, 95% CI 0.48-1.08 per log paraxanthine standard deviation). The median paraxanthine level in our cohort was 91 ng/mL (IQR 22-206). We identified serum paraxanthine levels above the lower limit of quantification (10 ng/mL) in 25/33 cases (76%) and 88/99 controls (89%), Fishers Exact p=0.08. There was a trend towards lower paraxanthine levels in women who subsequently developed severe preeclampsia as compared to controls (geometric mean 52.46 vs. 83.10) but this did not reach statistical significance (p=0.11). Higher serum paraxanthine was associated with lower odds of severe preeclampsia (OR 0.72, 95% CI 0.48-1.08 per log paraxanthine standard deviation). ConclusionConsistent with previous reports, we found an inverse association between maternal caffeine intake, indexed by serum paraxanthine level, and severe preeclampsia, although our findings did not reach statistical significance. Larger studies are needed to confirm this association. Consistent with previous reports, we found an inverse association between maternal caffeine intake, indexed by serum paraxanthine level, and severe preeclampsia, although our findings did not reach statistical significance. Larger studies are needed to confirm this association.

Purpose: This study examined carbon dioxide (CO2; 10,600 nm), diode (808 nm), and erbium (Er): yttrium-aluminum-garnet (YAG; 2,940 nm) laser applications on Staphylococcus aureus contaminated, sandblasted, large-grit, acid-etched surface titanium discs and performed a comparative evaluation of the obtained bactericidal effects and the applicability of these effects in clinical practice.Materials and Methods: This study was carried out in 5 main groups: Er: YAG laser in very short pulse (VSP) emission mode, Er: YAG laser in short pulse (SP) emission mode, diode laser with a 320-nm fiber optic diode laser with an R24-B handpiece, and CO2 laser. After laser irradiation, dilutions were spread on sheep blood agar plates and, after an incubation period of 24 hours, colony-forming units were counted and compared with the control group, and the bactericidal activity was assessed in relation to the colony counts.Results: The CO2 laser eliminated 100% of the bacteria at 6 W, 20 Hz, and a 10-ms exposure time/pulse with a 10-second application period (0.8-mm spot size). The continuous-wave diode laser eliminated 97% of the bacteria at 1 W using a 10-second application with a 320-mu m optic fiber, 100% of the bacteria were killed with a 1-W, 10-second continuous-wave application with an R14-B handpiece. The Er: YAG laser eliminated 100% of the bacteria at 90 mJ and 10 Hz using a 10-second application in a superpulse mode (300-ms exposure time/pulse). The Er: YAG laser also eliminated 99% to 100% of the bacteria in VSP mode at 90 mJ and 10 Hz with a 10-second application.Conclusions: The results of this study show that a complete, or near complete, elimination of surface bacteria on titanium surfaces can be accomplished in vitro using a CO2, diode, or Er: YAG laser as long as appropriate parameters are used. (C) 2012 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved. J Oral Maxillofac Surg 70: 1064-1069, 2012

We examined the relationship between type of skin incision at time of cesarean delivery and postoperative wound complications in the obese parturient. Women with a body mass index (BMI) of greater than 29 who had undergone cesarean delivery at The University of North Carolina were identified from the Pregnancy, Infection and Nutrition study. Inpatient and outpatient medical records were reviewed for maternal demographics as well as intrapartum and intraoperative characteristics. The exposure of interest was type of incision, classified as vertical or transverse. The primary outcome was wound complication, defined as partial or complete wound separation. Logistic regression analysis was used to create a final model of risk factors for wound complications while controlling for potentially confounding variables. From 1998 to 2005, 238 women with a BMI greater than 29 who underwent cesarean delivery were identified. Of these 238 women, a vertical skin incision was performed in 25 (11%) and a transverse skin incision in 213 (89%). The overall incidence of wound complications in this group was 13%. BMI was associated with wound complications (p < 0.01). After controlling for confounding factors, no difference in wound complication based on type of skin incision was apparent. The type of skin incision does not appear to be associated with wound complications in the obese parturient; however, larger studies would be needed to confirm this finding. Increased BMI is associated with a higher rate of wound complications.

BACKGROUND Few studies have examined the potential effects of periodontal treatment during pregnancy on pregnancy outcomes, periodontal status, and inflammatory biomarkers. METHODS A randomized, delayed-treatment, controlled pilot trial was conducted to evaluate the effects of second-trimester scaling and root planing and the use of a sonic toothbrush on the rate of preterm delivery (<37 weeks gestation). Secondary outcome measures included changes in periodontal status, levels of eight oral pathogens, levels of gingival crevicular fluid (GCF) interleukin-1beta (IL-1beta), prostaglandin E(2) (PGE(2)), 8-isoprostane (8-iso), and IL-6, and serum levels of IL-6, soluble intercellular adhesion molecule 1 (sICAM1), 8-isoprostane, soluble glycoprotein 130 (sGP130), IL-6 soluble receptor (IL-6sr), and C-reactive protein (CRP). Logistic regression models were used to test for effects of treatment on preterm delivery. Secondary outcomes were analyzed by analysis of covariance adjusting for subject baseline values. RESULTS Periodontal intervention resulted in a significantly decreased incidence odds ratio (OR) for preterm delivery (OR = 0.26; 95% confidence interval = 0.08 to 0.85), adjusting for baseline periodontal status which was unbalanced after randomization. Pregnancy without periodontal treatment was associated with significant increases in probing depths, plaque scores, GCF IL-1beta, and GCF IL-6 levels. Intervention resulted in significant improvements in clinical status (attachment level, probing depth, plaque, gingivitis, and bleeding on probing scores) and significant decreases in levels of Prevotella nigrescens and Prevotella intermedia, serum IL-6sr, and GCF IL-1beta. CONCLUSIONS Results from this pilot study (67 subjects) provide further evidence supporting the potential benefits of periodontal treatment on pregnancy outcomes. Treatment was safe, improved periodontal health, and prevented periodontal disease progression. Preliminary data show a 3.8-fold reduction in the rate of preterm delivery, a decrease in periodontal pathogen load, and a decrease in both GCF IL-1beta and serum markers of IL-6 response. However, further studies will be needed to substantiate these early findings.

ObjectiveTo determine if cervical length affects the impact of antepartum periodontal therapy on preterm birth rate.Study designThis was a randomized controlled pilot study to determine the effect of antepartum periodontal therapy on preterm birth risk among women at high risk for preterm birth (prior spontaneous PTB). Women with periodontal disease identified at dental screening visit <16 weeks were randomized to antepartum periodontal therapy. The antepartum intervention group received periodontal scaling and root planning at 16-20 weeks gestation followed by use of a Sonicare-Plus® power toothbrush with oral health instructions the remainder of the pregnancy. The control group received a manual toothbrush without oral health instructions. At 22 weeks' gestation, participants underwent a transvaginal ultrasound for cervical length measurement. The primary outcome was preterm delivery <37 weeks.ResultsBaseline characteristics including cervical length of the 31 women in the periodontal intervention group and the 32 women in the control group were similar, except for baseline periodontal pockets which were unbalanced after randomization. Among women with a cervical length <30 mm, preterm delivery was similar between the control and intervention groups (50% versus 38%, P=0.66). Compared to women with a cervical length 30 mm, preterm delivery was also similar between the control and intervention groups (41% versus 22%, P=0.17). However, after adjusting for the baseline imbalance in periodontal disease among women with a cervical length 30 mm, periodontal therapy significantly decreased the odds of preterm delivery (OR=0.12; 95% CI 0.02-0.78). For women with cervical length <30 mm the intervention did not reach significance (OR= 0.61; 95% CI 0.09-4.13).ConclusionIn women with periodontal disease at the beginning of pregnancy, periodontal treatment may be more effective in preventing preterm delivery among women with normal cervical length compared to women with shortened cervix. ObjectiveTo determine if cervical length affects the impact of antepartum periodontal therapy on preterm birth rate. To determine if cervical length affects the impact of antepartum periodontal therapy on preterm birth rate. Study designThis was a randomized controlled pilot study to determine the effect of antepartum periodontal therapy on preterm birth risk among women at high risk for preterm birth (prior spontaneous PTB). Women with periodontal disease identified at dental screening visit <16 weeks were randomized to antepartum periodontal therapy. The antepartum intervention group received periodontal scaling and root planning at 16-20 weeks gestation followed by use of a Sonicare-Plus® power toothbrush with oral health instructions the remainder of the pregnancy. The control group received a manual toothbrush without oral health instructions. At 22 weeks' gestation, participants underwent a transvaginal ultrasound for cervical length measurement. The primary outcome was preterm delivery <37 weeks. This was a randomized controlled pilot study to determine the effect of antepartum periodontal therapy on preterm birth risk among women at high risk for preterm birth (prior spontaneous PTB). Women with periodontal disease identified at dental screening visit <16 weeks were randomized to antepartum periodontal therapy. The antepartum intervention group received periodontal scaling and root planning at 16-20 weeks gestation followed by use of a Sonicare-Plus® power toothbrush with oral health instructions the remainder of the pregnancy. The control group received a manual toothbrush without oral health instructions. At 22 weeks' gestation, participants underwent a transvaginal ultrasound for cervical length measurement. The primary outcome was preterm delivery <37 weeks. ResultsBaseline characteristics including cervical length of the 31 women in the periodontal intervention group and the 32 women in the control group were similar, except for baseline periodontal pockets which were unbalanced after randomization. Among women with a cervical length <30 mm, preterm delivery was similar between the control and intervention groups (50% versus 38%, P=0.66). Compared to women with a cervical length 30 mm, preterm delivery was also similar between the control and intervention groups (41% versus 22%, P=0.17). However, after adjusting for the baseline imbalance in periodontal disease among women with a cervical length 30 mm, periodontal therapy significantly decreased the odds of preterm delivery (OR=0.12; 95% CI 0.02-0.78). For women with cervical length <30 mm the intervention did not reach significance (OR= 0.61; 95% CI 0.09-4.13). Baseline characteristics including cervical length of the 31 women in the periodontal intervention group and the 32 women in the control group were similar, except for baseline periodontal pockets which were unbalanced after randomization. Among women with a cervical length <30 mm, preterm delivery was similar between the control and intervention groups (50% versus 38%, P=0.66). Compared to women with a cervical length 30 mm, preterm delivery was also similar between the control and intervention groups (41% versus 22%, P=0.17). However, after adjusting for the baseline imbalance in periodontal disease among women with a cervical length 30 mm, periodontal therapy significantly decreased the odds of preterm delivery (OR=0.12; 95% CI 0.02-0.78). For women with cervical length <30 mm the intervention did not reach significance (OR= 0.61; 95% CI 0.09-4.13). ConclusionIn women with periodontal disease at the beginning of pregnancy, periodontal treatment may be more effective in preventing preterm delivery among women with normal cervical length compared to women with shortened cervix. In women with periodontal disease at the beginning of pregnancy, periodontal treatment may be more effective in preventing preterm delivery among women with normal cervical length compared to women with shortened cervix.

VAGINAL BLEEDING BETWEEN 20-37 WEEKS GESTATION? MICHAEL WHITE, THOMAS TREVETT JR, WATSON BOWES, ROBERT STRAUSS, University of North Carolina at Chapel Hill, Obstetrics and Gynecology, Chapel Hill, North Carolina OBJECTIVE: To determine whether white blood cell count (WBC) is predictive of preterm delivery (PTD) in women admitted with vaginal bleeding between 20-37 weeks. STUDY DESIGN: This was a retrospective cohort study of all women who were admitted to the University of North Carolina Hospitals with documented vaginal bleeding from 20-37 weeks gestation from 1996 to 2003. Women were excluded if there was evidence of placenta previa or preterm rupture of membranes. Potential risk factors for preterm delivery were extracted from the medical records. Clinical and laboratory factors were assessed at time of presentation. A multivariable logistic regression analysis was used to create odds ratios (OR) and 95% confidence intervals (CI). RESULTS: 105 patients met inclusion criteria for analysis. The risk of PTD in this cohort before 32 and 37 weeks gestation was 32 and 82%, respectively. History of preterm delivery and tobacco use in pregnancy were included in the final model although these variables did not prove to be significant. Predictors of preterm birth included race, white blood cell count, hematocrit, and systolic blood pressure. After controlling for possible confounding variables, for each 1unit increase in WBC, the risk of delivery prior to 37 weeks increased by an OR of 1.32 (95% CI 1.06-1.69). CONCLUSION: Women presenting with unexplained vaginal bleeding who have elevated WBC at initial evaluation are at increased risk of preterm delivery.

To determine whether there is an association between the severity of polyhydramnios and perinatal outcome. This was a retrospective study of all patients delivered at this institution between January 1996 and February 2004 who were given the diagnosis of polyhydramnios. Polyhydramnios was defined as amniotic fluid index (AFI) greater than 24 cm. Polyhydramnios was categorized into groups by severity: mild (AFI 25-29 cm), moderate (AFI 30-34 cm), and severe (AFI >35 cm). Outcome variables included preterm birth, preterm premature rupture of membranes, route of delivery, Apgar score at 5 minutes of <7, neonatal intensive care unit (NICU) admission, and perinatal death. Multivariable regression was used to create odds ratios (OR) and 95% confidence intervals (CI) to compare the groups. Seventy-four patients with singleton pregnancies and polyhydramnios were included in our analysis. Severe polyhydramnios was associated with Apgar scores at 5 minutes of <7 with an OR of 3.7 (95% CI: 1.2, 11.4). The presence of an anomaly detected by ultrasound in patients with polyhydramnios was associated with perinatal death with an OR of 7.44 (95% CI: 1.56, 35.46). All categories of severity of polyhydramnios had an increased rate of preterm birth with an overall rate of 79%. There was a trend toward increased rate of preterm birth in patients with severe polyhydramnios, however this was not statistically significant. Sixty-eight percent of the infants required NICU admission. Regardless of severity, polyhydramnios is a substantial risk factor for preterm birth and NICU admission. Consideration should be given to similar antepartum management for mild and severe polyhydramnios. Patients with both polyhydramnios and ultrasound detected anomalies should be counseled regarding their high risk for perinatal mortality.