Biomedical subjects

John C Hauth

Publications and source records attributed to John C Hauth.

At least 19 recordsLinked to original sources

PubMed2006

The Alabama Preterm Birth Project: placental histology in recurrent spontaneous and indicated preterm birth.

OBJECTIVE: For unknown reasons, a previous preterm birth (PTB) is a major risk factor for PTB in the current pregnancy. Our goal is to evaluate placental histology for clues related to the recurrent nature of PTB. STUDY DESIGN: Four hundred fifty-seven mother/infant dyads delivering between 23 and 32 weeks were first classified as having a spontaneous (S) or indicated (I) PTB, and then sorted into the following mutually exclusive categories by pregnancy history: 1) nulliparous; 2) having no previous PTB; 3) having any previous IPTB; or 4) having a previous SPTB. The placentas were evaluated for acute inflammation in the free membranes, umbilical cord, and chorionic plate, chronic inflammation in the membranes and decidua basalis, thrombosis in the chorionic plate and umbilical cord, and diffuse decidual leukocytoclastic necrosis (DDLN), a lesion associated with decreased placental perfusion. RESULTS: Women who had a SPTB were far more likely (85.5 vs 14.4 P < .0001) to have a SPTB in the previous pregnancy, while women with an IPTB were significantly more likely to have had a previous IPTB (89.7 vs 10.3 P < .0001). Nulliparas and women with previous term births each had about 64% SPTB and 36% IPTB. Acute inflammation at any site was present in 73.9% of SPTB versus 8.0% of IPTB (P < .0001). Chorionic plate thrombosis was also more common in SPTB than IPTB (16.2 vs 7.6, P = .01). Chronic inflammation at any site was more common in IPTB than SPTB (21.0 vs 12.7%, P = .02), as was DDLN (46.5 vs 16.1, P < .0001). When classified by SPTB and IPTB in the current pregnancy, the histologic results were not further influenced by the previous pregnancy history. CONCLUSION: SPTB and IPTB are strongly repetitive. Women with SPTB are significantly more likely to have acute inflammation in the free membranes, chorionic plate, and cord, and chorionic plate thrombosis, while women with an IPTB are significantly more likely to have chronic inflammation and especially DDLN. Past obstetric history does not further influence the placental histology.

Alabama↗

PubMed2006

The Alabama Preterm Birth Study: intrauterine infection and placental histologic findings in preterm births of males and females less than 32 weeks.

OBJECTIVE: The objective of the study was to determine whether there are differences in the placental histology and various markers of infection/inflammation between preterm male and female fetuses. STUDY DESIGN: The placentas and umbilical cords of 446 infants born at 23 to 32 weeks were examined histologically, cultured for aerobic and anaerobic bacteria and mycoplasmas, and the interleukin-6 levels in cord blood determined. RESULTS: Male infants were significantly more likely to have positive placental cultures than female infants (63.4% versus 51.8%, P = .01, odds ratio 1.5, 1.0 to 2.4). Cord blood Mycoplasma hominis and Ureaplasma urealyticum infections were marginally more common in male than female fetuses (27.6% versus 19.2%, P = .06, odds ratio 1.7, 0.9 to 2.9), but cord blood interleukin-6 levels were not different between male and female fetuses. The only significant histologic difference between male and female placentas was in decidual lymphoplasmacytic cell infiltration (6.3% versus 0.9%, P = .003, odds ratio 8.3, 1.8 to 39.0). Males had a higher percentage of decidual lymphohistiocytic cell infiltration, but the differences were not significant (11.3% versus 7.4%, P = .160, odds ratio 1.6, 0.8 to 3.2). CONCLUSION: Male infants were significantly more likely to have positive placental membrane cultures than female infants. Decidual lymphoplasmacytic cell infiltrations were more common in male versus female placentas, confirming a previous observation and suggesting that a maternal immune reaction to fetal tissue may be more common in male fetuses.

Alabama↗

PubMed2006

Association of asymptomatic bacterial vaginosis with endometrial microbial colonization and plasma cell endometritis in nonpregnant women.

OBJECTIVE: This study was undertaken to determine whether asymptomatic bacterial vaginosis (BV) is associated with an increased risk of endometrial microbial colonization or plasma cell endometritis in nonpregnant women. STUDY DESIGN: In this observational cohort study conducted between August 1995 and August 2001, microbial cultures (n = 769) and histopathology (n = 482) were performed on endometrial specimens obtained from women with a recent preterm or term delivery (83 +/- 16 days). Endometritis was defined as the presence of plasma cells. BV was defined using Amsel and Nugent criteria. RESULTS: The study population was 71% black, 29% white, 69% single, and 31% had 12 years or more of education. Endometrial cultures were positive for at least 1 microorganism in 83% (n = 637/769) of the women and plasma cell endometritis was present in 39% (n = 190/482). BV was present in 26% (n = 191/722) by Amsel and 38% (n = 289/769) by Nugent criteria. Women with Nugent-BV (RR [relative risk] = 1.12, 95% CI 1.05-1.19) but not Amsel-BV (RR = 1.06, 95% CI 1.00-1.13) were significantly more likely to have a positive endometrial culture. A consistent and significant association was observed between BV (by Amsel or Nugent criteria) and an increased frequency of endometrial colonization with BV-associated microorganisms grouped and defined in various ways (RR ranged from 1.96-4.22). No association between BV and plasma cell endometritis was observed. CONCLUSION: Asymptomatic BV is associated with a modest increased likelihood of endometrial microbial colonization and colonization by BV-associated bacteria but is not associated with plasma cell endometritis in nonpregnant women.

Adult↗

PubMed2006

Midpregnancy genitourinary tract infection with Chlamydia trachomatis: association with subsequent preterm delivery in women with bacterial vaginosis and Trichomonas vaginalis.

OBJECTIVE: The objective of the study was to estimate whether midpregnancy genitourinary tract infection with Chlamydia trachomatis is associated with an increased risk of subsequent preterm delivery. STUDY DESIGN: Infection with C. trachomatis was determined using a ligase chain reaction assay (performed in batch after delivery) of voided urine samples collected at the randomization visit (16(0/7) to 23(6/7) weeks' gestation) and the follow-up visit (24(0/7) to 29(6/7) weeks) among 2470 gravide women with bacterial vaginosis or Trichomonas vaginalis infection enrolled in 2 multicenter randomized antibiotic treatment trials (metronidazole versus. placebo). RESULTS: The overall prevalence of genitourinary tract C. trachomatis infection at both visits was 10%. Preterm delivery less than 37 weeks' or less than 35 weeks' gestational age was not associated with the presence or absence of C. trachomatis infection at either the randomization (less than 37 weeks: 14% versus 13%, P=.58; less than 35 weeks: 6.4% versus 5.5%, P=.55) or the follow-up visit (less than 37 weeks: 13% versus 11%, P=.33; less than 35 weeks: 4.4% versus 3.7, P=.62). Treatment with an antibiotic effective against chlamydia infection was not associated with a statistically significant difference in preterm delivery. CONCLUSION: In this secondary analysis, midtrimester chlamydia infection was not associated with an increased risk of preterm birth. Treatment of chlamydia was not associated with a decreased frequency of preterm birth.

Anti-Bacterial Agents↗

PubMed2006

Interconceptional antibiotics to prevent spontaneous preterm birth: a randomized clinical trial.

OBJECTIVE: We hypothesized that upper genital tract microbial infection associated with spontaneous preterm birth may precede conception. Our objective was to estimate if antibiotic administration during the interpregnancy interval in nonpregnant women with a previous preterm birth before 34 weeks' gestational age would reduce the rate of spontaneous preterm birth in the subsequent pregnancy. STUDY DESIGN: Women with a spontaneous preterm birth < 34 weeks' gestational age were randomized at 4 months' postpartum to receive oral azithromycin 1 g twice (4 days apart) plus sustained-release metronidazole 750 mg daily for 7 days, or identical-appearing placebos. This regimen was repeated every 4 months until the subsequent pregnancy. RESULTS: A total of 241 women were randomized; 124 conceived a subsequent pregnancy and were available for study, including 59 in the antibiotic group and 65 in the placebo group. In the antibiotic versus placebo group, neither subsequent spontaneous preterm birth (< 37 weeks: 52% vs 46%, P = .568; < 35 weeks: 40% vs 30%, P = .276; < 32 weeks: 31% vs 23%, P = .376) nor miscarriage (< 15 weeks: 12% vs 14%, P = .742) was significantly different. Although not statistically significant, mean delivery gestational age in the subsequent pregnancy was 2.4 weeks earlier in the antibiotic versus placebo group (32.0 +/- 7.9 vs 34.4 +/- 6.3 weeks, P = .082), and mean birth weight was lower in the antibiotic group (2046 +/- 1209 vs 2464 +/- 1067 g, P =.060). CONCLUSION: Intermittent treatment with metronidazole plus azithromycin of nonpregnant women with a recent early spontaneous preterm birth does not significantly reduce subsequent preterm birth, and may be associated with a lower delivery gestational age and lower birth weight.

Adult↗

PubMed2006

The Alabama preterm birth study: corticosteroids and neonatal outcomes in 23- to 32-week newborns with various markers of intrauterine infection.

OBJECTIVE: Intrauterine inflammation/infection is cited as a contraindication to the use of corticosteroids (CS). Our goal was to determine if CS given prenatally to enhance fetal maturity were harmful to infants with various indications of intrauterine infection. STUDY DESIGN: This was a retrospective analysis of data obtained from 457 consecutively enrolled infants delivered between 23 and 32 weeks. Cultures and a histologic examination of the placenta, and cord blood interleukin (IL)-6 levels were obtained. Neonatal outcomes included periventricular leukomalacia (PVL), intraventricular hemorrhage (IVH), respiratory distress syndrome (RDS), chronic lung disease (CLD), necrotizing enterocolitis (NEC), systemic inflammatory response syndrome (SIRS), and infant death. RESULTS: Of the 457 pregnancies, 57.6% had a positive placental culture, 49.8% had histologic chorioamnionitis/funisitis, 28.8% had elevated cord IL-6 levels, and 12.5% had clinical chorioamnionitis. With intrauterine infection/inflammation, none of the neonatal outcomes were significantly worse if mothers were treated with CS. For those with histologic chorioamnionitis/funisitis, of the outcomes historically improved with CS, RDS (59.9 vs 72.2% P = .16), IVH (9.7 vs 14.7% P = .38), and neonatal death (9.9 vs 11.1% P = .82) all occurred less frequently with CS treatment, but differences were not significant. Similar results were seen for women with a positive placental culture. For women with an elevated IL-6, RDS was significantly reduced (59.4 vs 84.2 %, P = .045). Neonatal SIRS was significantly reduced with CS in women with histologic chorioamnionitis/funisitis (39.7 vs 65.7%, P = .005), positive placental cultures (32.7 vs 56.3%, P = .01), and elevated IL-6 levels (42.7 vs 73.7%, P = .02). CONCLUSION: In women with intrauterine infection/inflammation, CS use was not associated with significant worsening in any neonatal outcome, and was associated with significant reductions in RDS and SIRS. These data suggest that CS use may not be contraindicated in the presence of intrauterine inflammation/infection.

Adrenal Cortex Hormones↗

PubMed2006

The Alabama Preterm Birth study: polymorphonuclear and mononuclear cell placental infiltrations, other markers of inflammation, and outcomes in 23- to 32-week preterm newborn infants.

OBJECTIVE: The purpose of this study was to better understand the relationship between placental polymorphonuclear and mononuclear cell infiltrations with bacterial cultures, markers of inflammation, and preterm outcomes. STUDY DESIGN: This was a prospective study in 446 women who were delivered of a singleton infant at <32 weeks of gestational age. Five placental sites were categorized as having polymorphonuclear or mononuclear infiltrations. Results were compared with placental and cord cultures, umbilical cord interleukin-6 levels, and neonatal outcomes. RESULTS: Polymorphonuclear, but not mononuclear, cell infiltrations were more common at the earliest gestational ages and in black women (56.0% vs 39.3%; P < .01). Polymorphonuclear infiltration was associated with spontaneous preterm birth (73.9% vs 8.0%; P < .0001), but not with preeclampsia (9.9% vs 34%; P < .0001). Women with positive cultures, high interleukin-6 levels, and clinical chorioamnionitis all had significantly more polymorphonuclear infiltrations than did women without those conditions (all probability values, <.0001). In all sites, polymorphonuclear infiltration was associated with neonatal systemic inflammatory response syndrome (P < .0001) and in the cord with necrotizing enterocolitis (22.4% vs 13.5%; P = .02). Intraventricular hemorrhage and neonatal death were not associated with polymorphonuclear infiltration. Polymorphonuclear infiltration at all sites was associated with less respiratory distress syndrome (P < .01). Mononuclear cell infiltration, when present in the decidua basalis, was associated with an increase in neonatal intraventricular hemorrhage (23.8% vs 7.4%; P < .0004). Plasmacytic infiltrates were associated with increased intraventricular hemorrhage (29.4% vs 8.3%; P = .01) and neonatal death (27.8% vs 9.2%; P = .02). CONCLUSION: Polymorphonuclear infiltrations of the free membranes, chorionic plate, and umbilical cord were associated with positive intrauterine cultures and elevated cord blood interleukin-6. There was also an association with systemic inflammatory response syndrome and necrotizing enterocolitis, but not with intraventricular hemorrhage or death, and with decreased respiratory distress syndrome. Decidual mononuclear cell infiltration was associated with an increased risk of intraventricular hemorrhage and decidual plasma cell infiltration with increased intraventricular hemorrhage and neonatal death.

Black or African American↗

PubMed2006

Spontaneous preterm labor and premature rupture of membranes at late preterm gestations: to deliver or not to deliver.

Nationwide the American College of Obstetricians and Gynecologists noted in 1995 that the survival rate for newborns at 34 weeks is within 1% of those born at or beyond 37 weeks. Newborn major morbidity is slightly but significantly increased from 34(0) to 36(6) compared with 37 or greater weeks. These data form the basis for and reflect the perinatal outcomes associated with the standardized obstetric practices of effecting delivery for women with amnion rupture and also of not attempting tocolysis for preterm labor at or beyond 34(0) weeks gestation. Pragmatically, a prospective randomized management trial of women at late preterm gestation (34(0) to 36(6)) and with spontaneous preterm labor or amnion rupture would require multi-institutional support to achieve a required study population.

Female↗

PubMed2006

Association of obesity with pulmonary and nonpulmonary complications of pregnancy in asthmatic women.

OBJECTIVE: To evaluate whether maternal obesity is associated with pulmonary and nonpulmonary pregnancy complications in asthmatic women. METHODS: This is a secondary analysis of the prospective cohort Asthma During Pregnancy Study. Asthma patients were classified as having either mild or moderate to severe disease at the beginning of the study. Rates of pulmonary complications of asthma in asthmatic women and rates of nonpulmonary complications of pregnancy among asthma patients and controls, were compared between obese (body mass index > or = 30 kg/m2) and nonobese women. RESULTS: Maternal body mass index and pregnancy outcome data were available for 1,699 of 1,812 asthmatic women and for 867 of 881 controls. Of the asthma subjects, 30.7% (521) were obese compared with 25.5% of the controls, P = .006. Obese women, regardless of whether they had asthma, were more likely to undergo cesarean delivery (OR 1.6, 95% confidence interval [CI]1.3-2.0) to develop preeclampsia or gestational hypertension (OR 1.7 95% CI 1.3-2.3) and gestational diabetes (OR 4.2, 95% CI 2.8-6.3). There were no differences in the rates of overall asthma improvement (20.6% compared with 23.6%, P = .36) or deterioration (33.3% compared with 28.8%, P = .20) between obese and nonobese asthma patients. After adjustment for confounding variables, obesity, not asthma, was associated with nonpulmonary complications of pregnancy, and obesity was associated with an increase in asthma exacerbations as well (OR 1.3, 95% CI 1.1-1.7). CONCLUSION: Obesity is associated with an increased risk of asthma exacerbations during pregnancy. The increased rate of nonpulmonary complications of pregnancy in asthma patients is associated with obesity in this population and not with asthma status. LEVEL OF EVIDENCE: II-1.

Adult↗

PubMed2006

Trial of labor or repeat cesarean delivery in women with morbid obesity and previous cesarean delivery.

OBJECTIVE: Assess effects of body mass index (BMI) on trial of labor after previous cesarean delivery and determine whether morbidly obese women have greater maternal and perinatal morbidity with trial of labor compared with elective repeat cesarean delivery. METHODS: Secondary analysis from a prospective observational study included all term singletons undergoing trial of labor after previous cesarean delivery. Body mass index groups were as follows: normal 18.5-24.9, overweight 25.0-29.9, obese 30.0-39.9, morbidly obese 40.0 kg/m2 or greater, and were compared for failure and maternal and neonatal morbidities. The morbidly obese trial of labor and elective repeat cesarean delivery were compared for maternal and neonatal morbidities. Multivariable logistic regression analysis controlled for confounding variables. RESULTS: There were 14,142 trial of labor participants and 14,304 elective repeat cesarean delivery participants. Increasing BMI was directly associated with failed trial of labor after previous cesarean delivery: from 15.2% in normal weight (1,344) to 39.3% in morbidly obese (1,638), with combined risk of rupture/dehiscence increasing from 0.9% to 2.1% in morbidly obese women. Among morbidly obese women, trial of labor carried greater than five-fold risk of uterine rupture/dehiscence (2.1% versus 0.4%), almost a two-fold increase in composite maternal morbidity (7.2% versus 3.8%) and five-fold risk of neonatal injury (1.1% versus 0.2%) (fractures, brachial plexus injuries, and lacerations), but no neonatal encephalopathy. Morbidly obese women failing a trial of labor had six-fold greater composite maternal morbidity than those undergoing a successful trial of labor (14.2% versus 2.6%). CONCLUSION: Body mass index correlates with outcomes in trial of labor after previous cesarean delivery. Morbidly obese women undergoing a trial of labor were at increased risk for failure. Increased BMI was associated with greater composite morbidity and neonatal injury compared with elective repeat cesarean delivery, but absolute morbidities were small. Increased risks should be considered before trial of labor after previous cesarean delivery. LEVEL OF EVIDENCE: II-2.

Adult↗

PubMed2006

Decision-to-incision times and maternal and infant outcomes.

OBJECTIVE: To measure decision-to-incision intervals and related maternal and neonatal outcomes in a cohort of women undergoing emergency cesarean deliveries at multiple university-based hospitals comprising the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. METHODS: All women undergoing a primary cesarean delivery at a Network center during a 2-year time span were prospectively ascertained. Emergency procedures were defined as those performed for umbilical cord prolapse, placental abruption, placenta previa with hemorrhage, nonreassuring fetal heart rate pattern, or uterine rupture. Detailed information regarding maternal and neonatal outcomes, including the interval from the decision time to perform cesarean delivery to the actual skin incision, was collected. RESULTS: Of the 11,481 primary cesarean deliveries, 2,808 were performed for an emergency indication. Of these, 1,814 (65%) began within 30 minutes of the decision to operate. Maternal complication rates, including endometritis, wound infection, and operative injury, were not related to the decision-to-incision interval. Measures of newborn compromise including umbilical artery pH less than 7 and intubation in the delivery room were significantly greater when the cesarean delivery was commenced within 30 minutes, likely attesting to the need for expedited delivery. Of the infants with indications for an emergency cesarean delivery who were delivered more than 30 minutes after the decision to operate, 95% did not experience a measure of newborn compromise. CONCLUSION: Approximately one third of primary cesarean deliveries performed for emergency indications are commenced more than 30 minutes after the decision to operate, and the majority were for nonreassuring heart rate tracings. In these cases, adverse neonatal outcomes were not increased. LEVEL OF EVIDENCE: II-2.

Adolescent↗

PubMed2006

Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery.

OBJECTIVE: To determine whether the risk for uterine rupture is increased in women attempting vaginal birth after multiple cesarean deliveries. METHODS: We conducted a prospective multicenter observational study of women with prior cesarean delivery undergoing trial of labor and elective repeat operation. Maternal and perinatal outcomes were compared among women attempting vaginal birth after multiple cesarean deliveries and those with a single prior cesarean delivery. We also compared outcomes for women with multiple prior cesarean deliveries undergoing trial of labor with those electing repeat cesarean delivery. RESULTS: Uterine rupture occurred in 9 of 975 (0.9%) women with multiple prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior operation (P = .37). Multivariable analysis confirmed that multiple prior cesarean delivery was not associated with an increased risk for uterine rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and transfusion (3.2% versus 1.6%, P < .001) were increased in women with multiple prior cesarean deliveries compared with women with a single prior cesarean delivery attempting trial of labor. Similarly, a composite of maternal morbidity was increased in women with multiple prior cesarean deliveries undergoing trial of labor compared with those having elective repeat cesarean delivery (odds ratio 1.41, 95% confidence interval 1.02-1.93). CONCLUSION: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women. LEVEL OF EVIDENCE: II-2.

Adult↗

PubMed2005

Is bacterial vaginosis a stronger risk factor for preterm birth when it is diagnosed earlier in gestation?

OBJECTIVE: It is stated commonly that the earlier in pregnancy bacterial vaginosis is diagnosed, the greater is the increase in risk of preterm birth compared with women without bacterial vaginosis. However, this contention is based on small numbers of women. STUDY DESIGN: In this analysis of 12,937 women who were screened for bacterial vaginosis as part of a previously conducted clinical trial, the odds ratio of preterm birth (<7 weeks of gestation) for asymptomatic bacterial vaginosis-positive versus bacterial vaginosis-negative women was evaluated among women who were screened from 8 to 22 weeks of gestation. RESULTS: The odds ratio of preterm birth among bacterial vaginosis-positive versus bacterial vaginosis-negative women ranged from 1.1 to 1.6 and did not vary significantly according to the gestational age at which bacterial vaginosis was screened. The odds ratio for preterm birth did not vary significantly by gestational age at diagnosis when bacterial vaginosis was subdivided into Gram stain score 7 to 8 or 9 to 10. CONCLUSION: Although bacterial vaginosis was associated with an increased risk of preterm birth, the gestational age at which bacterial vaginosis was screened for and diagnosed did not influence the increase.

Female↗

PubMed2005

Endometrial microbial colonization and plasma cell endometritis after spontaneous or indicated preterm versus term delivery.

OBJECTIVE: This study was undertaken to determine whether endometrial microbial colonization or plasma cell endometritis is increased after spontaneous versus indicated preterm delivery or a spontaneous term delivery. STUDY DESIGN: Postpartum, endometrial specimens were obtained after a spontaneous (mean 83, +/- 17.6 days) or indicated (mean 83, +/- 16.7 days) preterm delivery before 34 weeks' gestation and after a spontaneous term delivery (mean 82, +/- 15.7 days; P=.980). Cultures for aerobic and anaerobic bacteria, Trichomonas vaginalis, and genital mycoplasmas were performed. Histologic endometritis was defined as the presence of plasma cells. RESULTS: The study population (n=820) was 71% black, 29% white, 69% unmarried, and 31% had less than 12 years of education. Endometrial cultures were positive for at least 1 microorganism in 82% of the women. No significant difference in positive endometrial cultures were observed among women after a spontaneous versus an indicated preterm delivery (85% vs 79%, P=.102), or a spontaneous preterm versus a spontaneous term delivery (85% vs 81%, P=.123). Plasma cell endometritis was present in 39% of 506 specimens sufficient for histologic examination and was also similar in the three groups (P=.160). CONCLUSION: Microbial colonization of the endometrium and plasma cell endometritis are similar 3 months after spontaneous or indicated preterm or term births. Therefore, chronic infection and inflammation of the endometrium (documented at 3 months postpartum) do not appear to be risk factors for subsequent delivery in women with a prior spontaneous delivery less than 34 weeks' gestation.

Cervix Uteri↗

PubMed2005

The Maternal-Fetal Medicine Unit cesarean registry: trial of labor with a twin gestation.

OBJECTIVE: The purpose of this study was to identify the success rates and risks in women with a twin pregnancy who attempt a trial of labor after cesarean delivery. STUDY DESIGN: Cases were identified in the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network's Cesarean Registry with a woman with a twin pregnancy who had had at least 1 previous cesarean delivery. RESULTS: During the study period (1999-2002), 412 women fulfilled the study criteria, and 226 women had elective repeat cesarean delivery. Of the 186 women (45.1% of total) who attempted a trial of labor, 120 women were delivered successfully (success rate, 64.5%), and 66 women (35.5%) had a failed trial of labor. Thirty of the failed trials of labor involved a vaginal delivery for twin A and cesarean delivery for twin B. Women who attempted a trial of labor with twins had no increased risk of transfusion, endometritis, intensive care unit admissions, or uterine rupture when compared with elective repeat cesarean delivery. Fetal and neonatal complications were uncommon in either group at>or=34 weeks of gestation. CONCLUSION: A trial of labor with twins after previous cesarean delivery does not appear to increase maternal morbidity. Perinatal morbidity is uncommon at>or=34 weeks of gestation.

Adult↗

PubMed2005

The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery.

OBJECTIVE: The purpose of this study was to determine which factors influence the likelihood of successful trial of labor (TOL) after 1 previous cesarean delivery (CD). STUDY DESIGN: We performed a multicenter 4-year prospective observational study (1999-2002) of all women with previous CD undergoing TOL. Women with term singleton pregnancies with 1 previous low transverse CD or unknown incision were included for analysis. RESULTS: Fourteen thousand five hundred twenty-nine women underwent TOL, with 10,690 (73.6%) achieving successful VBAC. Women with previous vaginal birth had an 86.6% success rate compared with 60.9% in women without such a history (odds ratio [OR] 4.2; 95% CI 3.8-4.5; P < .001). TOL success rates were affected by previous indication for CD, need for induction or augmentation, cervical dilation on admission, birth weight, race, and maternal body mass index. Multivariate logistic regression analysis identified as predictive of TOL success: previous vaginal delivery (OR 3.9; 95% CI 3.6-4.3), previous indication not being dystocia (CPD/FTP) (OR 1.7; 95% CI 1.5-1.8), spontaneous labor (OR 1.6; 95% CI 1.5-1.8), birth weight <4000 g (OR 2.0; 95% CI 1.8-2.3), and Caucasian race (OR 1.8, 95% CI 1.6-1.9) (all P < .001). The overall TOL success rate in obese women (BMI > or = 30) was lower (68.4%) than in nonobese women (79.6%) (P < .001), and when combined with induction and lack of previous vaginal delivery, successful VBAC occurred in only 44.2% of cases. CONCLUSION: Previous vaginal delivery including previous VBAC is the greatest predictor for successful TOL. Previous indication as dystocia, need for labor induction, or a maternal BMI > or = 30 significantly lowers success rates.

Adult↗

PubMed2005

Progesterone for prevention of recurrent preterm birth: impact of gestational age at previous delivery.

OBJECTIVE: Preterm birth occurs in 1 of 8 pregnancies and may result in significant morbidity and mortality. 17-alpha hydroxyprogesterone caproate (17-OHP caproate) has been found to be efficacious in reducing the risk of subsequent preterm delivery in women who have had a previous spontaneous preterm birth (sPTB). This analysis was undertaken to evaluate if 17-OHP caproate therapy works preferentially depending on the gestational age at previous spontaneous delivery. We hypothesized that treatment with 17-OHP caproate is more effective in prolonging pregnancy depending on the gestational age of the earliest previous preterm birth (20-27.9, 28-33.9 vs 34-36.9 weeks). STUDY DESIGN: This was a secondary analysis of 459 women with a previous sPTB enrolled in a randomized controlled trial evaluating 17-OHP caproate versus placebo. Effectiveness of 17-OHP caproate for pregnancy prolongation was evaluated based on gestational age at earliest previous delivery according to clinically relevant groupings (20-27.9, 28-33.9, and 34-36.9 weeks). Statistical analysis included the chi-square, Fisher exact, and Kruskal-Wallis tests, logistic regression, and survival analysis using proportional hazards. RESULTS: Gestational age at earliest previous delivery was similar between women treated with 17-OHP caproate or placebo (P = .1). Women with earliest delivery at 20 to 27.9 weeks and at 28 to 33.9 weeks delivered at significantly more advanced gestational age if treated with 17-OHP caproate than with placebo (median 37.3 vs 35.4 weeks, P = .046 and 38.0 vs 36.7 weeks, P = .004, respectively) and were less likely to deliver <37 weeks (42% vs 63%, P = .026 and 34% vs 56%, P = .005, respectively). Those with earliest delivery at 34 to 36.9 weeks were not significantly different between 17-OHP caproate or control. CONCLUSION: 17-OHP caproate therapy given to prevent recurrent PTB is associated with a prolongation of pregnancy overall, and especially for women with a previous spontaneous PTB at <34 weeks.

17-alpha-Hydroxyprogesterone↗

PubMed2005

Use of vaginal polymorphonuclear to epithelial cell ratios for the prediction of preterm birth.

OBJECTIVE: To compare the use of midtrimester vaginal polymorphonuclear cell (PMN) counts on Gram-stain preparations with PMN to epithelial cell (EPI) ratios for the prediction of subsequent spontaneous preterm birth. METHODS: From a prospective cohort study, 83 women with a spontaneous preterm birth at less than 35 weeks of gestation (cases) were compared with a control group of 108 women who delivered at term. Vaginal Gram-stain preparations were obtained at the initial study visit (20-25 weeks). Vaginal PMN and epithelial EPI cell counts were assessed on 5 nonadjacent oil immersion fields under x 1,000 magnification. Vaginal PMN/EPI ratios for each evaluated slide field were calculated to control for intraslide variation in cellular density. RESULTS: Mean delivery gestational age was 31.5 +/- 3.5 weeks for the cases and 39.8 +/- 1.2 weeks for the controls. Mean PMN counts were similar in the cases (13 +/- 20 cells per oil immersion field) and the controls (10 +/- 14 cells per oil immersion field) (P = .17). The mean PMN/EPI ratio, however, was significantly higher among the cases (3.4 +/- 6.0) than among the controls (1.8 +/- 2.4, P = .01). When PMN counts and PMN/EPI ratios were dichotomized by the 95th percentile cutoff (based on control values), the PMN/EPI ratio was significantly associated with subsequent development of spontaneous preterm birth at less than 35 weeks of gestation (odds ratio 3.8, 95% confidence interval 1.3-11.2), whereas PMN counts were not (odds ratio 2.1, 95% confidence interval 0.7-6.1). CONCLUSION: Midtrimester vaginal PMN counts on Gram-stain preparations were not significantly associated with subsequent spontaneous preterm birth in this population. However, the ratio of PMN to EPI counts, which provides internal standardization of variation in slide cellular density, was significantly higher in women with subsequent spontaneous preterm birth at less than 35 weeks.

Adult↗