Gestational Weight Gain in Obese Patients and Adverse Pregnancy Events

Objectives: To examine pre-pregnancy obesity and gestational weight gain as predictors for adverse pregnancy outcomes in a predominantly non-white obstetric resident clinic population. Methods: Prenatal charts for patients with pre-pregnancy obesity cared for at our resident clinic from January 1, 2008 through December 31, 2010 were reviewed. Adverse maternal outcomes were grouped into a “Composite Morbidity Index” (CMI-M) and included gestational diabetes, gestational hypertension, preeclampsia, superimposed preeclampsia, dystocia, operative delivery, Cesarean section for arrest disorders, wound infection and disruption, and thromboembolic events. Fetal events, similarly categorized into a composite adverse fetal index (CMI-F), included macrosomia, Apgar at 5 minutes (≤3), NICU admission, congenital anomalies and intrauterine fetal demise. Results: 627 women with a singleton pregnancy and a pre-pregnancy body mass index (BMI) of 30 and greater were included in the analysis. As measured by the composite morbidity index, women with Class III obesity at their first prenatal visit were more likely to have at least one or more maternal and fetal complications compared to women with Class II or Class I obesity. For adverse maternal outcomes (CMI-M), 40.2%, 33.8%, and 27.4% of women within each respective obesity class experienced an adverse event (p = 0.027). Applying the CMI-F, fetal complications were observed in 28.2%, 18%, and 13.9% of Class III, II, and I obesity (p = 0.003). Total gestational weight gain per week was significantly greater for patients with one or more maternal complications (p = 0.045). Conclusion: Among an obese, resident clinic population comprised primarily of women of ethnic minorities, pre-pregnancy body mass index was the strongest indicator for adverse maternal and fetal outcomes.

What Prevents Eligible Patients from Receiving Progesterone Therapy to Prevent Recurrent Preterm Birth

Objective: The use of intramuscular 17-alpha-hydroxyprogesterone caproate (17-OHPC) has been shown to be beneficial for the prevention of preterm birth (PTB) in women with a prior history. Not all patients with a prior preterm birth receive 17-OHPC. The purpose of this study was to investigate potential barriers to receiving this therapy. Methods: A retrospective chart review of those patients at our institution who received the diagnosis of “previous preterm delivery” in 2010 and 2011 was performed to see whether they were offered and received 17-OHPC. Patients were considered eligible if they had a prior delivery at less than 36 weeks of gestation secondary to idiopathic preterm labor. For those patients that were deemed eligible but did not receive therapy, an explanation was sought. Results: Sixty-six charts were reviewed in detail. Forty-three patients were considered eligible to receive 17-OHPC. The remaining had medical indications for delivery including premature rupture of membranes (PROM) (15), intrauterine growth restriction (IUGR) (1), and hypertension (2). Of the 43 patients deemed eligible, 17 did not receive 17-OHPC. Of these, eight patients were not offered therapy, 2 patients declined therapy, 3 patients presented with therapy after 28 weeks (too late), and 4 received a prophylactic cerclage as their only therapy. There were no significant differences between the two groups. Conclusion: In an effort to increase 17-OHPC use among eligible patients, we must continually identify physician biases and patient barriers that prevent utilization of this intervention. In addition, patients who deliver preterm should be told the importance of presenting early in subsequent pregnancies in order to receive the full benefits of this therapy.

Strategies to prevent preterm birth and cerebral palsy: Compliance with current recommendations

Objective: Magnesium sulfate (MgSO4) administration to patients with preterm delivery has been associated with a decrease in cerebral palsy. At our institution, a protocol was established regarding the administration of magnesium sulfate for patients in preterm labor at less than 32 weeks of gestation. Despite this protocol, not all eligible patients received this therapy. The purpose of this study was to investigate potential barriers to MgSO4 administration. Methods: A retrospective chart review was performed of those patients who received the diagnosis of “Early Onset Delivery” or “preterm labor” from January through December of 2010, to see what therapies were offered and received. Results: 119 patients met initial criteria. Of those, 68 patients had preterm labor less than 32 weeks. 15 of the 68 patients (22%) received MgSO4. Of those patients that did not receive MgSO4, only 6 delivered <32 weeks. Five were considered eligible. One patient had a relative contraindication to therapy. There were no demographic differences between those patients that received MgSO4, and those that were eligible and did not. Potential barriers included short time frame from presentation to delivery, treatment not considered by healthcare provider, and unanticipated delivery. No patient declined therapy. Conclusions: At our institution, the rate of MgSO4 administration for neuroprotection to eligible candidates was 75%. The subgroup of patients where MgSO4 was not administered in eligible candidates was unanticipated delivery (4), and premature rupture of membranes (1). A 4 gram load of MgSO4 should be attempted prior to delivery of eligible patients, as this strategy has also been shown to be of benefit.

Demographic and Assisted Reproduction Related Factors Associated with Dichorionic Triplet Gestations

Our objective was to evaluate which demographic factors or assisted reproductive technologies were associated with IVF triplet gestations where one of the embryos split, resulting in a dichorionic triplet gestation. This was a case-control study of dichorionic versus trichorionic triplet gestations that underwent assisted reproductive technology over the last 5 years at our fertility center. There were 53 cases of dichorionic triamniotic triplet gestations compared to 119 trichorionic triplet controls. There were no significant demographic differences between the cases and controls. 51/53 dichorionic triplets and 86/119 trichorionic triplets were conceived through IVF, the remaining utilized intrauterine insemination. ICSI was performed in virtually all patients that underwent IVF. Of the potential risk factors studied, hatching was used in 70.6% of dichorionic compared to 89.5% of trichorionic IVF triplets (p = 0.005);embryo transfer was performed on Day 5 or 6 compared to Day 3 in 88.0% dichorionic vs 71.8% trichorionic (p = 0.028). Frozen sperm was utilized more frequently with dichorionic than with trichorionic triplets, 26.0% vs 10.9% (p < 0.011). Only 4 (7.5%) of the IVF cases underwent pre-implantation genetics. Certain assisted reproductive technologies appear to be associated with embryo splitting and a dichorionic triplet gestation. More research is needed in this area to further elucidate these findings.