Poor sleep in pregnancy and mode of delivery.
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Adult↗
Biomedical subjects
Aaron B Caughey
Publications and source records attributed to Aaron B Caughey.
Acyclovir prophylaxis for pregnant women with a known history of herpes simplex virus: a cost-effectiveness analysis.
OBJECTIVE: Previous literature has shown acyclovir to be cost-effective as prophylaxis for women with genital symptomatic herpes simplex virus infection recurrence during pregnancy. We extend this analysis by adding quality-adjusted life year measurements and considering women with a diagnosed history of herpes simplex virus infection but without recurrence in pregnancy. STUDY DESIGN: A decision analytic model was designed that compared acyclovir prophylaxis versus no acyclovir for women with a history of diagnosed genital herpes simplex virus infection but without recurrence in pregnancy. Sensitivity analysis and Monte Carlo simulations were performed to test for robustness. RESULTS: We found that 22,286 women must be treated to prevent 1 neonatal death, 8985 women to prevent 1 affected child, and 177 women to prevent 1 cesarean delivery. As compared with no acyclovir, acyclovir prophylaxis at 36 weeks of gestation saves approximately dollar 20 per person and increases total quality-adjusted life years by 0.01. In univariate sensitivity analysis, this result was robust to all reasonable probability and quality-adjusted life year estimates. Monte Carlo simulation demonstrated acyclovir to be cost-effective 100% of the time and cost saving >99% of the time. CONCLUSION: Acyclovir prophylaxis versus no treatment for pregnant women with a diagnosed history of genital herpes simplex virus infection but without recurrence during pregnancy is cost-effective over a wide range of assumptions.
Acyclovir↗
Screening for gestational diabetes: different cut-offs for different ethnicities?
OBJECTIVE: To examine whether screening guidelines for gestational diabetes should be modified based on ethnicity. STUDY DESIGN: This is a retrospective cohort study of 14,565 pregnancies screened for gestational diabetes. The primary outcome of interest was the diagnosis of gestational diabetes based on the results of the 100-g glucose tolerance test. A diagnosis was determined if any 2 of the 4 values (fasting or 1-, 2-, or 3-hour postprandial) were at or above 95, 180, 155, or 140 mg/dL, respectively. Values of the 50-g glucose-loading test were examined from 130 mg/dL to 150 mg/dL. The sensitivity, specificity, false-positive rates, and positive predictive values of various glucose-loading test cut-offs were compared among whites, African Americans, Latinas, and Asians. The sensitivities and specificities were compared using receiver-operator characteristic curves. RESULTS: Sensitivity and specificity of the glucose-loading test differ by ethnicity. Generally, African Americans achieved the highest sensitivities and specificities over the range examined. To achieve a false-positive rate of 10% for the glucose-loading test, the threshold value would be 133 mg/dL for African Americans, 140 mg/dL for whites, 143 mg/dL for Latinas, and 147 mg/dL for Asians. At the lower glucose-loading test values (130 and 135 mg/dL), Asians exhibited the highest positive predictive values (30.0% and 34.0%), whereas at higher values of the glucose-loading test (145 and 150 mg/dL), African Americans had the highest positive predictive values (46.0% and 51.5%). Throughout the glucose-loading test range, whites had the lowest positive predictive values (P < .001). CONCLUSIONS: To maximize the sensitivity and minimize the false-positive rate of the glucose-loading test, it may be reasonable to consider varying the threshold based on ethnicity. However, modification of glucose-loading test thresholds based on maternal ethnicity merit further study to determine whether improved perinatal outcomes can be achieved.
Adult↗
The interrelationship between ethnicity and obesity on obstetric outcomes.
OBJECTIVE: The purpose of this study was to evaluate the interrelationship between ethnicity and obesity on obstetric outcomes. STUDY DESIGN: This was a retrospective study examining the interaction between ethnicity and obesity for obstetric outcomes. Statistical methods included univariate and multivariate regression models. RESULTS: In this study population of 22,658 women, 2150 (9.4%) were obese (body mass index [BMI] >29). Obesity increased the rate of cesarean delivery, gestational diabetes, preeclampsia, and macrosomia in each ethnic group. When compared with obese white women, higher rates of cesarean delivery were noted in obese African American (odds ratio [OR] 1.50, P < .05) and Asian (OR 1.73, P < .05) women. Gestational diabetes was increased twofold in obese Latina (OR 1.94, P < .05) and Asian (OR 2.20, P < .05) women, while preeclampsia was increased only in obese Latina (1.93, P < .05) women. CONCLUSION: Obesity increases the risk of cesarean delivery, gestational diabetes, preeclampsia, and macrosomia, but this effect varies among different ethnicities. The biometrics of different ethnicities and associated obstetric outcomes needs further exploration.
Adult↗
Maternal ethnicity, paternal ethnicity, and parental ethnic discordance: predictors of preeclampsia.
OBJECTIVE: To examine the association of maternal and paternal ethnicity as well as parental ethnic discordance with preeclampsia. METHODS: Retrospective cohort study of all low-risk women delivered from 1995 to 1999 within a mature managed care organization. Rates of preeclampsia were calculated for maternal, paternal, and combined ethnicity using both univariate and multivariate analyses. RESULTS: Among the 127,544 low-risk women, when examining maternal ethnicity in a multivariate model controlling for maternal age, parity, education, and gestational age, we found that the rates of preeclampsia were higher among African American (5.2%; odds ratio [OR] 1.41, 95% confidence interval [CI] 1.25-1.62) women and lower among Latina (4.0%; OR 0.90, 95% CI 0.84-0.97) and Asian women (3.5%; OR 0.79, 95% CI 0.72-0.88), with all results being statistically significant as compared with white women. When paternal ethnicity was controlled for separately, however, the difference in the rate of preeclampsia among Asian women disappeared, the effect of African-American maternal ethnicity increased slightly (OR 1.49, 95% CI 1.33-1.72), and Asian paternity was found to be associated with the lowest rate of preeclampsia (3.2%; OR 0.76, 95% CI 0.68-0.85). Further, parental ethnic discordance was associated with an increase in the rate of preeclampsia (OR 1.13, 95% CI 1.02 - 1.26). CONCLUSION: We found that rates of preeclampsia were lower with Asian paternal ethnicity. We also found that having a differing paternal and maternal ethnicity was associated with increased rates of preeclampsia. For every 1,000 pregnancies, there would be approximately 10 fewer cases of preeclampsia in the setting of Asian paternity and 5 more cases of preeclampsia in the setting of parental ethnic discordance. These differences may be useful in further investigation of the cause of preeclampsia. LEVEL OF EVIDENCE: II-2.
Adult↗
Peritoneal closure at primary cesarean delivery and adhesions.
OBJECTIVE: To evaluate the effect of parietal peritoneal closure at cesarean delivery on adhesion formation. METHODS: A prospective cohort study of women undergoing first repeat cesarean delivery was designed. All surgeons were asked immediately after surgery to score the severity and location of adhesions. Patient records were then abstracted to assess prior surgical technique, including parietal peritoneal closure, other attributes of first surgery, and patient characteristics. Exclusion criteria included adhesions, other surgery, or use of permanent suture at the first cesarean, unavailable first postoperative note and course, wound infection or breakdown following first surgery, intervening pelvic surgery, insulin-dependent diabetes mellitus, and steroid-dependent disease. The chi2 test and multivariable logistic regression were used for statistical comparison and analysis. A total of 128 patients was required to have 80% power to detect a 50% reduction in adhesions when the parietal peritoneum was left open. RESULTS: One hundred seventy-three patients were enrolled. Prior parietal peritoneal closure was associated with significantly fewer dense and filmy adhesions (52% versus 73%, P = .006) and significantly fewer dense adhesions (30% versus 45%, P = .043). When controlling for potential confounding variables, including prior infection, visceral peritoneal closure, rectus muscle closure, payor status, ethnicity, maternal age, gestational diabetes, and labor, parietal peritoneal closure at primary cesarean delivery was 5-fold protective against all adhesions (odds ratio 0.20, 95% confidence interval 0.08-0.49), and 3-fold protective against dense adhesions (odds ratio 0.32, 95% confidence interval 0.13-0.79). Omental-fascial adhesions were decreased most consistently. CONCLUSION: Parietal peritoneal closure at primary cesarean delivery was associated with significantly fewer dense and filmy adhesions. The practice of nonclosure of the parietal peritoneum at cesarean delivery should be questioned.
Adult↗
Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing cesarean delivery.
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Cesarean Section↗
Forceps compared with vacuum: rates of neonatal and maternal morbidity.
OBJECTIVE: To compare perinatal outcomes between forceps- and vacuum-assisted deliveries. Our hypothesis was that the force vectors achieved in forceps delivery will lead to fewer shoulder dystocias, but greater perineal lacerations. METHODS: This was a retrospective cohort study of 4,120 term, cephalic, singleton, nonrotational operative vaginal deliveries at a single institution. Outcomes examined included rates of neonatal trauma, shoulder dystocia, and perineal lacerations. Potential confounders, including maternal age, birthweight, ethnicity, parity, station at delivery, episiotomy, attending physician, anesthesia, and length of labor, were controlled for using multivariate logistic regression. RESULTS: Among the 2,075 (50.4%) forceps- and 2,045 (49.6%) vacuum-assisted deliveries, the rate of shoulder dystocia was lower among women undergoing forceps delivery (1.5% compared with 3.5%, P < .001), as was the rate of cephalohematoma (4.5% compared with 14.8%, P < .001), whereas the rate of third- or fourth-degree perineal laceration was higher (36.9% compared with 26.8%, P < .001). These differences in perinatal complications persisted when controlling for the confounders listed above. The adjusted odds ratio for shoulder dystocia was 0.34 (95% confidence interval [CI] 0.20-0.57), for cephalohematoma was 0.25 (95% CI 0.19-0.33), and for third- or fourth-degree lacerations was 1.79 (95% CI 1.52-2.10) when comparing forceps to vacuum. CONCLUSION: Vacuum-assisted vaginal birth is more often associated with shoulder dystocia and cephalohematoma. Forceps delivery is more often associated with third- and fourth-degree perineal lacerations. These differences in complications rates should be considered among other factors when determining the optimal mode of delivery. LEVEL OF EVIDENCE: II-2.
Adult↗
How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes?
OBJECTIVE: The purpose of this study was to examine maternal and neonatal outcomes in relation to lengthening intervals of the second stage of labor. STUDY DESIGN: This is a retrospective cohort study of 15,759 nulliparous, term, cephalic, singleton births at the University of California, San Francisco, between 1976 and 2001. The second stage of labor was divided into 1-hour intervals. Maternal and neonatal outcomes were compared with the use of chi-squared and Student t tests, and a probability value of < or =.05 was used to indicate statistical significance. Potential confounders were controlled for with multivariate logistic regression. RESULTS: Increasing rates of cesarean delivery, operative vaginal delivery, and perineal trauma were associated with the second stage beyond the first hour. In multivariate analysis, the >4-hour interval group had higher rates of cesarean delivery (odds ratio, 5.65; P < .001), operative vaginal deliveries (odds ratio, 2.83; P < .001), 3rd- or 4th-degree perineal lacerations (odds ratio, 1.33; P = .009), and chorioamnionitis (odds ratio, 1.79; P < .001). There were no differences in neonatal acid-base status associated with length of second stage. However, there were fewer neonates with a 5-minute Apgar score of <7 (odds ratio, 0.45; P = .01). CONCLUSION: Although the length of the second stage of labor is not associated with poor neonatal outcome, a prolonged second stage is associated with increased maternal morbidity and operative delivery rates.
Analysis of Variance↗
Cost-effectiveness analyses in gynecologic oncology: methodological quality and trends.
OBJECTIVES: To evaluate methodological quality and trends of cost-effectiveness analyses (CEA) published in gynecologic oncology. METHODS: A medical literature search of articles from 1966 through 2002 was performed to identify original, English-language articles that included economic analyses in gynecologic oncology. We included articles that were cost-effectiveness or cost-benefit analyses or performed these analyses as part of their study. Ten methodological principles that should be incorporated in CEAs were assessed for each study. Each article was given a score of 0, 1, or 2 for each of the 10 methodological principles (max score = 20). Data were analyzed using the Student t test, ANOVA, and linear regression. RESULTS: We screened 693 articles to identify 68 that met our inclusion criteria. The articles focused on cervical cancer (n = 53; 78%), ovarian cancer (n = 11; 16%), uterine cancer (n = 2; 3%), and general perioperative care (n = 2; 3%). The mean (+/-SD) methodological principle score was 16.1 (+/-4.1) and we observed a significant improvement in the total score over time (P = 0.01). Primary CEA's (CEA identified as the objective of the study) were of higher quality than secondary CEA's (primary objective of the study was not CEA but CEA was included in the study; total scores 18.2 vs. 11.6, respectively; P<0.0001). Studies with at least one investigator in public health or healthcare economies also had higher quality (mean total score 17.7 vs. 15.2; P=0.006). The most common limitations of published CEAs were in methodology or presentation of incremental analyses, sensitivity analyses, and discounting. CONCLUSIONS: Cost-effectiveness analyses in gynecologic oncology showed significant improvement in quality over the last two decades. Despite this progress, methodological improvement is still needed in the areas of incremental comparisons and sensitivity analysis. Understanding the methodology of cost-effectiveness analysis is critical for researchers, editors, and readers to accurately interpret results of the growing body of CEA articles.
Analysis of Variance↗
Complications of term pregnancies beyond 37 weeks of gestation.
OBJECTIVE: To estimate when rates of pregnancy complications increase beyond 37 weeks of gestation. METHODS: We designed a retrospective, cohort study of all women delivered beyond 37 weeks of gestational age from 1992 to 2002 at a single community hospital. Rates of perinatal complications by gestational age were analyzed with both bivariate and multivariable analyses. Statistical significance was designated by P <.05. RESULTS: Among the 45673 women who delivered at 37 completed weeks and beyond, the rates of meconium and macrosomia increased beyond 38 weeks of gestation (P <.001), the rates of operative vaginal delivery, chorioamnionitis, and endomyometritis all increased beyond 40 weeks of gestation (P <.001), and rates of intrauterine fetal death and cesarean delivery increased beyond 41 weeks of gestation (P <.001). CONCLUSION: Risks to both mother and infant increase as pregnancy progresses beyond 40 weeks of gestation.
Adult↗
Assessment of demand for prenatal diagnostic testing using willingness to pay.
OBJECTIVE: To investigate the demand for invasive prenatal diagnostic testing (amniocentesis and chorionic villous sampling) in a racially/ethnically diverse group of pregnant women of all ages in the San Francisco Bay Area by using estimates of willingness to pay for these procedures. METHODS: We surveyed 447 women of varying ages, ethnicity, and socioeconomic levels to assess their desire to undergo and willingness to pay for invasive prenatal testing for chromosomal disorders. Each woman was asked what she would be willing to pay for invasive diagnostic testing up to the full cost of the procedure. We also asked several demographic and attitudinal questions. RESULTS: Overall, 49% of the women indicated an interest in undergoing invasive prenatal diagnostic testing. Women aged 35 years and older were more likely to desire testing as compared with women aged less than 35 years (72% versus 36%, P <.001). Of the women aged less than 35 years who desired testing, 31% indicated that they would be willing to pay the full price of $1,300, whereas 73% were willing to pay a portion of the cost. Maternal age of 35 years or greater (odds ratio [OR] 3.3; 95% confidence interval [CI] 2.0, 5.6) and willingness to have an elective abortion (OR 2.8; 95% CI 1.6, 4.9) were significant predictors of desire to undergo prenatal diagnostic testing after controlling for income, race/ethnicity, and education. Maternal age of 35 years or greater (OR 3.5; 95% CI 1.59, 7.88) and having an income greater than $35,000 (OR 2.3; 95% CI 1.02, 5.26) were significant predictors of willingness to pay the full price of testing. CONCLUSION: A substantial proportion of women of all ages indicate a desire to undergo and a willingness to pay for prenatal diagnostic testing. Variations in willingness to pay are correlated with both socioeconomic and attitudinal differences in addition to age. Guidelines regarding use of prenatal genetic diagnosis should be expanded to offer testing to all women, not just those deemed at increased risk. LEVEL OF EVIDENCE: II-2
Adult↗
Gestational weight gain, macrosomia, and risk of cesarean birth in nondiabetic nulliparas.
OBJECTIVE: To examine how the association between excessive weight gain and cesarean birth is modified by infant birth weight in nondiabetic women. METHODS: We designed a retrospective cohort study of singleton, term, nulliparous women with cephalic presentations delivering at a single university hospital. Subjects with diabetes were excluded. Bivariate and multivariate analyses were performed. Regression models controlled for maternal age, maternal prepregnancy body mass index, gestational age, ethnicity, smoking, birth weight, and date of delivery. RESULTS: Women gaining above Institute of Medicine guidelines were more likely to have a cesarean birth, even if birth weight was less than 4,000 g. In the multivariate analysis, women with excessive weight gain had an odds ratio of 1.40 (95% confidence interval 1.22-1.59) for cesarean birth. When absolute weight gain (total pregnancy weight gain minus birth weight and placental weight) was used in the multivariate analysis, excessive weight gain was still an independent predictor of cesarean delivery. Although macrosomia was a stronger predictor of cesarean than weight gain alone, excessive weight gain was much more common than macrosomia in our cohort. CONCLUSION: Excessive weight gain during pregnancy is an independent risk factor for cesarean birth, even when birth weight is not excessive. Other mechanisms besides macrosomia may be involved in the association between high weight gain and cesarean birth. We estimate that of the approximately 288,000 primary cesarean deliveries performed in nulliparas annually in the United States, 64,000 would be prevented if no women gained above Institute of Medicine recommendations. LEVEL OF EVIDENCE: II-2
Adult↗
Meconium-stained amniotic fluid is associated with puerperal infections.
OBJECTIVE: The purpose of this study was to determine whether meconium-stained amniotic fluid is associated with puerperal infection and whether the quality of the meconium is further associated with this risk. STUDY DESIGN: We designed a retrospective cohort study of all deliveries beyond 37 weeks gestational age from 1992 to 2002 at a single community hospital. Data were collected on rates of chorioamnionitis, endomyometritis, quality of amniotic fluid, and length of labor and analyzed with bivariate and multivariate analyses. RESULTS: We found that, among the 43,200 women who were delivered at term, 18.9% of the women had meconium staining (8.8% thin, 5.5% moderate, 4.6% thick). Compared with deliveries with clear amniotic fluid, those with meconium-stained amniotic fluid had higher rates of chorioamnionitis (2.3% vs 4.1%, P<.001) and endomyometritis (1.0% vs 1.7%, P<.001). Further, the severity of meconium staining was associated with increased rates of infection. CONCLUSION: We found that the presence and severity of meconium-stained amniotic fluid is associated with puerperal infection even when being controlled for confounders.
Adult↗
What is the best measure of maternal complications of term pregnancy: ongoing pregnancies or pregnancies delivered?
OBJECTIVE: The purpose of this study was to determine whether rates of hypertensive disorders of pregnancy increase beyond 37 weeks of gestation and to address how best to analyze these rates. STUDY DESIGN: This was a retrospective cohort study of all women delivered beyond 37 weeks' gestational age from 1995 to 1999 at all Kaiser Permanente Medical Care Program delivery hospitals in Northern California. Rates of gestational hypertension, preeclampsia, and eclampsia were calculated by use of both pregnancy delivered (PD) and ongoing pregnancy (OP) as the denominator. Bivariate and multivariate analyses were conducted with use of P<.05 to indicate statistical significance. RESULTS: Among the 135,560 women in this cohort, the rates of gestational hypertension, preeclampsia, and eclampsia were the same or decreased from 37 to 43 weeks' gestation using PD, but all three increased when calculated according to OP (P<.01). CONCLUSION: We found that among complications of pregnancy that are diagnosed ante partum, use of a different denominator led to contradictory conclusions. When hypertensive disorders of pregnancy are analyzed, ongoing pregnancies should be used as the denominator.
Adult↗
The association of maternal age and symptomatic uterine rupture during a trial of labor after prior cesarean delivery.
OBJECTIVE: To estimate whether maternal age is associated with a symptomatic uterine rupture during a trial of labor after prior cesarean delivery. METHODS: We retrospectively reviewed the medical records of all patients undergoing a trial of labor after prior cesarean delivery over a 12-year period. We analyzed the labors of women with one prior cesarean and no prior vaginal deliveries. The uterine rupture rate was determined with respect to maternal age. Multiple logistic regression was used to control for potential confounding variables. RESULTS: Overall, 32 (1.1%) uterine ruptures occurred among 3015 women. For women younger than 30 years, the risk of uterine rupture was 0.5%, and for those women aged at least 30 years, the risk of uterine rupture was 1.4% (P =.02). Controlling for birth weight, induction, augmentation, and interdelivery interval, the odds ratio for symptomatic uterine rupture for women aged at least 30 years compared with those less than 30 years was 3.2 (95% confidence interval 1.2, 8.4). CONCLUSION: Women aged 30 years or older have a greater risk of uterine rupture as compared with women younger than 30 years.
Adult↗
Recommendations for repeat courses of antenatal corticosteroids: a decision analysis.
OBJECTIVE: The objective was to review the evidence regarding multiple versus single courses of antenatal corticosteroids (ACS), devise dosing regimens based on this evidence, and then, by using decision analysis, compare 5 ACS regimens: (1) single course, (2) weekly courses, (3) every-other-week dosing, (4) every-other-week dosing with no more than 2 courses, and (5) an every-other-week dosing regimen with no third courses after 30 weeks and no second course after 32 weeks. STUDY DESIGN: The literature was examined for evidence regarding a dose response of the benefits and detriments of ACS. A decision analytic model was designed by using odds ratios, risks of morbidity and mortality, and birth rates from the literature. Mathematic modeling, based on data in the literature, was used to estimate the number of patients who would present at risk for preterm delivery and at what gestational age they would subsequently be delivered. A sensitivity analysis was performed to account for uncertainties in the data. RESULTS: Of approximately 4 million annual births in the United States, a conservative estimate of 138,000 patients will present between 24 and 34 weeks of gestation at risk for preterm delivery, with 91,915 deliveries. If the 5 different dosing regimens are applied to these patients, strategy 1, the single course of ACS, would result in 30,232 cases of respiratory distress syndrome (RDS) and 4032 neonatal deaths. Three of the other dosing regimens (2, 3, and 5) would all decrease the number of cases of RDS but would concomitantly increase neonatal deaths. Only dosing regimen 4 would decrease the cases of RDS by 2187 without increasing the number of neonatal deaths. CONCLUSION: There is evidence that there may be a decrease in the incidence of RDS secondary to the use of multiple doses of ACS; however, a concomitant increase in neonatal deaths may also occur. On the basis of our results, we recommend the following: (1) all fetuses between 24 and 34 weeks' gestation at risk for preterm delivery should be given the first course, (2) if there is a persisting risk of preterm delivery subsequent to this, the next course should be given 2 weeks later, and (3) no more than 2 courses should be given. These recommendations need to be examined in a randomized, controlled trial.
Adrenal Cortex Hormones↗
Delivery strategies for women with a previous classic cesarean delivery: a decision analysis.
OBJECTIVE: The purpose of this study was to compare four strategies for treating patients with a previous classic cesarean delivery by medical outcomes and quality-adjusted life years. STUDY DESIGN: A decision tree was designed that compared four strategies for a hypothetical cohort of 10,000 women with a previous classic cesarean delivery: (1) delivery at 39 weeks of gestation, (2) delivery at 36 weeks of gestation without amniocentesis, (3) amniocentesis at 36 weeks of gestation with delivery if the fetus was mature and antenatal corticosteroids if the fetus was immature, and (4) weekly amniocentesis starting at 36 weeks of gestation with delivery when mature. RESULTS: Strategy 2 provided the greatest maternal quality-adjusted life years. Comparing strategy 1 with strategy 2, it was determined that 27 cesarean deliveries must be performed at 36 weeks of gestation with one associated case of respiratory distress syndrome to prevent one case of uterine rupture. Sensitivity analysis revealed that the uterine rupture rate must be below 0.36% for any strategy to surpass strategy 2 (elective cesarean delivery at 36 weeks of gestation without amniocentesis). CONCLUSION: A 36-week delivery may be preferable because it provides a lower risk of severe adverse outcomes and higher maternal quality of life.
Adrenal Cortex Hormones↗