Showing papers in "Obstetric Anesthesia Digest in 2010"

A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes

Abstract: Although there is little evidence that the screening, identification, and treatment of mild gestational diabetes during pregnancy is beneficial, a number of professional organizations have recommended screening for this disorder in most pregnant women. The aim of this multicenter randomized trial was to determine whether treatment of women with mild gestational diabetes mellitus reduces perinatal and obstetrical complications. The participants were 958 women between 24 and 31 weeks of gestation who met criteria for mild gestational diabetes mellitus. They were randomly assigned to receive either formal nutritional counseling, diet therapy, and self-monitoring of blood glucose, together with insulin if required (treatment group, n = 485) or usual prenatal care (control group, n = 473). The primary study outcome was a composite outcome that included perinatal mortality (stillbirth or neonatal death) and neonatal complications that have been associated with maternal hyperglycemia: hypoglycemia, hyperbilirubinemia, neonatal hyperinsulinemia, and birth trauma. There was no significant difference between the 2 groups in the frequency of the composite primary perinatal outcomes of mortality and neonatal complications (treatment group: 32.4% and control group: 37.0%, respectively; the relative risk was 0.87, with a 97% confidence interval of 0.72–1.07; P = 0.14). However, compared with usual care, treatment was associated with significant reductions in several prespecified secondary neonatal or maternal outcomes including mean birth weight (3408 vs. 3302 g), neonatal fat mass (464 vs. 427 g), the frequency of large-for-gestational age infants (14.5% vs. 7.1%), birth weight greater than 4000 g (14.3% vs. 5.9%), shoulder dystocia (4.0% vs. 1.5%), and cesarean delivery (33.8% vs. 26.9%) (P < 0.02 for all comparisons). In addition, the frequency of the combined rates of preeclampsia and gestational hypertension was significantly lower in the treatment group (P < 0.01). These findings show that treatment of mild gestational diabetes mellitus is associated with a reduced risk of several secondary complications including fetal overgrowth, shoulder dystocia, cesarean delivery, and hypertensive disorders (preeclampsia and gestational hypertension).

Type 2 Diabetes Mellitus After Gestational Diabetes: A Systematic Review and Meta-Analysis

Abstract: Summary Background Women with gestational diabetes are at increased risk of developing type 2 diabetes, but the risk and time of onset have not been fully quantified. We therefore did a comprehensive systematic review and meta-analysis to assess the strength of association between these conditions and the effect of factors that might modify the risk. Methods We identified cohort studies in which women who had developed type 2 diabetes after gestational diabetes were followed up between Jan 1, 1960, and Jan 31, 2009, from Embase and Medline. 205 relevant reports were hand searched. We selected 20 studies that included 675 455 women and 10 859 type 2 diabetic events. We calculated and pooled unadjusted relative risks (RRs) with 95% CIs for each study using a random-effects model. Subgroups analysed were the number of cases of type 2 diabetes, ethnic origin, duration of follow-up, maternal age, body-mass index, and diagnostic criteria. Findings Women with gestational diabetes had an increased risk of developing type 2 diabetes compared with those who had a normoglycaemic pregnancy (RR 7·43, 95% CI 4·79–11·51). Although the largest study (659 164 women; 9502 cases of type 2 diabetes) had the largest RR (12·6, 95% CI 12·15–13·19), RRs were generally consistent among the subgroups assessed. Interpretation Increased awareness of the magnitude and timing of the risk of type 2 diabetes after gestational diabetes among patients and clinicians could provide an opportunity to test and use dietary, lifestyle, and pharmacological interventions that might prevent or delay the onset of type 2 diabetes in affected women. Funding None.

Duration of Lactation and Risk Factors for Maternal Cardiovascular Disease

Abstract: OBJECTIVE:To examine dose–response relationships between the cumulative number of months women lactated and postmenopausal risk factors for cardiovascular disease.METHODS:We examined data from 139,681 postmenopausal women (median age 63 years) who reported at least one live birth on enrolling in the

Association of Resident Fatigue and Distress With Perceived Medical Errors

Abstract: Results The mean response rate to individual surveys was 67.5%. Of the 356 participants providing error data (93.7%), 139 (39%) reported making at least 1 major medical error during the study period. In univariate analyses, there was an association of subsequent self-reported error with the Epworth Sleepiness Scale score (odds ratio [OR], 1.10 per unit increase; 95% confidence interval [CI], 1.03-1.16; P=.002) and fatigue score (OR, 1.14 per unit increase; 95% CI, 1.08-1.21; P.001). Subsequent error was also associated with burnout (ORs per 1-unit change: depersonalization OR, 1.09; 95% CI, 1.05-1.12; P.001; emotional exhaustion OR, 1.06; 95% CI, 1.041.08;P.001; lower personal accomplishment OR, 0.94; 95% CI, 0.92-0.97; P.001), a positive depression screen (OR, 2.56; 95% CI, 1.76-3.72;P.001), and overall QOL (OR, 0.84 per unit increase; 95% CI, 0.79-0.91; P.001). Fatigue and distress variables remained statistically significant when modeled together with little change in the point estimates of effect. Sleepiness and distress, when modeled together, showed little change in point estimates of effect, but sleepiness no longer had a statistically significant association with errors when adjusted for burnout or depression. Conclusion Among internal medicine residents, higher levels of fatigue and distress are independently associated with self-perceived medical errors.

Hypertensive Disorders and Severe Obstetric Morbidity in the United States

Abstract: OBJECTIVE: To examine trends in the rates of hypertensive disorders in pregnancy and compare the rates of severe obstetric complications for delivery hospitalizations with and without hypertensive disorders. METHODS: We performed a cross-sectional study using the 1998–2006 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Logistic regressions and population-attributable fractions were used to examine the effect of hypertensive disorders on severe complications. RESULTS: The overall prevalence of hypertensive disorders among delivery hospitalizations increased significantly from 67.2 per 1,000 deliveries in 1998 to 81.4 per 1,000 deliveries in 2006. Compared with hospitalizations without any hypertensive disorders, the risk of severe obstetric complications ranged from 3.3 to 34.8 for hospitalizations with eclampsia/severe preeclampsia and from 1.4 to 2.2 for gestational hypertension. The prevalence of hospitalizations with eclampsia/severe preeclampsia increased moderately from 9.4 to 12.4 per 1,000 deliveries (P for linear trend <0.001) during the period of study. However, these hospitalizations were associated with 38% of hospitalizations with acute renal failure and 19% or more of hospitalizations with ventilation, disseminated intravascular coagulation syndrome, pulmonary edema, puerperal cerebrovascular disorders, and respiratory distress syndrome. Overall, hospitalizations with hypertensive disorders were associated with 57% of hospitalizations with acute renal failure, 27% of hospitalizations with disseminated intravascular coagulation syndrome, and 30% or more of hospitalizations with ventilation, pulmonary edema, puerperal cerebrovascular disorders, and respiratory distress syndrome. CONCLUSION: The number of delivery hospitalizations in the United States with hypertensive disorders in pregnancy is increasing, and these hospitalizations are associated with a substantial burden of severe obstetric morbidity.

Short-term Neonatal Outcome in Low-risk, Spontaneous, Singleton, Late Preterm Deliveries

Abstract: OBJECTIVE:To estimate the effect of gestational age on short-term neonatal morbidity in cases of spontaneous, low-risk singleton late preterm deliveries and to identify predictors of adverse neonatal outcome.METHODS:This was a retrospective study of all spontaneous, low-risk late preterm deliveries

Maternal and Neonatal Herpes Simplex Virus Infections

Abstract: Whether it is caused by herpes simplex virus (HSV) type 1 or type 2, neonatal HSV infection is a devastating disease if untreated, and more than 30% of pregnant women in the United States have genital infection with HSV. This review summarizes the current facts on this disease and its early identification and treatment, as well as the prospects for more effective prevention.

Ultrasound-guided Transversus Abdominis Plane Block for Analgesia After Caesarean Delivery

Abstract: Background The landmark-guided transversus abdominis plane (TAP) block is an effective method of providing postoperative analgesia in patients undergoing lower abdominal surgery. We evaluated the analgesic efficacy of the ultrasound (US)-guided TAP block in patients undergoing Caesarean delivery. Methods A randomized, double-blind, placebo-controlled trial was performed at a tertiary maternity hospital. Fifty women undergoing Caesarean delivery received bilateral US-guided TAP blocks with either ropivacaine 0.5% or saline. All participants received a spinal anaesthetic with bupivacaine and fentanyl, followed by postoperative acetaminophen, non-steroidal anti-inflammatory drugs, and patient-controlled i.v. morphine without long-acting intrathecal opioids. Each patient was assessed 24 h after delivery for morphine usage, average pain score, nausea, vomiting, pruritus, drowsiness, and satisfaction with pain relief. Results Forty-seven participants completed the trial, 23 in the active group and 24 in the placebo group. Total morphine use in 24 h was reduced in the active group (median 18.0 mg) compared with the placebo group (median 31.5 mg, P Conclusions The US-guided TAP block reduces morphine requirements after Caesarean delivery when used as a component of a multimodal analgesic regimen. Registered with the Australia New Zealand Clinical Trials Registry ACTRN12608000540314. URL: http://www.anzctr.org.au/trial_view.aspx?ID=83176.

Amniotic Fluid Embolism: An Evidence-based Review

Abstract: We conducted an evidence-based review of information about [corrected] amniotic fluid embolism (AFE). The estimated incidence of AFE is 1:15,200 and 1:53,800 deliveries in North America and Europe, respectively. The case fatality rate and perinatal mortality associated with AFE are 13-30% and 9-44%, respectively. Risk factors associated with an [corrected] increased risk of AFE include advanced maternal age, placental abnormalities, operative deliveries, eclampsia, polyhydramnios, cervical lacerations, [corrected] and uterine rupture. The hemodynamic response in [corrected] AFE is biphasic, with initial pulmonary hypertension and right ventricular failure, followed by left ventricular failure. Promising therapies include selective pulmonary vasodilators and recombinant activated factor VIIa. Important topics for future research are presented.

Evidence for Participation of Uterine Natural Killer Cells in the Mechanisms Responsible for Spontaneous Preterm Labor and Delivery

Abstract: Objective The purpose of this study was to determine in a mouse model whether uterine natural killer (uNK) cell cytotoxic activation induces infection/inflammation-associated preterm labor and delivery. Study Design Wild type or interleukin (IL)-10 –/– mice were injected intraperitoneally with lipopolysaccharide on gestational day 14. Mice were either killed for collection of uteroplacental tissue, spleen, and serum or allowed to deliver. Uteroplacental tissue was used for histology and characterization of uNK cells. Results Low-dose lipopolysaccharide treatment triggered preterm labor and delivery in IL-10 –/– , but not wild type mice, in a manner independent of progesterone levels. Preterm labor and delivery in IL-10 –/– mice was associated with an increased number and placental infiltration of cytotoxic uNK cells and placental cell death. Depletion of NK cells or tumor necrosis factor (TNF)-α neutralization in these mice restored term delivery. Furthermore, TNF-α neutralization prevented uNK cell infiltration and placental cell apoptosis. Conclusion The uNK cell-TNF-α–IL-10 axis plays an important role in the genesis of infection/inflammation-induced preterm labor/delivery.

Ultrasound Imaging of the Lumbar Spine in the Transverse Plane: The Correlation Between Estimated and Actual Depth to the Epidural Space in Obese Parturients

Abstract: BACKGROUND: Prepuncture lumbar ultrasound scanning is a reliable tool to facilitate labor epidural needle placement in nonobese parturients. In this study, we assessed prepuncture lumbar ultrasound scanning as a tool for estimating the depth to the epidural space and determining the optimal insertion point in obese parturients. METHODS: We studied 46 obese parturients, with prepregnancy body mass index (BMI) >30 kg/m 2 , requesting labor epidural analgesia. Ultrasound imaging was done by one of the investigators to identify the midline, the intervertebral space, and the distance from the skin to the epidural space (ultrasound depth, UD) at the level of L3-4. Subsequently, an anesthesiologist blinded to the UD located the epidural space through the predetermined insertion point and marked the actual distance from the skin to the epidural space (needle depth, ND) on the needle with a sterile marker. The agreement between the UD and the ND was calculated using the Pearson correlation coefficient and a paired t-test. Bland-Altman analysis was used to determine the 95% limits of agreement between the UD and the ND. RESULTS: The prepregnancy BMI ranged from 30 to 79 kg/m 2 , and the BMI at delivery was 33-86 kg/m 2 . The Pearson correlation coefficient between the UD and the ND was 0.85 (95% confidence interval: 0.75-0.91), and the concordance correlation coefficient was 0.79 (95% confidence interval: 0.71-0.88). The mean (±SD) ND and UD were 6.6 ± 1.0 cm and 6.3 ± 0.8 cm, respectively (difference = 0.3 cm, P = 0.002). The 95% limits of agreement were 1.3 cm to ―0.7 cm. Epidural needle placement using the predetermined insertion point was done without reinsertion at a different puncture site in 76.1% of parturients and without redirection in 67.4%. CONCLUSIONS: We found a strong correlation between the ultrasound-estimated distance to the epidural space and the actual measured needle distance in obese parturients. We suggest that prepuncture lumbar ultrasound may be a useful guide to facilitate the placement of epidural needles in obese parturients.

Fear of Childbirth and Risk for Birth Complications in Nulliparous Women in the Danish National Birth Cohort

Abstract: Objectives To examine the associations between fear of childbirth and emergency caesarean section and between fear of childbirth and dystocia or protracted labour and fetal distress.

Optimal Management Strategies for Placenta Accreta

Abstract: Placenta accreta can be defined as placenta attached to the uterine wall, which is difficult to detach. Its occurrence during childbirth is associated with considerable maternal and neonatal morbidity and places the mother at high risk of bleeding during its removal. The marked persistent increase in cesarean delivery rates in recent years has been paralleled by increases in the incidence of placenta accreta and may reflect a general trend. Various management strategies have been employed for placenta accreta but there are limited data on optimal management. This retrospective cohort study determined which interventions employed at 2 tertiary care teaching hospitals were associated with reduced maternal morbidity. Between 1996 and 2008, women with pregnancies complicated by placenta accreta were identified using ICD-9 codes for placenta accreta, placenta praevia, and cesarean hysterectomy. Medical records were analyzed for maternal medical, obstetric, and gynecologic history, and for antepartum and intrapartum management. Maternal outcome measures analyzed were early morbidity (admission to intensive care unit >24 hours, early reoperation, coagulopathy, transfusion of ≥4 units of packed red blood cells, or ureteral injury) and late morbidity (occurrence of intra-abdominal infection, hospital readmission within 6 weeks, or need for delayed reoperation). Complications in women with suspected and unexpected placenta accreta were compared with respect to preoperative ureteric stent placement, attempts to remove the placenta before hysterectomy, and ligation of the hypogastric arteries. A total of 76 women with placenta accreta were identified. Of these, 57 (75%) had antenatally suspected accreta; 56 of the 57 (98%) had a hysterectomy at the time of delivery. Twenty-five percent (19/76) of the women had unsuspected accreta. Attempt at placental removal before hysterectomy in the women with antenatally suspected placenta accreta was associated with an increase in early maternal morbidity of almost 2-fold in comparison with women who had a cesarean hysterectomy without attempting placenta removal (67% vs. 36%, P = 0.04). The incidence of early morbidity was significantly lower among women with preoperative bilateral ureteric stents than those without (18% vs. 55%, P = 0.02). Ligation of the hypogastric arteries did not reduce maternal morbidity. These findings indicate that maternal morbidity is reduced following scheduled cesarean hysterectomy performed with preoperative ureteric stents and without attempting to remove the placenta before hysterectomy.

Induction of Labor Versus Expectant Monitoring for Gestational Hypertension or Mild Preeclampsia After 36 Weeks of Gestation (HYPITAT): a Multicenter, Open-label Randomized Controlled Trial

Abstract: COMMENT This report from the TOBY trial is an important contribution to the literature on a salutary effect of hypothermia on outcomes in infants with perinatal asphyxial encephalopathy. These are among the sickest children cared for in anNICU and include themost severe adverse neurodevelopmental outcomes. Of the 3 large trials published to date (CoolCap, NICHD, and TOBY), two (including this one) did not achieve a statistical reduction in the primary outcome of death or severe neurological outcome. However, the relative risks in all three studies are actually very similar, ranging from 0.72 to 0.86. This suggests that there is actually a lowering of the risk of death or severe neurologic disability of about 25%; the lack of statistical significance may derive from the fact that the studies were powered to detect somewhat larger differences (although the current study enrolled 20% more patients than needed by their initial power analysis). Meta-analysis combining the various results does indeed suggest that hypothermia is beneficial to selected infants with severe perinatal asphyxia. And therein lies the rub. Hypothermia has very rapidly become the standard of care, so future randomized trials will be difficult to organize. Yet we do not know precisely which infants benefit the most (only those with severe asphyxia or those with only moderately severe entry criteria), which method (selective head cooling or total body cooling) works best, or even what is the optimal cooling temperature and duration of therapy. Nowadays, I would not in good conscience withhold hypothermia in any severely asphyxiated infant, yet I am troubled by the very basic clinical questions that remain. One interesting finding in this study was the fact that almost 25% of the noncooled infants had rectal temperatures of >381C (100.41F). Is it hypothermia or prevention of hyperthermia that is most important? The TOBY study also found improvement in a variety of secondary neurological outcomes, including,most importantly, the percentage of survivors with no severe neurodevelopmental deficits. Cerebral palsy and gross motor abnormalities were also less common in the cooled group, and Bayley Mental Developmental Index and Psychomotor Developmental Index scores trended higher. While these are gratifying results, it is very important to note (as the authors do in their summary), that neurodevelopmental testing at 18 months, as well as developmental testing later in childhood could affect the results, and will be necessary before the final assessment of this new and exciting therapy can be written.

Severe Obstetric Morbidity in the United States: 1998-2005

Abstract: OBJECTIVE:To examine trends in the rates of severe obstetric complications and the potential contribution of changes in delivery mode and maternal characteristics to these trends.METHODS:We performed a cross-sectional study of severe obstetric complications identified from the 1998–2005 Nationwide I

Neonatal Outcomes After Elective Cesarean Delivery

Abstract: OBJECTIVE: To examine the outcomes of neonates born by elective repeat cesarean delivery compared with vaginal birth after cesarean (VBAC) in women with one prior cesarean delivery and to evaluate the cost differences between elective repeat cesarean and VBAC. METHODS: We conducted a retrospective cohort study of 672 women with one prior cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Women were grouped according to their intention to have an elective repeat cesarean or a VBAC (successful or failed). The primary outcome was neonatal intensive care unit (NICU) admission and measures of respiratory morbidity. RESULTS: Neonates born by cesarean delivery had higher NICU admission rates compared with the VBAC group (9.3% compared with 4.9%, P.025) and higher rates of oxygen supplementation for delivery room resuscitation (41.5% compared with 23.2%, P<.01) and after NICU admission (5.8% compared with 2.4%, P<.028). Neonates born by VBAC required the least delivery room resuscitation with oxygen, whereas neonates delivered after failed VBAC required the greatest degree of delivery room resuscitation. The costs of elective repeat cesarean were significantly greater than VBAC. However, failed VBAC accounted for the most expensive total birth experience (delivery and NICU use). CONCLUSION: In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay.

Loop Electrosurgical Excision Procedure and the Risk for Preterm Birth

Abstract: OBJECTIVE: To study whether loop electrosurgical excision procedure (LEEP) conization is associated with preterm birth and to study the effect of cone size on preterm birth. METHODS: This was a retrospective cohort study from Southern Finland conducted from 1997 to 2003, with a follow-up for subsequent births until 2006. We identified the cases from the Hospital Discharge Register and Medical Birth Register and collected additional information from the hospital records. Our cohort consisted of 624 women who delivered after LEEP conization. We calculated expected preterm birth rates by using the Medical Birth Register data. In subgroup analysis (n258 women) we used internal controls, ie, deliveries before the treatment. The main outcome measure was preterm birth rate in different subgroups. RESULTS: The risk for preterm delivery (before 37 weeks) was increased almost threefold (relative risk [RR] 2.61, 95% confidence interval [CI] 2.02–3.20; number needed to treat for harm14) and repeat treatments more than fivefold (RR 5.15, 95% CI 2.45–7.84; number needed to treat for harm5) after LEEP conization compared with the background rate of preterm birth (4.61%). Large or repeat cones increased the risk twofold (RR 2.45, 95% CI 1.38–3.53) when compared with small or medium-sized cones. For women having a birth before and after LEEP conization, the preterm birth rate was 6.5% before and 12.0% after the procedure (RR 1.94, 95% CI 1.10–3.40; number needed to treat for harm18). Adjusting for maternal age, parity, or both did not change the results. The risk for preterm birth was especially increased (RR 3.38, 95% CI 2.31–4.94) among women without previous preterm birth. CONCLUSION: Loop electrosurgical excision procedure surgery of the cervix predisposes patients to preterm birth. Loop electrosurgical excision procedure conization increased the risk for preterm birth especially among women without previous preterm birth. The rates were highest after repeat procedures. (Obstet Gynecol 2009;114:504–10) LEVEL OF EVIDENCE: II

Episiotomy in the United States: Has Anything Changed?

Abstract: Objective The objective of the study was to describe episiotomy rates in the United States following recommended changes in clinical practice. Study Design The National Hospital Discharge Survey, a federal data set sampling inpatient hospitals, was used to obtain data based on International Classification of Diseases , Clinical Modification , 9th revision, diagnosis and procedure codes from 1979 to 2004. Age-adjusted rates of term, singleton, vertex, live-born spontaneous vaginal delivery, operative vaginal delivery, cesarean delivery, episiotomy, and anal sphincter laceration were calculated. Census data for 1990 for women 15-44 years of age was used for age adjustment. Regression analysis was used to evaluate trends in episiotomy. Results The rate of episiotomy with all vaginal deliveries decreased from 60.9% in 1979 to 24.5% in 2004. Anal sphincter laceration with spontaneous vaginal delivery declined from 5% in 1979 to 3.5% in 2004. Rates of anal sphincter laceration with operative delivery increased from 7.7% in 1979 to 15.3% in 2004. The age-adjusted rate of operative vaginal delivery declined from 8.7 in 1979 to 4.6 in 2004, whereas cesarean delivery rates increased from 8.3 in 1979 to 17.2 per 1000 women in 2004. Conclusion Routine episiotomy has declined since liberal usage has been discouraged. Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds to a sharp increase in cesarean delivery, which may indicate that practitioners are favoring cesarean delivery for difficult births.

Anesthesia for Cesarean Delivery and Learning Disabilities in a Population-based Birth Cohort

Abstract: Background Anesthetics administered to immature brains may cause histopathological changes and long-term behavioral abnormalities. The association between perinatal exposure to anesthetics during Cesarean delivery (CD) and development of learning disabilities (LD) was determined in a population-based birth cohort.

Effect of Periodontal Disease Treatment During Pregnancy on Preterm Birth Incidence: A Meta-analysis of Randomized Trials

Abstract: In the majority of cases of preterm birth (PTB), no specific cause can be identified. Intrauterine infection most likely contributes to a large portion of PTBs. Pathogens from remote sites may gain access to the chorionic cavity through invasive procedures or hematogenous seeding through the placenta. Periodontal disease (periodontitis and gingivitis) is a possible contributing factor to PTB and the delivery of low birthweight (LBW) infants. A recent meta-analysis of primarily observational studies indicated such an association, but randomized trials that have compared nonsurgical treatment versus no treatment on the rates of PTB and LBW infants in parturients with periodontal disease, have shown mixed results. This metaanalysis of up-to-date, controlled, randomized trials sought to determine whether treatment of periodontal disease during pregnancy has the potential to reduce the incidence of PTB and/or LBW. Eligible trials compared treatment with periodontal scaling and/or root planning versus no treatment or prophylaxis in parturients with documented disease. Report sources were obtained from the Cochrane Central Trials Registry, Web of Science, Medline, references of eligible trials, cross searches of lead investigators, and articles published during the last 5 years in 3 journals. Data on trial methods, patient characteristics, inclusion criteria, and birth outcomes (PTB, LBW, and spontaneous abortions/stillbirths) were extracted. Periodontal status was based on the number of natural teeth, bleeding on probing, probing depth, and clinical attachment loss. Seven trials met requirements: 4 assessed PTBs as the primary outcome and the other 3 assessed both PTBs and LBW infants. The 7 trials had a combined population of 2663 women with periodontal disease, including 1491 who received treatment during pregnancy and 1172 who did not (controls). All trials reported PTBs: 136 (9.7%) occurred in women who received treatment and 165 (14.7%) occurred in women who received no treatment.Meta-analysis regarding PTB rate showed a strong, statistically significant increase in PTBs among controls (pooled odds ratio 0.55; 95% confidence interval 0.35-0.86), suggesting that treatment of periodontal disease during pregnancy may reduce the incidence of PTB. In 5 trials reporting on LBW infants, 71 (5.1%) such infants were found in the treatment groups and 102 (8.7%) in the no treatment groups, also suggesting that treatment during pregnancy might lower the rate of LBW infants. Spontaneous abortions/stillbirths were reported in 6 trials, with insignificant differences found: 22 events occurred in women with treatment and 26 in the control group. This meta-analysis shows evidence in favor of periodontal disease treatment during pregnancy. Its limitations include possible publication bias and inclusion of only reports published in the literature. In contrast, preliminary results from the ongoing Obstetrics and Periodontal Therapy Study do not show benefits in the use of periodontal treatmentduringpregnancy.Theauthors feel, however, that if larger, well-designed, randomized trials support their findings, current practices might need to be reassessed, and clinicians should be cautious about rejecting treatment with periodontal scaling and/or root planning during pregnancy to prevent PTB.

Periodontal Disease and Adverse Pregnancy Outcomes: Is There an Association?

Abstract: Some studies have reported an association between peridontal disease and adverse pregnancy outcomes, including preeclampsia (PRE) and preterm birth (PTB), while other studies have found no such association. This multicenter prospective cohort study compared the risk of a composite of adverse pregnancy outcomes and the single pregnancy outcomes of PTB, PRE, fetal growth restriction (FGR), or perinatal death among a population of 786 women with and without peridontal disease. This study, part of the Peridontal Infection and Prematurity Study, recruited the study subjects in 3 urban centers from 2004 to 2007. Peridontal disease was identified early in pregnancy. The comparison group was an observational cohort of women without peridontal disease. All participants were between 6 and 20 weeks' gestation. Peridontal disease was defined as peridontal attachment loss greater than or equal to 3 mm on 3 or more teeth. Multivariable logistic regression was used to control for potential confounding variables. Of the 786 women in the final analysis, 311 had peridontal disease and 475 did not. In unadjusted analyses, no association was found between the presence of peridontal disease and the composite outcome, and individual outcomes of PRE or PTB. Following adjustment for confounding variables, no association was found between peridontal disease and the composite outcome (adjusted odds ratio [aOR], 0.81; 95% confidence interval [CI], 0.58-1.15; P = 0.24), PRE (aOR, 0.71; 95% CI, 0.37-1.36; P = 0.30), or PTB (aAOR, 0.77; 95% CI, 0.49-1.21; P = 0.25). In contrast to several observational studies suggesting an association between peridontal disease and adverse pregnancy outcomes, these findings show no such association.