Our objective was to determine the factors involved in the development of shoulder dystocia in association with operative vaginal delivery. In this prospective study, patients who were candidates for operative vaginal delivery were randomized either to forceps (N = 315) or vacuum with M-cup (N = 322) and timed from initial placement of instrument to final delivery. Data were gathered prior to and after instrumental delivery. Statistics used were Pearson chi square, Fisher's exact, analysis of variance, and multiple logistic regression. There were a total of 21 patients with shoulder dystocia in both groups (3.3% incidence). Discriminant factors that did nor meet significance included use of epidural analgesia (P = .12), station (P = .99), previous vaginal delivery (P = .99), fetal gender (P = .54), indication for operative vaginal delivery (P = .63), > 45 degrees rotation (P = .68), use of episiotomy (P = .62), maternal weight (P = .26), and maternal diabetes (P = .08). Nearly attaining significance in univariate analysis was randomization to vacuum (P = .052). Significant factors included gestational age (P = .03), time required to effect delivery (P = .007), and birthweight (P = .0001). When these factors were subjected to stepwise multiple logistic regression, three factors remained as significant associations with shoulder dystocia: randomization to vacuum (P = .04), time for delivery (P = .03), and birthweight (P = .0001). In this operative vaginal delivery trial, shoulder dystocia was strongly associated with large fetal size, longer time to delivery, and the use of vacuum for delivery.

Birth Injuries↗

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Ultrasonic assessment of the amniotic fluid volume in diamniotic twins.

OBJECTIVE: We sought to determine amniotic fluid (AF) volume in diamniotic twin gestations and to relate these findings to estimates using standard ultrasonic techniques. METHODS: In this prospective study, AF volume in 45 diamniotic twin gestations at 27-38 weeks was assessed by sonography using the largest vertical pocket technique, the AF index, and the two-diameter pocket method. After the three different sonographic estimations of AF volume, the true amount of AF was determined using amniocentesis and a dye-dilution technique. RESULTS: The individual sac AF volume was less than 500 mL in 35 amniotic cavities, 500-2000 mL in 48 sacs, and greater than 2000 mL in seven. Individual AF volume between 500 and 2000 mL was correctly predicted by sonographic use of the largest vertical pocket in 47 of 48 patients (98%), the AF index in 47 of 48 (98%), and the two-diameter pocket method in 39 of 48 (81%). Estimation of AF volume less than 500 mL was significantly more accurate using the two-diameter pocket method compared with either the AF index (P = .015) or the largest vertical pocket technique (P < .0001). CONCLUSIONS: Currently available ultrasonic techniques to assess mid-range AF volume (500-2000 mL) in twin pregnancy are very accurate (81-98%). Oligohydramnios (less than 500 mL) is poorly identified by any sonographic method.

Adult↗

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Secretory component in human amniotic fluid and gestational tissues: a potential endogenous phospholipase A2 inhibitor.

OBJECTIVES: Prostaglandins (PGs) are essential mediators of labor during human pregnancy. Phospholipase A2 (PLA2) provides the essential substrate for PG synthesis through the liberation of arachidonic acid from membrane phospholipid stores. Nonlaboring amniotic fluid (NL-AF) contains secretory component (SC)-like protein(s) that suppress in vitro PLA2 activity. This study characterizes the biologic activity, identity, and tissue distribution of these protein(s) in NL-AF and gestational tissues. METHODS: Third-trimester NL-AF was collected by amniocentesis, fractionated by ammonium sulfate precipitation, and submitted to an in vitro PLA2 assay. Identity of the PLA2 inhibitor in NL-AF was confirmed by Western blot and antibody neutralization studies. Secretory component-immunoreactive proteins were purified by immunoaffinity chromatography and visualized by sodium dodecyl sulfate-gel electrophoresis. Tissue distribution of SC in gestational tissues was determined by immunohistochemistry. RESULTS: The 100% pellet and supernatant fractions of NL-AF suppressed PLA2 activity, and this activity was neutralized by a polyclonal antibody to SC. Western blot studies revealed an SC-reactive protein in the 70-80-kD range in the 100% pellet fraction of NL-AF. Two SC-reactive proteins were detected in the 60-80-kD range in the eluate from the SC immunoaffinity column, along with minor proteins of 30 and greater than 100 kD. Immunohistochemical studies revealed SC in placental trophoblast, amniotic membranes, and decidual epithelium. CONCLUSIONS: These results demonstrate that proteins homologous to SC are present in human gestational tissues and possess anti-PLA2 activity. These proteins may contribute to the maintenance of pregnancy by suppressing local PG production.

Amniocentesis↗

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Maternal hypoglycemia: is it associated with adverse perinatal outcome?

OBJECTIVE: To determine if maternal hypoglycemia is associated with adverse perinatal outcome, particularly low birth weight. STUDY DESIGN: In this prospective study, all patients after 24 weeks' gestation were screened for gestational diabetes using 50 gm of glucola (oral) followed by a 1-hour plasma glucose measurement and hypoglycemia was defined as < or = 88 mg/dl. RESULTS: In these 426 women the mean (+/- SD) 1-hour plasma glucose value was 99.8 +/- 22.7 mg/dl. Of these, 16 were diagnosed with gestational diabetes and 46 were lost to follow-up leaving 364 patients; 116 with hypoglycemia and 248 with euglycemia. Women with hypoglycemia weighed less at the beginning of pregnancy and at delivery, but total weight gain during pregnancy was similar between both groups. There was no difference between groups in maternal symptomatology, birth weight, or the rate of fetal growth restriction. CONCLUSION: Hypoglycemia on the 1-hour glucola screen is not predictive of fetal growth restriction or other adverse perinatal consequence.

Birth Weight↗

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Detection of intra-amniotic infection by gas-liquid chromatography.

The use of gas-liquid chromatography to detect short-chain organic acids in the amniotic fluid of patients with amnionitis has been previously described. Most of the studies describe patients in the early third trimester with such infections. The purpose of the current study was to confirm the correlation of infection with increased production of organic acids and to assess the effect of gestational age on the presence of these short-chain fatty acids in the amniotic fluid. Six patients with confirmed chorioamnionitis were used as positive control subjects. Seventy-two patients at various gestational ages from 18 to 42 weeks with negative Gram's stain and culture results from the amniotic fluid were used as negative control subjects. The data revealed an increased production of organic acids, particularly pyruvic, oxalic and succinic, in patients with amnionitis regardless of gestational age. Interestingly, patients with noninfected amniotic fluid also revealed an increase in the concentrations of volatile organic acids between 27 and 32 weeks' gestation. It appears from this study that previous results correlating chorioamnionitis with an increased production of organic acids in the amniotic fluid may have been confounded by gestational age.

Amniotic Fluid↗

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Accelerated recovery from severe preeclampsia: uterine curettage versus nifedipine.

OBJECTIVE: We investigated the ability of uterine curettage and nifedipine to accelerate postpartum recovery from severe preeclampsia. METHODS: Forty-five parturients with severe preeclampsia were randomly assigned to one of three groups following delivery. Patients in group 1 were managed with intravenous magnesium sulfate (2 g/hour) and observed in the obstetric recovery room until blood pressure had stabilized (systolic blood pressure less than 150 mmHg and diastolic blood pressure less than 100 mmHg) and adequate diuresis was noted. Group 2 was treated in a similar manner but with the addition of oral nifedipine, 10 mg every 4 hours postpartum for 48 hours. Group 3 underwent an ultrasound-directed curettage immediately following delivery in the delivery/operating room and was then treated as in group 1. All three groups were assessed postpartum for mean arterial pressure (MAP) and urine output (UO) every 2 hours, hematocrit and platelet count every 6 hours, and lactic dehydrogenase/aspartate aminotransferase every 12 hours for 48 hours postpartum. RESULTS: Fifteen women were assigned to each of the three treatment groups. The MAP decreased significantly (P < .0001) in all three groups during the first 48 hours postpartum. Treatment interaction indicated specific differences among the groups. Standard therapy (group 1) was significantly inferior to nifedipine (group 2) and curettage (group 3) in regard to MAP decrease (P = .0017) and UO increase (P = .0137). No statistical differences existed between nifedipine and curettage. The rise in the platelet count following delivery was significantly different among the three groups (P = .033), with a much more rapid recovery in the curettage group (12-18 hours) than in the other groups (P = .0106). CONCLUSIONS: Nifedipine and uterine curettage both appear to accelerate recovery from severe preeclampsia, as measured by MAP and UO. Uterine curettage appears the most effective in rapidly resolving the thrombocytopenia associated with severe preeclampsia.

Adult↗

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Amniotic fluid interleukin-6 and interleukin-8 levels predict the success of tocolysis in patients with preterm labor.

OBJECTIVE: To determine whether the levels of the cytokines interleukin-6 (IL-6) and IL-8 in amniotic fluid identify patients with preterm labor who are resistant to tocolysis. METHODS: Amniocenteses were performed in 23 women with documented preterm labor at 20-32 weeks' gestational age who were treated subsequently with tocolytics. The concentrations of IL-6 and IL-8 in amniotic fluid were determined by double-antibody radioimmunoassay methods using recombinant human IL standards. RESULTS: Of the 23 patients, five failed to respond to tocolysis (four delivered within 48 hours), and of the remaining 18, all delivered more than 9 days after tocolysis was initiated (mean 31 +/- 10 days; range 9-61). In women who had failed tocolysis, discriminatory concentrations of IL-6 and IL-8 were 20 and 15 ng/mL, respectively. Of the patients who had amniotic fluid concentrations higher than these thresholds, all failed tocolysis (100% positive predictive value) and delivered within 6 days. The patients with levels below these discriminatory concentrations had successful tocolysis, and 17 of 18 delivered more than 2 weeks after treatment (95% negative predictive value). CONCLUSION: The success of tocolysis and thus delivery remote from an episode of preterm labor is associated with discriminatory amniotic fluid IL-6 and IL-8 levels of less than 20 and less than 15 ng/mL, respectively. If the immunologic response that causes the release of IL-6 and IL-8 has not occurred, the likelihood of successful tocolysis is extremely high. However, if both IL-6 and IL-8 are elevated, tocolysis is likely to fail and delivery may occur within 48 hours.

Adult↗

PubMedDate not supplied

Hospital mergers and the threat to women's reproductive health services: applying the antitrust laws.

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Antitrust Laws↗

PubMedDate not supplied

Hemorrhage associated with cesarean delivery: when is transfusion needed?

Our objective was to determine the incidence of blood administration after cesarean delivery and whether such transfusions are always beneficial. In this retrospective study 1610 women underwent cesarean delivery during a 2-year period and 127 of these patients had hemorrhage during or after operation. Of these subjects 103 received blood because of intraoperative hemorrhage, a reduction in the hematocrit of more than 10 points, or because the postoperative hematocrit was < 24%. These subjects were compared with the remaining women (n = 24) who met the same criteria for hemorrhage but did not receive transfusion. The maternal age, race, and parity were similar in both groups. The estimated blood loss (873 +/- 484 ml) and the preoperative hematocrit (33.4% +/- 6.4%) in the women who did not receive transfusion were not significantly different from those of patients who received packed red blood cells (854 +/- 576 ml and 30.0% +/- 5.4%, respectively). The postdelivery hematocrit was similar in both groups: 25.9% +/- 4.3% in the nontransfused group and 24.5% +/- 5.6% in the transfused group. Patients in the transfused group received a mean of 3.8 +/- 4.9 units of packed red blood cells, with a range of 1 to 40 units. The mean equilibrated (stable) hematocrit after transfusion was 28.4% +/- 5.4%, which was significantly greater than the mean equilibrated postoperative hematocrit of 22.7% +/- 4.6% in patients who did not receive transfusion (p < 0.0001). Nonetheless, the hospital stay, incidence of postoperative infection, and incidence of wound complications were similar in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗