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A cystic ovarian teratoma (COT), previously undiagnosed either clinically or by ultrasonography, presented as acute intra-abdominal disease complicating premature labor. This report emphasizes the potentially catastrophic complications of COT and stresses that, despite the availability of ultrasonography, there is still a need for conventional radiography in abdominal catastrophes in pregnant women.
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OBJECTIVE: To evaluate the deleterious effects of maternal obesity on obstetrical complications and neonatal outcomes. PATIENTS AND METHODS: Historical cohort study including all patients delivered in our maternity between 1st January 2002 and 31st December 2004. Intra uterine death and fetal loss before 22 weeks were excluded. Women were categorized by the Body Mass Index: less than 25, between 25 and 30, and more than 30. Maternal data, obstetrical complications, labor and its complications, and neonatal outcomes were studied. RESULTS: During these 3 years, 23.5% (1336/5686) of patients were overweight and 7.5% (425/5686) were obese. Obstetrical pathologies (gestational diabetes mellitus, hypertension, preeclampsia and fetal macrosomia) and labour induction were more significantly frequent in obese patients (P < 0.01). We noted twice more caesarean sections during labour in obese patients. The rate of artificial placental delivery was significantly higher in obese patients (P < 0.01). Obese patients with prior caesarean sections had a rate of vaginal delivery significantly lower than non obese patients with prior C-sections (23.6 vs 43.8%; P < 0.01). Mean children birth weight was significantly higher in obese patients (3305 vs 3181 g; P < 0.01) with no impact on Apgar score. DISCUSSION AND CONCLUSION: Our study confirms that obesity is responsible for major obstetrical complications, for what should no doubt be considered as high risk pregnancies. Our practices must take these complications into account by ensuring an adapted and early management in order to improve maternal and neonatal issues.
Both epidural and combined spinal epidural (CSE) analgesia can provide maternal pain relief during labor. Currently, there are few data comparing the risks and complications of these two techniques. We recorded the incidence and severity of anesthetic-related complications in 1022 laboring parturients. Ninety-eight women opted for either no or parenteral analgesia, 388 chose epidural, and 536 requested CSE analgesia. Women choosing CSE analgesia most often received an intrathecal injection of sufentanil 10 micrograms at the time of epidural catheter insertion. The epidural catheters were then dosed as needed as the intrathecal analgesia waned. Women who received CSE analgesia were more likely to itch (41.4% vs 1.3%) or complain of nausea (2.4% vs 1.0%) or vomiting (3.2% vs 1.0%) than those receiving solely epidural analgesia. Patients who requested only epidural analgesia were more likely to suffer an unintended dural puncture (4.2% vs 1.7%). Fewer than 10% developed hypotension with either technique. The risk of headache was the same with both anesthetics (4%-10%) and did not differ from the incidence of headache in women not receiving neuraxial analgesia (10%-14%). Six patients required epidural blood patch for moderate to severe postural headache. Four of these women suffered a dural puncture with the 18-gauge Hustead epidural needle. The other two women had reportedly uncomplicated epidural and CSE analgesia. These data suggest either neuraxial analgesic technique can safely relieve the pain of labor. CSE analgesia is a safe alternative to epidural analgesia for labor and delivery.
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BACKGROUND: Intrapartum antibiotics can prevent early-onset neonatal group B streptococcal (GBS) disease but have not been widely used. Obstacles include difficulty in implementing screening for GBS colonization and uncertainty about cost-effectiveness. The GBS vaccines for disease prevention are now being developed. METHODS: We developed a decision analysis model and used standard cost-effectiveness and cost-benefit analysis methods. We compared the outcomes and costs of the recent practice of no intervention with those expected for three prevention strategies: (1) intrapartum antibiotics administered to colonized women with labor complications, (2) an alternative strategy that does not require screening but uses epidemiologic criteria and labor complications to target intrapartum antibiotics, and (3) maternal vaccination. We used data from multistate population-based surveillance to estimate the potential impact of each strategy on disease and costs in the United States. RESULTS: Intrapartum antibiotic prophylaxis of high-risk women identified by screening could prevent approximately 3300 cases (47% of neonatal disease) annually in the United States and could save approximately $16 million in direct medical costs. Chemoprophylaxis of high-risk women identified using epidemiologic criteria could potentially be equally effective (3200 cases prevented) and would avoid the logistical difficulties of screening; the net savings would be approximately $66 million. Vaccinating 80% of pregnant women with a vaccine that prevents 80% of cases among infants born at or after 34 weeks of gestation would prevent approximately 4100 neonatal cases annually with a net savings of $131 million. CONCLUSIONS: Universal prenatal screening for GBS and chemoprophylaxis of colonized women with labor complications is likely to be cost-beneficial in the United States. Development of alternative strategies should be further explored for populations in which GBS screening is impractical. Continued development of a GBS vaccine is an important public health priority.
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BACKGROUND: One of every four parturient in Norway receives epidural analgesia during labour. Even though epidural analgesia is considered very safe, there is a tendency to blame the epidural whenever there are neurological complications after labour. METHODS: This paper presents a case report on a woman who developed femoral mononeuropathy after labour. The various neurological complications after labour are discussed. DISCUSSION: Gynaecologists, neurologists, mid-wives and even anaesthesiologists seem unaware of the fact that the incidence of neurological complications are four to five times higher as a result of the labour per se than complications caused by the epidural. Peripheral neurological symptoms after labour occur in 1:2-3,000 labours. Postpartum drop-foot and femoral mononeuropathy are the most frequent complications. Half of all parturients will experience low back pain during pregnancy and/or labour, and one in four will complain of headache in the immediate postpartum period. Urinary bladder dysfunction after pregnancy is not uncommon, but the incidence is the same among mothers who have received epidural analgesia and those who have not. Complications after epidural analgesia, such as haematoma, abscesses and direct nerve damage are extremely rare, but need immediate treatment.
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To evaluate intracervical PGE2 plus low dose oxytocin in the induction of cervical changes and labor, we studied 36 pregnant patients who had one of the following complications: Intrauterine death, anencephaly, gestational trophoblastic disease, missed abortion and PRM with pregnancy less than 28 weeks of gestational age. 200 mcgs of PGE2 were applied in the cervix, and immediately an oxytocin infusion was started at 2 mlU, the dose of oxytocin was increased in the arithmetic fashion until labor was started. The latency between the application of PGE2 and the beginning of labor was 3.57 +/- 3.29 h., between the beginning of labor and birth was 5.59 +/- 3.39 h. The cervix changed from a Bishop score of 2.1 +/- 1.5 to 6.2 +/- 1.8 (p less than 0.0001). The hospital stay was of 1.6 +/- 0.6 days. The secondary affects were minimal, and the births were all vaginal.
OBJECTIVE: To assess the effects of clinical chorioamnionitis and labor complications on short-term neonatal morbidity, including seizures. METHODS: This was a retrospective cohort study of all live-born term infants who weighed more than 2500 g delivered between 1988 and 1997 at Parkland Memorial Hospital, Dallas, Texas. Infant outcomes were compared between women with and without clinical diagnoses of chorioamnionitis. Chorioamnionitis was based on maternal fever of 38C or greater with supporting clinical evidence including fetal tachycardia, uterine tenderness, and malodorous infant. RESULTS: A total of 101,170 term infants were analyzed, 5144 (5%) of whom were born to women with chorioamnionitis. Apgar scores of 3 or less at 5 minutes, umbilical artery pH of 7.0 or less, delivery-room intubation, sepsis, pneumonia, seizures in the first 24 hours, and meconium aspiration syndrome were all increased in infants exposed to chorioamnionitis. After adjustment for confounding factors, including route of delivery and length of labor, chorioamnionitis remained significantly associated with intubation in the delivery room (odds ratio [OR] 2.0; 95% confidence interval [CI] 1.5, 2.6), pneumonia (OR 2.2; 95% CI 1.7, 2.8), and sepsis (OR 2.9; 95% CI 2.1, 4.1). Short-term neurologic morbidity, manifest as seizures, was not related to maternal infection during labor, but was significantly related to other labor complications. CONCLUSION: The main short-term neonatal consequence of chorioamnionitis is infection. Short-term neurologic morbidity in infants is related to labor complications and not chorioamnionitis per se.
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Maternal plasma zinc levels, red blood cell levels, and serum alkaline phosphatase activity were used as indices of zinc status in 279 pregnant women at delivery and were compared with the incidence of complications during the antenatal period and major dysfunctional labor patterns. The median values for plasma zinc, red blood cell zinc, and alkaline phosphatase were used as cutoff points to subdivide the patient population into "low" and "high" groups. Low levels of maternal plasma zinc were associated with more complications in the antenatal or intrapartum periods than maternal levels of either alkaline phosphatase or red blood cell zinc. Plasma zinc levels less than the median value were more commonly associated with mild toxemia (p = 0.02), vaginitis (p = 0.01), and postdates (p = 0.01) in the antenatal period. During the intrapartum period, low plasma zinc levels were associated with a prolonged latent phase (p = 0.05), a protracted active phase (p = 0.04), labor greater than 20 hours (p = 0.03), second stage greater than 2.5 hours (p = 0.01), and cervical and vaginal lacerations (p = 0.02). Low levels of maternal alkaline phosphatase were strongly associated with a history of previous stillbirth (p = 0.0005). A low maternal red blood cell zinc level was not associated with complications during either period. Since a low plasma zinc level is a valid predictor of pregnancy complications and abnormal labor, the results suggest that plasma zinc screening, as part of the patient's antenatal workup should be evaluated.
OBJECTIVE: To study women at the time of admission to the labor and delivery unit to determine which type of ultrasonographic assessment of the amniotic fluid--amniotic fluid index (AFI), single deepest vertical pocket (DVP) or amniotic fluid distribution (AFD)--had the greatest clinical utility in predicting labor complications. STUDY DESIGN: Patients not at term, with a nonvertex presentation, or with ruptured membranes, polyhydramnios, or known maternal or congenital abnormalities were excluded. We included 266 low-risk pregnant women admitted for labor. Medical charts were reviewed for documentation of meconium-stained amniotic fluid (Mec), cesarean section (C/S) for fetal indications and admissions to the neonatal intensive care unit (NICU). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for AFI, DVP and AFD were calculated in relation to the three outcome variables. Positive findings were defined as: AFI < 5.0, DVP < 2.5 cm and AFD, sum of the two lower quadrants of the AFI with a lower value than the sum of the two upper quadrants. RESULTS: Mec was documented in 56 patients (21%), 13 patients (4.8%) had a C/S for fetal indications, and 4 infants (1.5%) were admitted to the NICU. Abnormal AFI was detected in 35 patients (13%), abnormal DVP in 38 patients (14%) and abnormal AFD in 117 patients (44%). PPV and NPV for prediction of Mec, C/S and NICU were: Mec 31% and 80% for AFI, 26% and 80% for DVP; 31% and 91% for AFD; C/S 8.6% and 95% for AFI, 5% and 95% for DVP; 8.6% and 100% for AFD and NICU, 0% and 98% for AFI, 0% and 95% for DVP, and 2.7% and 99% for AFD. CONCLUSION: Normal ultrasonographic values for AFI and AFD are associated with a very low risk of labor complications.
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