THE PREDICTION OF PREMATURE LABOR BY OBSERVATION OF THE CERVIX AND EXTERNAL TOCOGRAPHY.
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Adolescent↗
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Mitochondrial myopathy and preeclampsia associated with pregnancy.
Mitochondrial myopathy is characterized by weakness, exercise intolerance, and acidosis. Pregnancy has been reported to accelerate the disease process. This report discusses pregnancy and management of labor complicated by mitochondrial myopathy and the therapeutic dilemmas that arise when preeclampsia is diagnosed.
Female↗
Impact of a nurses' strike on the cesarean birth rate.
OBJECTIVE: Our purpose is to describe the impact of a 31-day nurses' strike on the cesarean birth rate in the province of Manitoba, Canada. STUDY DESIGN: Computerized hospital records, obtained for all births over a 24-month period, were used to identify complications of labor indicating cesarean section, method of delivery, and adverse maternal and newborn outcomes. The strike interval was compared with a 16-month prestrike period. RESULTS: The cesarean section rate in the strike interval, 12.5 per 100 deliveries, was significantly lower than the prestrike rate of 14.6 per 100 deliveries (p < 0.05). Reductions occurred primarily among breech deliveries and among women with a previous cesarean section. No differences were observed in the rates of individual adverse maternal or newborn outcomes. However, the pooled incidence of adverse newborn outcomes was significantly higher during the strike than during the prestrike period (10.2 vs 8.1/100 deliveries, odds ratio 1.27, 95% confidence interval 1.07 to 1.52). CONCLUSION: In response to constraints imposed by a reduced nursing complement, physicians increased the frequency of vaginal birth in breech presentation and among women with previous cesarean section.
Breech Presentation↗
Severe fetal acidemia: neonatal neurologic features and short-term outcome.
The objectives of this study were to determine if infants delivered with severe acidemia (cord umbilical arterial pH < 7.0) had short-term neurologic effects and whether infants with persistent bradycardia who received cardiopulmonary resuscitation (CPR) in the delivery room would be at greatest risk for subsequently developing neonatal seizures. Forty-seven infants (39 term, 8 preterm) delivered with severe fetal acidemia were studied. The mean (+/- S.D.) for pH, PaCO2, and base deficit for the 47 infants was 6.86 +/- 0.11, 97 +/- 22 mm Hg, and -17 +/- 4, respectively. Labor complications were common and included placental abruption in 8, ruptured uterus in 4, cord prolapse in 3, fetal heart rate decelerations in 12, and other (n = 14). Most infants were delivered via emergency cesarean section (n = 29). Delivery room interventions included oxygen and bag/mask ventilation only (n = 20) and intubation and ventilation (n = 22); 7 of 22 infants received CPR and epinephrine for persistent bradycardia (heart rate < 80 beats/min despite ventilatory support). Five infants required no intervention. Eight infants (17%) had seizures; 6 of these infants received CPR in the delivery room. Short-term outcomes were abnormal in 7 of 8 infants (i.e., death in 5, abnormal neurologic examination at discharge in 2). In 39 infants without seizures, 32 had transient neurologic abnormalities (i.e., irritability, hyperreflexia, proximal hypotonia) which resolved by discharge, and 2 had abnormal and 5 normal examinations.(ABSTRACT TRUNCATED AT 250 WORDS)
Acid-Base Equilibrium↗
Occurrence and clinical predictors of operative delivery for the vertex second twin after normal vaginal delivery of the first twin.
OBJECTIVE: This study was undertaken to estimate occurrence and explore clinical predictors of abdominal and vaginal operative delivery in vertex second twin after normal vaginal delivery of the first twin. METHODS: Data from a historical cohort study that was based on a twin registry in the United States (1995-1997) were used. RESULTS: Among 42,417 vertex second twins following normal vaginal delivery of the first twins, rates of abdominal and vaginal operative delivery were 6.3% and 8.3%, respectively. Cord prolapse, fetal distress, maternal complications, abnormal labor, and birth weight 25% larger than first twin were the most important predicators for operative deliveries. Fetal distress and cord prolapse had a stronger effect on abdominal than vaginal operative delivery. CONCLUSION: In general population, abdominal and vaginal operative delivery rates were 6.3% and 8.3%, respectively, in vertex second twin after normal vaginal delivery of the first twin. The most important predictors for operative delivery are cord prolapse and fetal distress.
Adult↗
Primary infertility associated with isolated cervical collecting diverticulum.
OBJECTIVE: To describe a previously unreported isolated congenital cervical diverticulum and its gynecologic, reproductive, and obstetrical implications. DESIGN: Case report. SETTING: A university hospital. PATIENT: A 31-year-old woman presenting with menometrorrhagia and primary infertility. Investigation revealed an isolated collecting cervical diverticulum causing prolonged postmenstrual spotting, possibly interfering with sperm capacitation and access to the uterine cavity. INTERVENTION(S): The examination included hysterosalpingography and magnetic resonance imaging. The combined hysteroscopy and laparoscopy revealed a 5 x 5 cm cervical diverticulum, around 1 cm from the external cervical os, leading to a short cervical canal connected to a normal uterine cavity. The patient achieved a pregnancy after controlled ovarian hyperstimulation and ultrasonographically guided intrauterine insemination. MAIN OTUCOME MEASURE(S): Pregnancy and obstetrical outcome. RESULT(S): Extensive evaluation revealed the patient's condition to be a previously undescribed congenital cervical anomaly. The patient's infertility was corrected by ovulation induction and sonographically guided intrauterine insemination, which resulted in a twin pregnancy. After 27 weeks of gestation, preterm labor complicated the delivery. CONCLUSION(S): The diagnosis and management of this unusual congenital cervical diverticulum present a particular challenge, as this congenital abnormality has not been previously described or reported.
Adult↗
The Apgar score revisited: influence of gestational age.
We tested the hypothesis that Apgar scores are in part related to the newborn infant's level of maturity. Seventy-three pregnant women with normal fetuses of gestational age 22 to 42 weeks were studied. Fetal well-being was documented by a prospectively designed recording of pregnancy history, labor complications, and birth outcome, including cord blood pH and base deficit measurements. The 1- and 5-minute Apgar scores were directly related to gestational age. Respiratory efforts, muscle tone, and reflex were the major determinants for a decreasing Apgar score with declining gestational age. We conclude that the 1- and 5-minute Apgar scores are influenced by the infant's level of maturity and that our data may be useful in evaluating the true value of Apgar scores in assessing the fetal and neonatal condition of low birth weight infants.
Apgar Score↗
Exercise during pregnancy. A clinical update.
Research dealing with exercise during pregnancy continues to demonstrate marked benefits for mother and fetus. The type, intensity, frequency, and duration of the exercise seem to be important determinants of its beneficial effects. Maternal benefits include improved cardiovascular function, limited weight gain and fat retention, improved attitude and mental state, easier and less complicated labor, quick recovery, and improved fitness. Fetal benefits may include decreased growth of the fat organ, improved stress tolerance, and advanced neurobehavioral maturation. Currently, the offspring are leaner at 5 years of age and have a slightly better neurodevelopmental outcome. Postpubertal effects are still unknown. In the absence of medical contraindications, women should be encouraged to maintain their prepregnancy activity level.
Bicycling↗
Folic acid awareness and intake survey in the United Arab Emirates.
OBJECTIVE: The aim of this study was to determine the level of knowledge and use of periconceptional folic acid supplementation in a sample of postpartum women recruited from three hospitals. DESIGN: Cross-sectional survey in which a structured questionnaire was used in a face-to-face encounter between the subject and a trained nurse. SETTINGS: Two teaching hospitals associated with Faculty of Medicine and Health Sciences and one private hospital. SUBJECTS: Postpartum women in the three hospitals were recruited during a 40-day period in November 1999. Women who did not agree to participate, had complicated labor, delivered babies with congenital malformations, or were too exhausted or difficult to examine, were excluded. RESULTS: Univariate analyses showed that overall 46.4% of the respondents had heard about folic acid and only 8.7% knew that it prevented birth defects. 45.5% of respondents took folic acid in the first trimester. The percentage of women who had ever heard about folic acid was higher in those with higher education, and those who were not UAE nationals. Use of folic acid was associated with non-UAE nationality. CONCLUSION: Awareness of the value of periconceptional folic acid was very low and use of folic acid was less prevalent among women of UAE nationality.
Adult↗
Validation of birth certificate data. A study of women in New Jersey's HealthStart program.
PURPOSE: This study assesses the accuracy of 1989-1992 birth certificate data from New Jersey for a group of high-risk women. METHODS: Birth records were linked to data on women who participated in HealthStart, a program of enriched prenatal care for pregnant women on Medicaid. Concordance was assessed for all variables common to the two data sets. RESULTS: The birth records had accurate reporting of birth-weight, demographic characteristics, and most methods of delivery. Prenatal care use was over-reported, and alcohol, tobacco, transfer status, medical risk factors, obstetric procedures, as well as complications of labor and delivery were underreported. CONCLUSIONS: While many variables are reported very accurately on birth certificates, other measures must be used cautiously. Analyses using birth certificate data, particularly those focusing on high-risk women, need to take the low levels of sensitivity for many risk factors into consideration.
Birth Certificates↗
Neonatal status in relation to incision intervals, obstetric factors, and anesthesia at cesarean delivery.
Uterine incision to delivery interval has been suggested as a critical determinant of neonatal outcome; however, studies of skin incision and uterine incision to delivery intervals have usually not analyzed the contribution of obstetric factors relative to time factors in determining outcome. A group of 204 patients undergoing cesarean delivery were studied. Stepwise multivariate regression was used to examine the relative contribution of obstetric and anesthetic factors to Apgar scores and umbilical cord blood gases. Apgar scores and umbilical cord blood gases were significantly influenced by labor complications (fetal distress, meconium, and pre-eclampsia), infant weight, type of cesarean delivery (primary vs. repeat), and type of anesthesia. Skin incision and uterine incision to delivery intervals did not significantly contribute to Apgar scores nor umbilical cord blood gases when corrected for these factors. We conclude that careful attention to maternal status prior to cesarean delivery and optimal anesthetic management appear to be the most important factors for good neonatal outcome. Surgical techniques should be directed at gentle, atraumatic delivery of the fetus for the good of the fetus and the mother.
Anesthesia, Obstetrical↗
Fetal pulse oximetry and cesarean delivery.
BACKGROUND: Knowledge of fetal oxygen saturation, as an adjunct to electronic fetal monitoring, may be associated with a significant change in the rate of cesarean deliveries or the infant's condition at birth. METHODS: We randomly assigned 5341 nulliparous women who were at term and in early labor to either "open" or "masked" fetal pulse oximetry. In the open group, fetal oxygen saturation values were displayed to the clinician. In the masked group, the fetal oxygen sensor was inserted and the values were recorded by computer, but the data were hidden. Labor complicated by a nonreassuring fetal heart rate before randomization was documented for subsequent analysis. RESULTS: There was no significant difference in the overall rates of cesarean delivery between the open and masked groups (26.3% and 27.5%, respectively; P=0.31). The rates of cesarean delivery associated with the separate indications of a nonreassuring fetal heart rate (7.1% and 7.9%, respectively; P=0.30) and dystocia (18.6% and 19.2%, respectively; P=0.59) were similar between the two groups. Similar findings were observed in the subgroup of 2168 women in whom a nonreassuring fetal heart rate was detected before randomization. The condition of the infants at birth did not differ significantly between the two groups. CONCLUSIONS: Knowledge of the fetal oxygen saturation is not associated with a reduction in the rate of cesarean delivery or with improvement in the condition of the newborn. (ClinicalTrials.gov number, NCT00098709 [ClinicalTrials.gov].).
Adult↗
Pregnancy and birth outcomes in families with asthma.
Studies of maternal asthma in pregnancy have shown an increased risk of adverse neonatal and maternal outcomes such as preeclampsia, hypertension, cesarean delivery, prematurity, low birth weight, and perinatal/neonatal mortality. However, results are not consistent between studies. We studied the association between maternal asthma and various adverse neonatal and maternal outcomes and explored whether there is any evidence that pregnancy exacerbates maternal asthma. The data were collected as part of the Childhood Asthma Prevention Study. Pregnant women with asthma or women whose partners or other children had current symptoms of asthma were recruited at six Sydney hospitals. All women recruited were post 36 weeks gestation and were living within 30 km of the study recruitment center. Information about family history of asthma was collected using a questionnaire at 36 weeks gestation and subsequent information about antenatal and perinatal events was obtained from hospital records. Data from 611 pregnant women were available for analysis, 340 of whom had asthma. Hypertension was significantly more common in asthmatics than in nonasthmatics [OR = 2.16 (1.02-4.6), p < 0.043]. The prevalence of gestational diabetes, labor complications, delivery complications, and adverse neonatal outcomes did not differ significantly between the groups. We also found that the course of maternal asthma usually remains unchanged during pregnancy, but that more severe asthma is likely to get worse. We have confirmed previous observations that women with asthma are at increased risk of hypertension in pregnancy, which is consistent with studies that show that pregnant asthmatic women have a slightly increased risk of preeclampsia. However, we did not find evidence of an increased risk of adverse perinatal outcomes.
Adult↗
Weight gain and energy intake during pregnancy.
The ideal weight gain or energy intake for an individual woman cannot be determined from research studies. Current guidelines for maternal gain, however, combined with individualized assessment and follow-up, can provide the clinician and the pregnant women with a meaningful target and plan for achieving a healthy weight gain. For some women, increased amounts of maternal weight gain may improve fetal growth prenatally and therefore improve fetal health. For other women, high gains, or even gains within the recommended range, may enhance fetal growth to the point where labor complications, operative deliveries, permanent maternal obesity, and other health problems may occur. Balancing the health benefits and risks of maternal weight gain is a challenge that we will continue to face in the future.
Adolescent↗
The current status of intrapartum fetal monitoring.
Intensive intrapartum fetal monitoring, using direct fetal EKG leads and intrauterine pressure sensing transducers, seems to add another level of care for the fetus. As with other laboratory aids or devices, fetal monitoring data should not be exclusively relied on in decision making processes. When used with other modern monitor aids, such as scalp pH, it can aid immensely in the management of both normal and complicated labors. When fetal heart rate patterns remain normal throughout labor there can be a high degree of confidence that the fetal outcome will be good. If abnormal patterns occur, however, great care should be taken in interpreting these data, and it should be combined with the overall status of the mother and the fetus, and used together with the clinical acumen of the physician in determining a method of approach to the management of intrapartum situations. Continuous monitoring techniques can and should be applied in the neonatal nursery for intensive neonatal management and care (79,80). As experience is gained in clinical fetal monitoring and as new techniques and methods become available, intensuve intrapartum fetal monitoring will become an increasingly important and significant technique for management of labor (4, 139).
Acid-Base Imbalance↗
Treated maternal gonorrhea without adverse effect on outcome of pregnancy.
Infants born to mothers with gonorrhea are at risk for neonatal gonococcal infection, primarily ophthalmitis. To determine whether gonorrhea during pregnancy may have other adverse effects, we compared the outcome of pregnancy to gonorrheal status for all women who were delivered of infants at Grady Memorial Hospital in 1976 and 1977. The incidence of positive cultures was 41.1 per thousand pregnant women. For 85% of women with positive cultures, treatment was recorded in the chart. Women with positive cultures were younger (P less than .0001) and of lower parity (P less than .001) than women was negative cultures. There were no differences, however, in selected complications of labor and delivery, in the incidence of premature or low birthweight babies, or in the neonatal death rate of babies born to mothers with positive or negative gonorrhea cultures. These results indicate that gonorrhea during pregnancy, if treated, does not adversely affect the fetus or newborn.
Adolescent↗
Maternal and perinatal morbidity of caesarean delivery at full cervical dilatation compared with caesarean delivery in the first stage of labour.
To estimate maternal and perinatal morbidity associated with caesarean delivery at full cervical dilatation, a population-based cohort study from 1997 to 2002 was used, which included 1623 nullipara with singleton pregnancies at 37-42 weeks of gestation requiring caesarean delivery in labour. Compared to caesarean delivery at less than full dilatation, women undergoing caesarean delivery at full dilatation were more likely to have complications of intraoperative trauma (RR 2.6, P < 0.001) and infants with perinatal asphyxia (RR 1.5, P < 0.05). There was no difference in maternal or perinatal morbidity when duration of the second stage of labour or when failed assisted vaginal delivery was considered.
Adult↗
Subcutaneous fat necrosis, hypercalcemia, and prostaglandin E.
We present two patients with subcutaneous fat necroses (SCFN) in whom endocrinologic studies revealed an association with elevated prostaglandin E (PGE) levels. A boy born after prolonged labor complicated by meconium aspiration developed erythematous, indurated plaques over the back, arms, buttocks, and cheeks at 4 days of age. A biopsy specimen of involved skin showed panniculitis with foci of necrotic adipocytes containing radially arranged, needle-shaped clefts and a granulomatous infiltrate in the septae. Laboratory studies revealed hypercalcemia of 13.6 mg/dl (normal 8.8-10.1 mg/dl), elevated 1.25-1.25(OH)2D3, and increased urinary excretion of PGE2. The child was hospitalized and treated with systemic steroids and diuretics, with resolution of SCFN and hypercalcemia. The second patient was a girl born with cyanotic heart disease. A diagnosis of Ebstein anomaly was made, and intravenous PGE1 was started to keep patent the ductus arteriosus. Four days later erythematous, indurated plaques were noted on the knee, back, and anterior chest. A skin biopsy specimen revealed SCFN. There was no associated laboratory abnormality. On discontinuing PGE1, no new lesions formed and the existing panniculitis resolved. These two cases demonstrate the association between SCFN and elevated PGE levels (endogenous in patient 1, exogenous in patient 2). No previous reports of SCFN after the administration of PGE1 have appeared in the literature.
Biopsy↗