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Bacterial vaginosis in pregnancy: diagnosis, screening, and management.

Bacterial vaginosis is the most common lower genital tract infection among women of reproductive age. It has been associated with a number of significant obstetric and gynecologic complications, such as preterm labor and delivery, preterm premature rupture of membranes, spontaneous abortion, chorioamnionitis, postpartum endometritis, postcesarean delivery wound infections, postsurgical infections, and subclinical pelvic inflammatory disease. This article focuses on bacterial vaginosis in pregnancy, and discusses approaches to diagnosis, screening, and management.

Anti-Infective Agents↗

Emergency peripartum hysterectomy.

OBJECTIVES: By means of hospital-based data over 9 years we sought to evaluate the clinical indications and incidence of emergency peripartum hysterectomy by demographic characteristics and reproductive history. STUDY DESIGN: From the obstetric records of all deliveries at Brigham and Women's Hospital between Oct. 1, 1983, and July 31, 1991, we identified all women undergoing emergency peripartum hysterectomy, calculated crude and adjusted incidence rates, conducted statistical tests of linear trends and heterogeneity, and observed the clinical indications preceding the onset of this procedure. RESULTS: There were 117 cases of peripartum gravid hysterectomy identified during this period, for an overall annual incidence of 1.55 per 1000 deliveries. The rate increased with increasing parity and was significantly influenced by placenta previa and a history of cesarean section. The incidence by parity increased from one in 143 deliveries in nulliparous women with placenta previa to one in four deliveries in multiparous women with four or more deliveries with placenta previa. Likewise, the incidence increased from one in 143 deliveries in women with one prior live birth and a prior cesarean section to one in 14 deliveries in multiparous women with four or more deliveries with a history of a prior cesarean section. Both these trends were highly significant (p < 0.001). Abnormal adherent placentation was the most common cause preceding gravid hysterectomy (64%, p < 0.001), with uterine atony accounting for 21%. Although no maternal deaths occurred, maternal morbidity remained high, including postoperative infection in 58 (50%), intraoperative urologic injury in 10 patients (9%), and need for transfusion in 102 patients (87%). CONCLUSIONS: The data identify abnormal adherent placentation as the primary cause for gravid hysterectomy. The data also illustrate how the incidence of emergency peripartum hysterectomy increases significantly with increasing parity, especially when influenced by a current placenta previa or a prior cesarean section. Maternal morbidity remained high although no maternal deaths occurred.

Adult↗

Elevated second trimester human chorionic gonadotropin level associated with adverse pregnancy outcome.

OBJECTIVE: Our purpose was to determine whether unexplained elevations in maternal serum human chorionic gonadotropin in the second trimester may be associated with adverse pregnancy outcome. METHOD: Between April 1992 and April 1995, 610 pregnant women undergoing second trimester triple marker screening for Down syndrome who delivered at our institution were evaluated. Eighty-one women with a hCG level greater than 2.0 multiples of the median (MoM) were included in the study group while 481 women with hCG levels < 2.0 MoM served as controls. Pregnancies with fetal chromosomal and structural anomalies and maternal serum alpha-fetoprotein levels greater than 2.0 MoM were excluded from the study. Pregnancy outcomes were obtained from hospital delivery records. Statistical analysis were performed by Student's t-test; odds ratios and 95% confidence intervals were also calculated. RESULTS: Women with elevated human chorionic gonadotropin levels showed an increased risk for preeclampsia (odds ratio (OR): 5.93, 95% confidence interval (CI): 1.97-15.88), intrauterine growth retardation (OR: 5.34, 95% CI: 2.14-13.34), preterm delivery (OR: 5.66, 95% CI: 3.22-9.98), and preterm premature rupture of membranes (OR: 3.15, 95% CI: 1.23-8.07). CONCLUSION: Unexplained elevation of human chorionic gonadotropin in the second trimester appears to be associated with adverse pregnancy outcome.

Abruptio Placentae↗

Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period.

OBJECTIVES: This study was performed to assess the intra-operative surgical complications and postoperative maternal morbidity rate of caesarean section. STUDY DESIGN: A total of 2647 women, delivered by caesarean section in our department between 1983 and 1992, were studied retrospectively. Three caesarean section groups were formed: (1) primary elective, (2) primary acute, without any effort to deliver vaginally, and (3) secondary acute, due to a failed vaginal delivery. The Student's-t-, Fisher-exact- and chi 2-test were used for statistical analysis. RESULTS: The overall maternal intra-operative complication rate was 14.8%. The most common complications were lacerations of the uterine corpus (10.1%) and bloodloss > or = 1000 ml (7.3%). The complication rate of the secondary group (23.4%) was significantly higher (p < 0.001) compared to both primary groups (7.4%). The overall maternal postoperative morbidity rate was 35.7%. Fever (24.6%), bloodloss between 1000 and 1500 ml (4%), haematoma (3.5%) and urinary tract infections (3.0%) were the most frequent complications. The primary elective group showed significantly (p < 0.001) lower major (2.6%) and minor (23.7%) complication rates compared to the emergency groups (major 5.2%, minor 34%). CONCLUSION: Emergency caesarean sections carried the greatest risks regarding maternal complications compared to elective procedures.

Cesarean Section↗

Influence of aboriginal and socioeconomic status on birth outcome and maternal morbidity.

OBJECTIVE: To assess the association of Aboriginal and socioeconomic status with birth outcome and maternal morbidity in Alberta. METHODS: A retrospective cohort study using Alberta health service and vital statistics data from 1997 to 2000. Aboriginal women registered with the Department of Indian and Northern Development (DIAND) were linked to a personal health number. Low socioeconomic status was defined as either receiving subsidization for the Alberta Health Care Insurance premium or receiving welfare. RESULTS: Women registered with DIAND and women receiving subsidy or welfare were younger, more often unmarried, smoked more, consumed more alcohol, and abused more illicit drugs than other women in Alberta during the time period studied. Fewer women registered with DIAND and women receiving subsidy or welfare had physician prenatal visits, attended prenatal classes, had forceps or vacuum deliveries, and more of these women frequently had gestation ages less than 37 weeks. Women registered with DIAND had more deliveries in smaller, non-metropolitan facilities; and more of these women delivered outside their region of residence; more had longer lengths of hospital stay; more mothers and neonates were re-admitted to hospital within 28 days of discharge after delivery; fewer delivered small for gestational age neonates; fewer delivered neonates with birth weight less than 2500 g, but more delivered neonates with birth weight greater than 4000 g. There were fewer Caesarean sections in women registered with DIAND (OR = 0.84, 95% CI 0.76-0.93) and in women receiving subsidy or welfare (OR = 0.88, 95% CI 0.82-0.93). CONCLUSION: Women receiving subsidy or welfare and women registered with DIAND had many demographic similarities and generally had worse maternal and neonatal outcomes than other women in Alberta. Medical system interaction may be different for these two groups of women than it is for other women in Alberta.

Adolescent↗

Relative cervical incompetence in twin pregnancy. Assessment and efficacy of cervical suture.

A total of 88 women with a twin pregnancy who had elective cervical suture were compared with 76 women with a twin pregnancy who had cervical assessment between the 13th and the 28th weeks of gestation but received no active treatment. The incidence of spontaneous onset of labour before 36 weeks was higher in the cervical suture group, and 53.4% of them sustained cervical damage.

Cervix Uteri↗

Indications for caesarean section.

Caesarean section rates are rising. Caesarean section confers an increase in maternal mortality and morbidity as well as having considerable financial implications. Caesarean section is usually justified by the assumed benefit for the fetus. These benefits are often unquantified and based on scanty evidence. The changing trends in the rates of caesarean section for various indications may be explained partly by improved anaesthetic and neonatal techniques. Cultural changes and expectations in the general population and obstetricians' fear of litigation may have made the changing rate and indications for caesarean section seem more acceptable. There is little research evidence in this area. The evidence that caesarean section is the optimal mode of delivery for various major indications is critically examined. The obstetrician is under an obligation to share the evidence that caesarean section is the optimum mode of delivery with the pregnant woman and her birth attendants to allow the woman to make wise decisions about her management.

Abruptio Placentae↗

Stillbirth: tissue findings with environmental and genetic links.

This article discusses stillbirth from a pathologist's perspective. Stillbirth may be caused by many different mechanisms. There are specific maternal and fetal disorders leading to stillbirth, and some of these have genetic and environmental associations. Frequently, an autopsy examination may determine the specific cause of the fetal death. We illustrate tissue findings in stillbirth to put individual faces on this condition.

Chromosome Aberrations↗

[Premature birth rate, incidence of cesarean section and perinatal mortality between 1945 and 1980. An analysis of 55,000 births].

56,686 single births between 1945 and 1980 were evaluated in a retrospective study. The results reflect the change which has taken place in obstetrics. Perinatal mortality dropped in a straight line from 48.50/00 to 17.20/00. At the same time, the frequency of Caesarian section increased in non-linear progression from an initial value of 1.9% (1945-1949) to 14.0% (1975-1980). The rate of early births dropped in the first ten years only from 10.6% to 7.3%, followed by an approximately constant value up to 1969. From 1970 onwards, there is a rising tendency (6.7% to 7.7%) which was found in all weight categories. The share of early births in perinatal mortality dropped during the first years only, from 77% to 63%, and has since remained constant. If we compare the periods 1945 to 1959 and 1970 to 1980 with regard to indications for Caesarian section, assuming a birth weight of more than 2500 g, the indication of cessation of labour would rise from the 4th rank to the 1st position, whereas disproportion and asphyxia of the newborn continue to occupy the 2nd and 4th ranks, respectively, despite a relative increase. Meanwhile, the indication "condition after Caesarian section" now occupies the 3rd rank. In newborn weighing less than 2500 g, the prominent indications are early birth, asphyxia, desire to have a child and breech presentation, whereas emergency indications were previously the most important ones.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗