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PubMed2004

Higher rates of tachysystole among patients with clinically apparent uterine leiomyomas.

OBJECTIVE: This study was undertaken to determine uterine and fetal heart rate (FHR) tracing patterns associated with clinically apparent uterine leiomyomas. STUDY DESIGN: Uterine and FHR patterns of 44 women with diagnosed uterine leiomyomas were compared with 601 tracings of controls. Tracings were interpreted during the first stage of labor, using the National Institute of Child Health and Human Development Research Planning Workshop guidelines. Stratified analysis that used the Mantel-Haenszel technique was performed to control for confounders. RESULTS: Patients with leiomyomas had higher rates of uterine tachysystole as compared with those without leiomyomas (22.7% vs 1.3%; odds ratio [OR] = 21.8, 95% CI 7.4-65.6; P < .001). No significant differences were noted between the groups regarding FHR patterns. Higher rates'of prostaglandin induction and oxytocin augmentation were noted in the uterine leiomyomas group (6.8% vs 0.8%; P = .005 and 52.3% vs 10.5%; P < .001, respectively). However, controlling for prostaglandin induction and oxytocin augmentation, with the use of the Mantel-Haenszel procedure, did not change the significant association between uterine leiomyomas and tachysystole (weighted OR 12.5, 95% CI 6.2-75.1, and weighted OR 8.7, 95% CI 3.6-43.1, respectively). CONCLUSION: Clinically apparent uterine leiomyomas, although not coupled with abnormal FHR patterns, are associated with higher rates of tachysystole.

Female↗
PubMed2004

Accuracy of simulated cervical dilation and effacement measurements among practitioners.

OBJECTIVE: To determine whether hard or soft cervical models produced more accurate results when examined by practitioners of various experience levels. STUDY DESIGN: Simulated hard and soft cervical models were placed in a chamber designed to simulate a realistic vaginal examination. These cervical dilation and effacement models ranged from 1 cm to 6 cm and from thick (4 cm) to complete (0.2 cm). Each examiner had 20 seconds to evaluate each of 12 models of varying dilation and effacement using the soft and then the hard models. Models of the same dilation and effacement were presented to each practitioner in the same sequence. Physicians, nurses, and residents did the cervical evaluations. RESULTS: Of 360 recorded dilation measurements, only 19% were exactly correct using the soft models, whereas 54% were exact using the hard models. The percentages correct using hard cervix models progressively decreased with advancing cervical dilation. No consistent trend was found using the soft models. The respective results for correct effacement measurements were 49% soft versus 58% hard. CONCLUSIONS: Assessment of cervical dilation and effacement was consistently more accurate in the hard, compared with the soft, cervical model. The greatest deviation between the models was noted among the residents, suggesting that beginning practitioners may benefit from learning on firm models before progressing to more realistic soft models. However, it should also be noted that all practitioners might benefit from practice with soft models, especially to determine accurate dilation because scores in this category were consistently below what might be expected.

Equipment Design↗
PubMed2006

United States multicenter clinical usage study of the STAN 21 electronic fetal monitoring system.

OBJECTIVE: The fetal electrocardiogram system for electronic fetal monitoring (EFM) (STAN S21, Neoventa Medical, Moelndal, Sweden) has led to improved perinatal outcomes in other countries. We aimed to assess the ability of United States (US) obstetricians to use this system appropriately for intrapartum care. STUDY DESIGN: A prospective nonrandomized trial was conducted in 6 sites. Enrollment required a singleton vertex fetus, >36 weeks' gestation, with indications for direct fetal monitoring during first stage of labor. Appropriate use was measured by negative predictive value (NPV) of nonintervention for fetuses with nonreassuring fetal heart rate (FHR) patterns, normal STAN readings, and normal neonatal outcomes with umbilical cord arterial pH >7.12; and percent agreement (PA) for intervention decisions with 3 STAN experts who conducted retrospective case reviews blinded to outcome. RESULTS: Five hundred and thirty patients were enrolled. An NPV of 95.2% was achieved while PA between investigators and STAN experts was 84%, and 90%, for intervention and nonintervention, respectively. No fetus with metabolic acidosis requiring intervention was missed by US clinicians. CONCLUSION: US clinicians used the STAN system appropriately in a manner similar to that of experienced STAN users.

Acidosis↗
PubMed2004

Perinatal changes of brain-derived neurotrophic factor in pre- and fullterm neonates.

BACKGROUND: Brain-derived neurotrophic factor (BDNF) is abundant in brain and peripheral nerves, affects normal development, growth and survival and is implicated in immune response. AIM: To determine in single preterm (P) and fullterm (F) neonates, circulating intra- and extrauterine levels of BDNF, supposingly reflecting their neuronal and immune maturity. STUDY DESIGN: Prospective study. SUBJECTS: Thirty healthy, appropriate for gestational age (AGA) F (mean gestational age 39.2+/-1.4 weeks), 15 healthy AGA P (29.4+/-1.3 weeks), and their mothers. OUTCOME MEASURES: BDNF was measured by enzyme immunoassay methods in the serum of: mothers at the first stage of labor (MS), the umbilical cord (UC) and the neonates on days 1 (N1) and 4 (N4) postpartum. RESULTS: Levels of BDNF in (a). FMS did not differ from PMS, but both were significantly higher than respective (F or P) UC, N1 and N4 (p ranging from <0.01 to <0.001), (b). FUC, FN1 and FN4 were significantly higher than PUC (p<0.001), PN1 (p<0.03) and PN4 (p<0.02), respectively, (c). PN1 increased significantly as compared to PUC (p<0.05). CONCLUSIONS: Higher BDNF MS levels may reflect the mature nervous and immune systems of mothers. Higher BDNF levels in F than P may also be due to advanced maturity in the former. Increased BDNF levels in PN1 as compared to PUC may indicate stimulation of immune response with exposure to antigenic stimuli from the extrauterine environment. Nevertheless, this stimulation is insufficient in P, who by decreasing N4 levels are by far less protected than F.

Adult↗
PubMed2006

Management of cervical weakness based on the measurement of cervical resistance index.

OBJECTIVE: To assess the value of measuring cervical resistance index (CRI) as an aid to selecting patients with a history of spontaneous mid-trimester miscarriage for cervical cerclage in subsequent pregnancies. STUDY DESIGN: An observational study of 175 patients with a history of one or more spontaneous mid-trimester losses and 123 non-pregnant women who had CRI measurements performed while undergoing routine gynaecological surgery. Those women whose CRI indicated an incompetent cervix were recommended for cervical cerclage in future pregnancies while women with a normal CRI were recommended for conservative management without cerclage. RESULTS: The median CRI in the 123 control women was 38.26 N while the median CRI in the study group was 17.00 N. In 62 of the 175 study women (35%) the CRI findings were at variance with the history of previous mid-trimester loss; 30 (16.6%) were deemed competent on CRI whereas the history suggested incompetence and 32 (18.4%) were incompetent on CRI while the history suggested that the cervix should be competent. The 175 study women had had 486 previous pregnancies with a successful outcome in 27.4% of the pregnancies. Ninety-four patients have now had 148 pregnancies with a successful outcome in 75.8% of the pregnancies. CONCLUSIONS: Non-pregnant women with a history of spontaneous mid-trimester miscarriage have a significantly lower cervical resistance index than parous women who have not suffered mid-trimester loss. In 35% of patients the CRI was at variance with the history of the previous loss. CRI may be a useful technique to aid the diagnosis of cervical weakness allowing a rational selection for treatment with prophylactic cervical cerclage.

Adolescent↗
PubMed2004

High and low dose oxytocin in augmentation of labor.

OBJECTIVE: To compare the efficacy and safety of high dose oxytocin in the augmentation of labor. METHOD: Two hundred pregnant women requiring augmentation of labor were randomly assigned to receive oxytocin by either a low dose protocol (1.5 microm/min initially, increased by 1.5 microm/min every 30 min) or a high dose protocol (4.5 microm/min initially, increased by 4.5 microm/min every 30 min). RESULTS: High dose of oxytocin was associated with a significant shortening of labor 4 (1.10-10) vs. 6 (1-10) h, p<0.0001 without a significant difference in cesarean delivery rate, neonatal and maternal outcome. CONCLUSION: The use of high dose oxytocin is associated with significantly shorter labor without any adverse fetal and maternal effects.

Adult↗
PubMed2006

A randomised double-blinded controlled trial of the effect of diluent volume on the efficacy of a single dose of epidural ropivacaine for labour analgesia.

BACKGROUND: Few studies have systematically investigated the effect of diluent volume on the efficacy of epidural local anaesthetics for labour analgesia and no data are available for ropivacaine. Our aim was to compare epidural ropivacaine given in three different volumes for labour analgesia. METHODS: In a double-blinded study, we randomly assigned 60 labouring parturients with cervical dilatation <5 cm to receive epidural ropivacaine 30 mg diluted to 5 mL (group 5, n=20), 10 mL (group 10, n=20) or 20 mL (group 20, n=20) for analgesia. We measured visual analogue scale pain scores at the peak of contraction for 30 min plus onset and duration of analgesia. RESULTS: Pain scores at 30 min were similar among group 5 (median 22 [interquartile range 0-44] mm), group 10 (9 [0-21] mm) and group 20 (37 [0-51] mm), P=0.35. The number of patients who achieved a decrease in pain score to < or =30% of baseline was similar among group 5 (12/20 (60%)), group 10 (17/20 (85%)) and group 20 (11/19 (58%)), P=0.13. Onset and duration of analgesia, the incidence of motor block and patient satisfaction were similar among groups. CONCLUSIONS: Under the conditions of this study, within the range of 5-20 mL, the volume and concentration were not significant factors influencing the efficacy of a single 30-mg bolus of epidural ropivacaine given for labour analgesia. This suggests that the most important factor influencing analgesic efficacy was drug mass.

Adult↗
PubMed2005

Macrophages and not granulocytes are involved in cervical ripening.

To clarify the role of leucocytes in human cervical ripening and dilatation, cervical biopsies were obtained from six non-pregnant women, eight women undergoing early termination of pregnancy, 18 pregnant women undergoing elective Caesarean section at term (both with and without a ripe cervix as determined by Bishop score) and 11 women after term vaginal delivery. Leucocytes were localised by immunohistochemistry labelling and quantified in subepithelial and deep stromal areas. CD45+ leucocytes were more numerous in the subepithelial area of the cervix than in the deep stroma in all groups (P<0.01). CD14+ macrophages and CD15+ granulocytes were increased in both the subepithelial and deep stromal areas only in the vaginal delivery group (P<0.01). The number of macrophages in the ripening cervix (Bishop score above 4) was higher than in the unripe cervix (Bishop score 4 or less; P<0.05) with no differences in other leucocyte populations. CD3+ CD8+ T cells in the subepithelial area were reduced in late pregnancy and after vaginal delivery (P<0.01), but showed no relationship to Bishop score. Macrophages and granulocytes may be involved in the process of cervical dilatation, but macrophage infiltration into the ripening cervix before labour suggests their role in the ripening process. Reduced numbers of CD3+ CD8+ T-lymphocytes in late pregnancy and after vaginal delivery suggests that local immunity is down-regulated in the late pregnancy period. Regional differences in leucocyte subpopulations in the cervix indicate that leucocyte infiltration is likely to be regulated by local factors.

Antigens, CD↗
PubMed2005

Preliminary evaluation of a coping strategy enhancement method of preparation for labour.

OBJECTIVES: To compare the use and effects of enhanced pre-existing coping strategies with the use and effects of coping strategies usually taught in National Health Service (NHS) antenatal education on women's experience of pain and emotions during labour. DESIGN: A between-group comparison of women who chose to attend NHS antenatal education where courses of preparation were randomly assigned to include either a new method of coping strategy enhancement (CSE) or standard taught coping strategies. SETTING: Two large maternity units in one city in the North of England. PARTICIPANTS: 20 women participated in antenatal classes incorporating the CSE method and 21 women participated in antenatal classes incorporating the standard approach to developing coping strategies for labour. FINDINGS: Women who attended CSE classes used enhanced coping strategies for a larger proportion of their labour than women who attended standard classes who used taught coping strategies. Birth companions were more involved in women's use of enhanced than taught strategies. Self-efficacy for use of coping strategies and subsequent experiences of pain and emotions during labour were equivalent between groups. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: An approach based on enhancing pre-existing coping strategies was associated with greater coping strategy use and involvement from the birth companion, and provided benefits to women's overall experience of labour at least equivalent to that associated with standard preparation. Further research should explore this novel approach in larger groups, and for women who may choose not to attend group antenatal preparation.

Adaptation, Psychological↗
PubMed1991

Umbilical artery blood flow velocity waveforms during variable deceleration of the fetal heart rate.

Blood flow velocities of the umbilical arteries were measured by Doppler ultrasonography during variable decelerations of the fetal heart rate. The flow velocity waveforms, being normal between uterine contractions, showed either an unchanged flow velocity waveform with an exclusive fetal heart rate effect on end-diastolic velocities or a rapid change to absent and reverse diastolic flow during the decelerations, indicating an abrupt increase in placental resistance with a halt in placental perfusion. Computer-aided reconstruction of the fetal heart rate curve revealed the exact temporal relationship between the reduction of umbilical artery perfusion and deceleration of fetal heart rate. We showed that variable decelerations of fetal heart rate can be observed during only slightly changed umbilical perfusion or can be caused by a halt in placental perfusion, which does not necessarily mean an absence of any movement of the fetal blood column, but is a result of a systolic forward and diastolic reverse flow to the same extent.

Blood Flow Velocity↗
PubMed1993

Collagenase, its inhibitors, and decorin in the lower uterine segment in pregnant women.

OBJECTIVE: It is postulated that collagenase activity in the cervix and lower uterine segment is important for dilatation at the time of labor. If so, the enzyme must partially escape from control by inhibitors. A second hypothesis is that an elevated ratio of decorin (dermatan sulfate proteoglycan) to collagen may also contribute to the dilatation process. STUDY DESIGN: The activity of collagenase, its natural inhibitors (tissue inhibitor of metalloproteinase-1 and alpha 2-macroglobulin), elastase, hydroxyproline (collagen), and decorin were quantified in biopsies of the lower uterine segment at term (not dilated) and during active labor. RESULTS: Collagenase concentration is 23 times higher in the cervix of patients in labor than at term. The sum of alpha 2-macroglobulin plus tissue inhibitor of metalloproteinase-1 increased only twofold in labor, as did elastase. The ratio of decorin to collagen doubled. CONCLUSION: The imbalance caused by collagenase increasing much more than its inhibitors may contribute to collagen breakdown and dilatation. Neutrophils may be responsible for much of this increase of collagenase. The increased ratio of decorin to collagen supports the hypothesis that the interaction of these two components is important in dilatation.

Adult↗
PubMed1992

Presacral neurectomy for the treatment of pelvic pain associated with endometriosis: a controlled study.

OBJECTIVE: Our objective was to evaluate the efficacy of presacral neurectomy combined with conservative surgery for the treatment of pelvic pain associated with endometriosis. STUDY DESIGN: In a randomized, controlled study performed in a tertiary institution 71 patients with moderate or severe endometriosis and midline dysmenorrhea were randomly assigned to conservative surgery alone (n = 36) or conservative surgery and presacral neurectomy (n = 35). Main outcome measures were relief of dysmenorrhea, pelvic pain, and deep dyspareunia after surgery according to a multidimensional and an analog pain scale. RESULTS: Presacral neurectomy markedly reduced the midline component of menstrual pain, but no statistically significant differences were observed between the two groups in the frequency and severity of dysmenorrhea, pelvic pain, and dyspareunia in the long-term follow-up. After presacral neurectomy, constipation developed or worsened in 13 patients and urinary urgency occurred in three and a painless first stage of labor in two. CONCLUSION: Presacral neurectomy should be combined with conservative surgery for endometriosis only in selected cases.

Adult↗
PubMed1984

The scalp stimulation test: a clinical alternative to fetal scalp blood sampling.

Intrapartum fetal heart rate response to various scalp stimuli and its correlation with scalp pH was studied in a prospective manner. One hundred fetuses with heart rate tracings judged by the resident responsible for the patient to be suggestive of fetal asphyxia were entered into the study. Each fetus was subjected to firm digital pressure on the head followed by a gentle pinch of the scalp with an atraumatic clamp. Scalp blood sampling was then performed in the usual manner. Response to either of these stimuli by an acceleration of the fetal heart rate of 15 bpm lasting at least 15 seconds was uniformly associated with a scalp blood pH of greater than or equal to 7.19. Fifty-one fetuses so stimulated responded with an acceleration. Of the remaining fetuses, 19 had a scalp pH less than 7.19 and 30 were associated with a pH greater than 7.19. Clinical application of such a scalp stimulation test could, therefore, reduce the necessity for scalp blood sampling by approximately 50% in the presence of a fetal heart rate pattern suggesting acidosis. Such a provocative test may also be very useful with an abnormal fetal heart rate pattern suggestive of acidosis when the cervix is sufficiently dilated to permit scalp blood sampling.

Female↗
PubMed1998

The role of cytokines in cervical ripening: correlations between the concentrations of cytokines and hyaluronic acid in cervical mucus and the induction of hyaluronic acid production by inflammatory cytokines by human cervical fibroblasts.

OBJECTIVES: The purpose of our study was (1) to explain the relationship between levels of inflammatory cytokines and levels of hyaluronic acid in cervical mucus of pregnant women and (2) to investigate whether cytokines promote hyaluronic acid production by human cervical fibroblasts in vitro. STUDY DESIGN: The concentration of hyaluronic acid, interleukin-1beta, and interleukin-8 were measured in cervical mucus of pregnant women, and hyaluronic acid production by cytokine-treated (interleukin-1beta and interleukin-8) cultured fibroblasts was measured. RESULTS: Hyaluronic acid concentrations in the mucus of pregnant women with threatened premature labor were higher than in mucus of normal pregnant women (P < .05). Correlations were found between hyaluronic acid concentrations and interleukin-1beta (P = .018) and interleukin-8 (P = .003) concentrations in cervical mucus. Cytokines (especially interleukin-8) stimulated hyaluronic acid production by cultured cervical fibroblasts. CONCLUSION: Cytokines induce hyaluronic acid production by human cervical fibroblasts, which may promote cervical ripening.

Adult↗