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PubMed1998

Different patterns of obstetric complications in myotonic dystrophy in relation to the disease status of the fetus.

The obstetric histories of 26 women with myotonic dystrophy (DM), who had a total of 67 gestations, were reviewed retrospectively comparing gestations with affected (DM-fetuses) and unaffected fetuses (UA-fetuses). Second, the influence of gestation on the disease course and the personal attitude towards family planning in DM was assessed. Miscarriages and terminations occurred in 11 pregnancies. Of the 56 infants carried to term, 29 had or most likely had inherited the gene for DM from their affected mothers at the time of investigation; 18 (61%) in this series were affected by the congenital form of DM. Perinatal loss rate was 11% and associated with congenital DM. The rate of obstetric complications was significantly increased in all women. However, preterm labor was a major problem in gestations with DM-fetuses (55 vs. 20%), as was polyhydramnios (21% vs. none). While forceps deliveries or vacuum extractions were required in 21% of deliveries with DM-fetuses and only 5% of UA-fetuses, the frequency of Cesarean sections was similar in both groups (24 and 25%). Obstetric problems were inversely correlated with age at onset of maternal DM, while no effect of age at delivery or birth order on gestational outcome was seen. DNA analysis confirmed the diagnosis in 19 patients by the presence of enlarged CTG repeats (EcoRI-expansions) on chromosome 19. Of the 17 patients whose CTG repeat length was known, 59% were classified as E2 (corresponding to 500-1000 repeats), 24% as E1 (<500 repeats), while larger expansions (E3; 1000-1500 repeats, or E4; >1500 repeats) were seen in three patients (17%). Obstetric complications or congenitally affected children occurred in all maternal phenotypes and CTG repeat classes. Eight (31%) patients experienced a worsening of symptoms that was temporary, weight related in three cases, and persistent in five. With the exception of three patients, most new mothers were able to care for their families. To conclude, pregnant women with DM need constant obstetric monitoring and should be advised to deliver in centres with perinatal facilities.

Adult↗
PubMed2002

Fetal shoulder dystocia.

Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%. An increase in the incidence of shoulder dystocia has been recorded over the last 20 years, probably just because it has now been regularly registered at maternity wards as an obstetric complication. The risk factors for shoulder dystocia include fetal macrosomia, fetal malformations and tumors, maternal adiposity, excessive weight gain during pregnancy, diabetes mellitus, pathologic pelvis, multiparity, short maternal stature, advanced maternal age, postterm pregnancy, so-called midforceps delivery or vacuum extraction, prolonged delivery stage II, oxytocin labor induction, premature fetal expression according to Kristeller, and previous shoulder dystocia in macrosomatic children. The sequels of shoulder dystocia and obstetric maneuvers for incarcerated shoulder release include clavicular fracture, brachial plexus lesions, sternocleidomastoid muscle distension with or without hematoma, diaphragmatic paralysis, Horner's syndrome, peripartal asphyxia and consequential cerebral lesions (cerebral palsy), and peripartal death. Maternal complications due to shoulder dystocia are postpartal hemorrhage, cervical and vaginal lacerations, frequent infections during the puerperium, symphysiolysis and rupture of the uterus, and secondary cesarean section with related complications due to unsuccessful obstetric procedures or as continuation of Zavanelli's maneuver. McRoberts' maneuver (or Gaskin maneuver) is recommended as the initial procedure for shoulder release in case of shoulder dystocia. If it fails, other obstetric procedures such as Resnik's suprapubic pressure and Woods' grip with posteriorly placed arm release should be used, always with gross lateral episiotomy. The performance of all these obstetric procedures requires skilfull and highly experienced obstetrician and obstetric team as a whole.

Delivery, Obstetric↗
PubMed1997

Upgrading obstetric care at the health center level, Juaben, Ghana. The Kumasi PMM Team.

PRELIMINARY STUDIES: Inventory and observations at Juaben Teaching Health Center (JTHC) revealed an inability to treat obstetric complications. Women with complications needed to be referred to other institutions, resulting in delays. INTERVENTIONS: During 1993 and 1994, an operating theater and blood bank were established and equipped, the maternity refurbished, and a revolving drug fund created. A physician was posted and trained in obstetrics, and midwives were trained in life-saving skills. A running water supply was established. Subsequent community interventions focused on improving access and reducing the delay in seeking care. RESULTS: The number of women with complications coming for care increased almost three-fold, from 26 in 1993 to 73 in 1995 and the proportion of these who were referred for treatment dropped from 42 to 14%. Surgical obstetric procedures performed at JTHC increased from 23 in 1993 to 90 in 1995. Midwives performed 32% of manual removals, 58% of vacuum extractions and 98% of episiotomy repairs. No deaths occurred among the women treated. COSTS: The cost of improvements was approximately US $30,000, mostly for equipment and supplies. Forty percent came from project funds, 36% from non-governmental organizations (NGOs), 15% from government and 9% from community members. The salary of the new physician cost an additional $4700 annually. CONCLUSIONS: Modest improvements can increase the provision and utilization of emergency obstetric care. Collaboration with NGOs, government and the community can be beneficial.

Community Health Centers↗