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PubMed1992

Endothelin-1,2 levels are increased in the amniotic fluid of women with preterm labor and microbial invasion of the amniotic cavity.

The purpose of this study was to determine the effect of gestational age, labor, and microbial invasion of the amniotic cavity on amniotic fluid concentrations of endothelin-1,2. Amniotic fluid was retrieved by amniocentesis from 148 women: patients at term with and without labor, patients with preterm labor with and without intraamniotic infection, and women in the second trimester of pregnancy. Endothelin-1,2 was measured by a sensitive and specific radioimmunoassay. Immunoreactive endothelin-1,2 was detectable in all samples of human amniotic fluid. Advancing gestational age and spontaneous term labor did not result in changes in amniotic fluid concentrations of endothelin-1,2. Women with preterm labor and positive amniotic fluid cultures for microorganisms had higher amniotic fluid concentrations of endothelin-1,2 than did those without microbial invasion of the amniotic cavity (p less than 0.05). These results support a role for endothelins in the mechanisms responsible for preterm delivery associated with intraamniotic infection.

Adult↗
PubMed1993

Antibiotic treatment of preterm labor with intact membranes: a multicenter, randomized, double-blinded, placebo-controlled trial.

OBJECTIVE: Although an association between subclinical intrauterine infection and preterm birth is well established, there is conflicting evidence regarding the benefits of antibiotic administration to women in preterm labor with intact membranes. We attempted to determine the effect of ampicillin-amoxicillin and erythromycin treatment on prolongation of pregnancy, the rate of preterm birth, and neonatal morbidity in patients with preterm labor and intact membranes. STUDY DESIGN: A multicenter, randomized, double-blinded, placebo-controlled trial was designed and implemented by the Maternal-Fetal Medicine Units Network of the National Institute of Child Health and Human Development. Two hundred seventy-seven women with singleton pregnancies and preterm labor with intact membranes (24 to 34 weeks) were randomly allocated to receive either antibiotics or placebos. RESULTS: Of the 2373 patients screened for participation in this study in six medical centers, 277 women were enrolled (n = 133 for antibiotics group vs n = 144 for placebo group). In each study group, 60% of patients completed all the study medications. The overall prevalence of microbial invasion of the amniotic cavity was 5.8% (14/239). No significant difference between the antibiotic group and the placebo group was found in maternal outcomes, including duration of randomization-to-delivery interval, frequency of preterm delivery (< 37 weeks), frequency of preterm premature rupture of membranes, clinical chorioamnionitis, endometritis, and number of subsequent admissions for preterm labor. Similarly, no significant difference in neonatal outcomes could be detected between the two groups including respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, sepsis, and admission and duration of newborn intensive special care unit hospitalization. CONCLUSION: The results of this study do not support the routine use of antibiotic administration to women in preterm labor with intact membranes.

Administration, Oral↗
PubMed1993

Interleukin-6 levels in amniotic fluid in normal and abnormal pregnancies: preeclampsia, small-for-gestational-age fetus, and premature labor.

OBJECTIVE: Our purpose was to determine if abnormal amniotic fluid interleukin-6 levels correlate with pregnancies complicated by preeclampsia, small-for-gestational-age fetus, and premature labor. STUDY DESIGN: A case control study design was used to compare third-trimester amniotic fluid interleukin-6 levels from women with normal pregnancies (n = 25) and pregnancies complicated by preeclampsia (n = 15), small-for-gestational-age perinates (n = 8), and premature labor (n = 29). RESULTS: Amniotic fluid interleukin-6 levels in women with preeclampsia and small-for-gestational-age perinates were less than in controls (p < 0.01). Interleukin-6 levels in women with preterm labor refractory to tocolysis were higher than those in women with preterm labor responsive to tocolysis (p < 0.01). CONCLUSIONS: Interleukin-6 is normally present in amniotic fluid. In the third trimester of pregnancy low levels correlate with small-for-gestational-age fetuses and preeclampsia, whereas elevated levels correlate with preterm labor and delivery.

Amniotic Fluid↗
PubMed1993

Maternal placental vasculopathy and infection: two distinct subgroups among patients with preterm labor and preterm ruptured membranes.

OBJECTIVE: Our aim was to find out whether patients delivered preterm because of preterm labor or preterm premature rupture of membranes can be categorized according to clinical characteristics and placental pathologic findings. STUDY DESIGN: We performed a case-control study of 105 patients who were delivered preterm, 42 because of preterm labor and 63 because of premature rupture of membranes, and 105 patients who were delivered at term after uncomplicated pregnancies. RESULTS: Maternal placental vascular lesions were present in 14 (34.1%) patients with preterm labor, 19 (35.1%) patients with premature rupture of membranes, and 9 (11.8%) control patients (odds ratios 3.8 and 4.0, 95% confidence intervals 1.3 to 11.1 and 1.5 to 10.8, p = 0.0065 and 0.0022, respectively). Infection of the products of conception was found in 16 patients (38%) with preterm labor, 23 patients (36.5%) with premature rupture of membranes, and 19 control patients (18%) (odds ratios 2.7 and 2.6, 95% confidence intervals 1.1 to 6.6 and 1.2 to 5.6, p = 0.017 and 0.01, respectively). Patients with maternal placental vasculopathy had significantly different characteristics compared with those of infected patients. CONCLUSIONS: It is possible to identify two subgroups of patients among those who are delivered preterm because of preterm labor or premature rupture of membranes, one with infection of the products of conception and another with maternal placental vasculopathy.

Case-Control Studies↗
PubMed1995

Fetal oxytocin and its extended forms at term with and without labor.

OBJECTIVE: We examined the concentrations of oxytocin and extended forms of oxytocin in umbilical plasma with and without labor. STUDY DESIGN: Umbilical venous and arterial blood were sampled in 27 term fetuses delivered vaginally and 13 delivered abdominally before labor. Extended forms and oxytocin were measured by radioimmunoassay and compared by analysis of variance or t test. RESULTS: Concentrations of extended forms were higher than oxytocin concentrations (24.7 +/- 3.1 vs 6.1 +/- 1.2 pg/ml, p < 0.01). Extended forms were higher in umbilical venous than in arterial plasma (29.6 +/- 5.0 vs 19.8 +/- 3.1 pg/ml, p < 0.05); oxytocin concentrations were not significantly different (4.7 +/- 1.6 vs 7.8 +/- 1.8 pg/ml). Concentrations of extended forms were markedly lower with than without labor (17.1 +/- 3.0 vs 37.1 +/- 5.7 pg/ml, p = 0.01). Ratios of extended forms over oxytocin decreased with labor. CONCLUSION: In umbilical plasma extended forms of oxytocin are more abundant than oxytocin. Extended forms originate in the uterus and decrease markedly with labor.

Female↗
PubMed1995

New perspectives for the effective treatment of preterm labor.

Preterm birth (before 37 completed weeks of gestation) continues to account for the vast majority of neonatal morbidity and mortality. The incidence of preterm birth can be reduced by appropriate social interventions and antenatal care. Currently available tocolytic agents suffer from low uterospecificity and prolong pregnancy only marginally, although postponement of birth by a few days may be of some value. Further progress is needed in at least four areas: prevention of preterm labor; identification of preterm labor; selection of candidates for tocolysis, and treatment of preterm labor. Effective, early treatment of vaginosis offers particular promise for the prevention of preterm labor and identification of specific biochemical markers will facilitate early detection of this process. Oxytocin antagonists offer greater specificity than current tocolytics and can be expected to show improved efficacy and risk profiles. Such compounds will allow more effective treatment of preterm labor with a lower risk of side effects.

Female↗
PubMed1995

Early versus late amniotomy for labor induction: a randomized trial.

OBJECTIVE: Our purpose was to determine the impact of early and late amniotomy on labor induction with continuous oxytocin infusion at term. STUDY DESIGN: A total of 209 women admitted for labor induction were randomized to early or late amniotomy. The early amniotomy group (n = 106) had membranes ruptured as soon as it was deemed safe and feasible. The late amniotomy group (n = 103) had membrane rupture performed at > or = 5 cm dilatation. The first 103 women received a continuous oxytocin infusion with incremental adjustments at 60-minute intervals as required. The next 106 women had adjustments every 30 minutes as required. Statistical analysis was confined to concurrent groups. RESULTS: Early amniotomy was associated with shorter labor (13.3 vs 17.8 hours, p = 0.001), chorioamnionitis (22.6% vs 6.8%, p = 0.002), and significant fetal umbilical cord compression (12.3% vs 2.9%, p = 0.017). The benefit regarding shortening of labor was limited to women having oxytocin increments every 30 minutes as required (13.3 vs 17.8 hours, p = 0.001). Alternatively, the increase in chorioamnionitis was confined to the 60-minute group (39% vs 11%, p < 0.001), which also demonstrated a trend toward increased moderate and severe variable decelerations (19.6% vs 6.4%, p = 0.08). CONCLUSIONS: When a protocol of 60-minute increments in oxytocin infusion rate is desired, amniotomy should be performed late in labor to reduce chorioamnionitis and significant umbilical cord compression. Alternatively, if early amniotomy is necessary, oxytocin should be adjusted every 30 minutes as tolerated.

Adolescent↗
PubMed1995

A comparison of misoprostol and prostaglandin E2 gel for preinduction cervical ripening and labor induction.

OBJECTIVE: Our purpose was to compare the safety and efficacy of intravaginal misoprostol versus intracervical prostaglandin E2 (dinoprostone) gel for preinduction cervical ripening and induction of labor. STUDY DESIGN: One hundred thirty-five patients with indications for induction of labor and unfavorable cervices were randomly assigned to receive either intravaginal misoprostol or intracervical dinoprostone. Fifty microgram tablets of misoprostol were placed in the posterior vaginal fornix every 3 hours for a maximum of six doses. Prostaglandin E2 in gel form, 0.5 mg, was placed into the endocervix every 6 hours for a maximum of three doses. Medication was not given after either spontaneous rupture of membranes or beginning of active labor. RESULTS: Among 135 patients enrolled, 68 received misoprostol and 67 received dinoprostone. The average interval from start of induction to vaginal delivery was shorter in the misoprostol group (903.3 +/- 482.1 minutes) than in the dinoprostone group (1410.9 +/- 869.1 minutes) (p < 0.001). Oxytocin augmentation of labor occurred more often in the dinoprostone group (65.7%) than in the misoprostol group (33.8%) (p < 0.001). There were no significant differences between routes of delivery. Ten of the misoprostol-treated patients (14.7%) and 13 of the dinoprostone-treated patients (19.4%) had cesarean deliveries. There was a higher prevalence of tachysystole (six or more uterine contractions in a 10-minute window for two consecutive 10-minute periods) in the misoprostol group (36.7%) than in the dinoprostone group (11.9%) (p < 0.001). However, there were no significant differences in frequency of uterine hyperstimulation or hypertonus. There was a higher prevalence of meconium passage in the misoprostol group (27.9%) than in the dinoprostone group (10.5%) (p < 0.05). There was no significant difference in frequency of abnormal fetal heart rate tracings, 1- or 5-minute Apgar scores < 7, neonatal resuscitations, or admissions to the neonatal intensive care unit between the two groups. CONCLUSIONS: Vaginally administered misoprostol is an effective agent for cervical ripening and induction of labor; however when given at this dosage, it is associated with a higher prevalence of tachysystole and meconium passage than is dinoprostone. Further studies to compare the safety of misoprostol to that of dinoprostone and to delineate an optimal dosing regimen for misoprostol are needed.

Adult↗
PubMed1995

Misoprostol: an effective agent for cervical ripening and labor induction.

OBJECTIVE: Our purpose was to compare the safety and efficacy of intravaginal misoprostol versus intracervical prostaglandin E2 gel (dinoprostone) for preinduction cervical ripening and induction of labor. STUDY DESIGN: Two hundred seventy-six patients with indications for induction of labor and unfavorable cervices were randomly assigned to receive either intravaginal misoprostol or intracervical dinoprostone. Twenty-five micrograms of misoprostol were placed in the posterior vaginal fornix every 3 hours, with a potential maximum of eight doses. Prostaglandin E2 in gel form, 0.5 mg, was placed in the endocervix every 6 hours, with a maximum of three doses. Further medication was withheld with the occurrence of spontaneous rupture of membranes, entry into active phase of labor, or a "prolonged contraction response." RESULTS: Among those evaluated, 138 received misoprostol and 137 received dinoprostone. The average interval from start of induction to vaginal delivery was shorter in the misoprostol group (1323.0 +/- 844.4 minutes) than in the dinoprostone group (1532.4 +/- 706.5 minutes) (p < 0.05). Need for oxytocin augmentation of labor occurred more commonly in the dinoprostone group (72.6%) than in the misoprostol group (45.7%) (p < 0.0001). There were no significant differences in the routes of delivery. Twenty-eight of the misoprostol-treated patients (20.3%) and thirty-eight of the dinoprostone-treated patients (27.7%) required abdominal delivery. Complications such as uterine tachysystole and thick meconium passage occurred with similar frequency in the two treatment groups. CONCLUSIONS: Intravaginal administration of misoprostol appears to be as effective as intracervical dinoprostone for cervical ripening and labor induction. Complications associated with prostaglandin administration were not statistically different between the two treatment groups. The cost of misoprostol ($0.36/100 micrograms) is much less than that of dinoprostone ($75/0.5 mg).

Cervix Uteri↗
PubMed1983

Induction of labor with oral prostaglandin E2 tablets in high-parity patients.

Labor was induced with two low-dose regimens of prostaglandin E2 (PGE2) tablets in 46 high-parity women at term who had singleton pregnancies with a success rate of 97.8%. Of the successfully induced patients, 42 had vaginal delivery and three were delivered by cesarean section for cephalopelvic disproportion. There was one failure of induction. Both dose regimens (0.5 mg and 0.75 mg hourly) were equally effective in inducing labor. The pattern of labor and mean induction-delivery interval of 5.8 h was similar to a comparable group of high-parity patients with spontaneous labor. It appears from this study that induction of labor with PGE2 tablets is safe in high-parity patients.

Administration, Oral↗
PubMed1990

A comparative randomized study of oral prostaglandin E2 (PGE2) tablets and intravenous oxytocin in induction of labor in patients with premature rupture of membranes before 37 weeks of pregnancy.

In a randomized prospective study, we compared the use of intravenous oxytocin with oral PGE2 tablets for stimulation of labor in cases of premature rupture of membranes (PROM) before term, where the onset of spontaneous labor did not occur within the first 3 h. This study represents the first of its kind in which oral PGE2 and oxytocin have been directly compared as oxytocic agents for PROM before 37 weeks. Labor induction was successful in 96% of patients in the PGE2 group compared with 84% in the oxytocin group. The incidence of cesarean section (CS) was 5% and 16% in the PGE2 and the oxytocin groups, respectively. While 10% of the CS were performed due to fetal bradycardia in the oxytocin group, none was performed in the PGE2 group despite the fact that the latter group had relatively lower Bishop scores. The data presented indicate that oral PGE2 is safe and effective in initiating active labor in healthy women at pre-term with PROM. Thus we recommend its use to induce labor 3 h after rupture of membranes before 37 weeks gestation.

Administration, Oral↗
PubMed1994

Duration of labor in patients delivered vaginally after one previous lower segment cesarean section.

OBJECTIVES: To determine the presence or significance of labor patterns in women attempting vaginal birth after a previous cesarean. METHODS: This prospective study was performed for patients who have only had one prior birth by cesarean section. Eighty-four women who had a cesarean section for failure to progress in labor had a trial of labor. RESULTS: Fifty-eight were delivered vaginally. This has been matched to nulliparous and multiparous controls. The duration of the first and second stages of labor were similar in the study group and controls. There was no significant difference in oxytocin requirements among the three groups. CONCLUSIONS: Patients who have had a previous cesarean section for failure to progress, have a duration of labor similar to primiparous patients.

Cesarean Section↗
PubMed1994

Maternal genital Chlamydia trachomatis infection and the risk of preterm labor.

OBJECTIVE: To determine the association between maternal genital Chlamydia trachomatis infection in pregnancy and the risk of preterm labor. The hypothesis tested was that a greater proportion of women experiencing preterm labor would have Chlamydia trachomatis than controls who were not experiencing preterm labor. METHODS: A case-control study in Yaoundé (Cameroon), involving 126 women of gestational age between 28 and 34 weeks, using serology and cervical swab cultures. Data analysis involved simple comparative descriptive statistics as well as univariate and multivariate analysis. RESULTS: The odds of experiencing preterm labor and having genital chlamydial infection were 72.59 (exact 95% C.I. 0.99-7.14); O.R.MH (Mantel-Haenszel) 2.80 (approximate 95% C.I. 1.13-6.97) using serological tests. The proportion of women with positive cervical swab cultures was statistically significantly different between cases and controls (Fisher's exact test, P = 0.02). CONCLUSION: Routine screening and treatment of pregnant women with Chlamydia trachomatis (along with their partners) may be beneficial in reducing the incidence of preterm labor and delivery and hence the perinatal mortality rate.

Case-Control Studies↗
PubMed1995

Low-dose vaginal misoprostol for induction of labor with a live fetus.

OBJECTIVE: To test the effectiveness and safety of low-dose vaginal misoprostol for induction of labor with a live fetus. METHODS: Labor was induced in 666 pregnant women with a live fetus in the cephalic position, who had no medical complications and no history of uterine surgery. One-fourth of a 200-micrograms tablet of misoprostol (50 micrograms) was placed in the posterior vaginal fornix every 12 h for a maximum of four doses or until active labor commenced. Time from induction to delivery, side effects and neonatal outcome were evaluated. RESULTS: Labor was successfully induced in all cases. The mean time from induction to delivery was 10.4 h. The cesarean section rate was 7.8%. There were eight perinatal deaths, six of which occurred in low birth weight fetuses. There was one case of abruptio placenta, which was less than that expected in the study population. CONCLUSION: Vaginal misoprostol, in very low doses, was a remarkably efficient and safe method for induction of labor with a live fetus.

Administration, Intravaginal↗
PubMed1986

Intracervical application of prostaglandin E2 tablets for elective induction of labor in grand multiparae: a prospective controlled study.

In a prospective and controlled study labor was induced electively in 150 grand multiparae (GM) between 38 and 42 wk gestation by intracervical application of PGE2 tablets (induction group). Another 150 GM who went into labor spontaneously served as controls for comparison of labor characteristics and outcome (control group). In the induction group labor was successfully induced in 147 GM (98.0%), of whom 142 (96.5%) delivered vaginally. The mean duration of the active phase of labor was 2.1 +/- 0.79 h in GM who delivered on the first day of induction and 2.8 +/- 0.47 h in women who delivered on the second day, as compared to 4.7 +/- 2.2 h in the controls. Similarly, the mean duration of the second and third stage was longer in the controls. Operative deliveries were 2--3-times more frequent among controls, as were complications in the second and third stages. The group profiles of the I.U.P. charts indicating rise time, fall time, amplitude and Montevideo units at different stages of cervical dilatation showed significant differences at 4-5 cm dilatation only between the two groups of women. It is concluded that elective induction in GM between 38 and 42 wk is safe for mother and fetus.

Adult↗
PubMed1995

A randomized trial of management of pre-labor rupture of membranes at term in multiparous women using vaginal prostaglandin gel.

OBJECTIVE: To compare conservative management of pre-labor spontaneous rupture of membranes (SROM) with the use of prostaglandin (PG) E2 in healthy parous women at term (gestational age at least 37 weeks). METHODS: An open randomized study was conducted with 100 parous women; 50 were treated conservatively for 24 hours, and 50 were managed actively using PGE2 gel (1 mg), administered at admission and repeated 6 hours later if labor was not established. Both groups received intravenous oxytocin if labor did not start within 24 hours after admission. RESULTS: The use of PGE2 gel led to a significant reduction in the mean interval (+/- standard error of the mean) from SROM to onset of labor: 17.26 +/- 1.51 hours in the conservative group versus 6.50 +/- 1.23 in the PGE2 group. A significantly smaller proportion of subjects required oxytocin in the PGE2 group (12 versus 38%, P < .02). The two groups were comparable with respect to analgesic requirements. Within 24 hours of SROM, 80% of the women in the PG group and 56% in the conservative group had delivered (P < .02). Most women delivered vaginally, 96% of those managed conservatively and 100% of those managed actively with PGE2. CONCLUSION: Active management using PGE2 gel in parous women with pre-labor SROM significantly improves the time to delivery without influencing the cesarean rate or fetal-maternal infective morbidity.

Administration, Intravaginal↗
PubMed1996

Adjunctive antibiotic treatment in preterm labor and neonatal morbidity: a meta-analysis.

OBJECTIVE: To estimate the effect of prophylactic antibiotics on neonatal mortality and morbidity in patients with preterm labor, based on a meta-analysis of seven published randomized clinical trials. DATA SOURCES: We searched 18 medical data bases, including MEDLINE from 1964 and EMBASE from 1974, to identify all literature included under preterm or premature labor and antibiotics. We scanned all abstracts from the computer printouts, the retrieved full-text reports, the references from each retrieved report, and review articles to determine whether studies met our inclusion criteria. METHODS OF STUDY SELECTION: The following criteria were used to select studies for inclusion: article-original published report written in English; study design-randomized controlled trial; population-patients with preterm labor, defined as labor before 37 weeks' gestation; intervention-antibiotic treatment; and one or more of the following outcomes-neonatal mortality, sepsis, pneumonia, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. TABULATION, INTEGRATION AND RESULTS: We analyzed study patients and methods, and abstracted quantitative outcome data. For each outcome, both odds ratio (OR) and 95% confidence interval (CI) were calculated. Seven trials, published between 1989 and 1995 included a total of 795 patients. Adjunctive antibiotic therapy appeared to reduce the risk of pneumonia (OR 0.45, 95% CI 0.12-1.72) and necrotizing enterocolitis (OR 0.38, 95% CI 0.14-1.08) and to increase the risk of neonatal mortality (OR 3.25, 95% CI 0.93-11.38), but it had no effect on neonatal sepsis (OR 0.98, 95% CI 0.34-2.83), respiratory distress syndrome (OR 0.93, 95% CI 0.54-1.87), and intraventricular hemorrhage (OR 1.01, 95% CI 0.20-5.10). None of the effects observed reached a significance level of P < .05. CONCLUSION: The results of this meta-analysis do not support the routine use of adjunctive antibiotic treatment in patients with preterm labor diagnosed on the basis of subjective uterine contractions and the resulting cervical changes.

Anti-Bacterial Agents↗
PubMed1987

Increase in urinary thromboxane excretion during pregnancy and labor.

Urinary TXB2 excretion was measured during pregnancy and labor using high pressure liquid chromatography and radioimmunoassay. From the first trimester onwards TXB2 levels in urine of pregnant women (n = 60) were significantly (p less than 0.001) higher than in non-pregnant women (n = 12) and they increased, albeit not significantly, with advancing gestation. Labor was associated with a two-fold increase in urinary TXB2 excretion. Levels in established labor were significantly higher than at any other time in pregnancy (p less than 0.001), but the levels in incipient labor showed considerable overlap with these in late pregnancy. Thus urinary TXB2, while not necessarily originating from the pregnant uterus, appears to reflect the uterine activity of labor and may be the expression of a general stimulation of prostanoid production during parturition.

Adult↗