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Preterm Labor
Author:
Edward R Newton, MD, Chairman, Professor, Department of
Obstetrics and Gynecology, Pitt County Memorial Hospital,
East Carolina University Brody School of
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Preterm and Age medline |
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Premature Labour Nursing care
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Premature Labour Prevention medline |
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Feeding Medline |
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Preterm Labor Management
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Tuberculosis and pregnancy.
Tripathy SN, Tripathy SN.
Department of Obstetrics and Gynecology, SCB Medical College, Cuttack, India
OBJECTIVES: There are many myths surrounding pregnancy and tuberculosis (TB),
and outcome of treatment. This prospective study was conducted at the Department
of Obstetrics and Gynecology, SCB Medical College, Cuttack, India, and at the
authors' private clinics from 1986 to 2001 to determine the outcome of pregnancy
if TB is treated properly. METHODS: A total of 111 pregnant women diagnosed as
having pulmonary and glandular TB were included in the study. They were matched
for age, parity, and socioeconomic status with 51 pregnant women without TB
(first control group), and 51 women with pulmonary TB but without pregnancy
(second control group). The usual pregnancy management was given to the women in
the study group, along with a short course of chemotherapy: either ethambutol,
INH, or rifampicin and pyrazinamide for 2 months followed by INH and rifampicin
for 4 months; or ethambutol, INH, and rifampicin for 2 months followed by INH
and rifampicin for 7 months. Statistical analysis was done using a chi(2)-test.
RESULTS: There were no statistical differences in duration of gestation, preterm
labor, and other complications of pregnancy, labor, and puerperium between the
pregnancy groups. There were no congenital anomalies in the babies born to the
groups. Pregnancy had no effect on the course of TB as regards sputum
conversion, stabilization of the disease, and non-relapse even after 2-5 years
of follow-up and a further delivery in a few cases. CONCLUSIONS: If proper and
adequate chemotherapy is given to pregnant women with TB, they are not a higher
risk than non-pregnant women with TB. Neither the disease nor chemotherapy is
threatening to mother or newborn. However, today the ominous combination of
human immunodeficiency virus, TB, and pregnancy poses a new challenge.
PMID: 12628525 [PubMed - in process]
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Preterm premature rupture of the membranes.
Mercer BM.
Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case
Western Reserve University, Cleveland, Ohio 44109-1989, USA.
Preterm premature rupture of membranes (PROM) affects over 120,000 pregnancies
annually in the United States and is associated with significant maternal,
fetal, and neonatal risk. Management of PROM requires an accurate diagnosis as
well as evaluation of the risks and benefits of continued pregnancy or
expeditious delivery. An understanding of gestational age-dependent neonatal
morbidity and mortality is important in determining the potential benefits of
conservative management of preterm PROM at any gestation. Where possible, the
treatment of pregnancies complicated by PROM remote from term should be directed
towards conserving the pregnancy and reducing perinatal morbidity due to
prematurity while monitoring closely for evidence of infection, placental
abruption, labor, or fetal compromise due to umbilical cord compression. Current
evidence suggests aggressive adjunctive antibiotic therapy to reduce gestational
age-dependent and infectious infant morbidity. Similarly, review of evaluable
data indicates that antenatal corticosteroid administration in this setting
enhances neonatal outcome without increasing the risk of perinatal infection. It
is not clear that tocolysis in the setting of preterm PROM remote from term
reduces infant morbidity. When preterm PROM occurs near term, particularly if
fetal pulmonary maturity is evident, the patient is generally best served by
expeditious delivery.
Publication Types:
PMID: 12517665 [PubMed - indexed for MEDLINE]
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[Article in German]
Hirtenlehner-Ferber K, Krampl E, Strohmer H, Husslein P.
Universitatsklinik fur Frauenheilkunde, Abteilung fur Geburtshilfe und
Gynakologie, Universitat Wien. Kora.Hirtenlehner@akh-wien.ac.at
The incidence of multiple pregnancies has increased considerably over the past
20 years in the western world. The number of twin pregnancies has increased by
approximately 25% and the rate of triplet and higher order multiple pregnancies
has more than doubled. This is due to the use of ovarian hyperstimulation and
assisted reproduction techniques, and to the increasing maternal age. Multiple
pregnancy can be considered as the most important adverse outcome of infertility
treatment. The main determinant for outcome and management of multiple
pregnancies is the chorionicity. This can be determined by ultrasound until 14
weeks of gestation. Twenty percent of all twin pregnancies are monochorionic,
and 15% of these develop severe twin to twin transfusion syndrome, which is best
treated by LASER separation of the communicating blood vessels. Obstetric
complications associated with multiple gestation also occur more frequently in
monochorionic twins. They include increased incidence of preterm labor,
intrauterine growth restriction and assisted or surgical delivery. Neonatal
problems include low birthweight and increased prevalence of congenital
malformations. Overall, there has been a decrease in neonatal mortality of twins
and triplets over the past 10 years, which is mainly due to the enormous
advances in neonatal intensive care.
PMID: 12584957 [PubMed - in process]
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An update on the controversies of tocolytic therapy for the
prevention of preterm birth.
Ingemarsson I, Lamont R.
Departments Obstetrics and Gynecology.
Acta Obstet Gynecol Scand 2003; 82: 1-9. Copyright Acta Obstet Gynecol Scand
2003 Preterm birth is the major cause of perinatal mortality and morbidity in
the developed world. Where there are no contraindications to their use,
tocolytics can improve neonatal survival rates by approximately 3% per day
between 23 and 27 weeks gestation with a concomitant reduction in morbidity. The
ultimate aim of tocolytic therapy is to prolong pregnancy until growth and
maturation is complete, but even short-term delay may enable the administration
of antepartum glucocorticoids to reduce hyaline membrane disease or to arrange
transfer to a center with neonatal intensive care facilities. Both of these have
been shown to reduce neonatal mortality and morbidity. Until recently, none of
the currently used tocolytics, whether licensed or unlicensed, were developed
specifically for the inhibition of preterm labor and consequently, they exhibit
various potentially serious side-effects. As a result of the recent licensing of
the oxytocin antagonist, atosiban, developed for the treatment of preterm labor
and due to its high utero-specificity, obstetricians have experienced an advance
in their options for the management of spontaneous preterm labor.
PMID: 12580832 [PubMed - in process]
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Terbutaline pump maintenance therapy after threatened preterm
labor for preventing preterm birth.
Nanda K, Cook LA, Gallo MF, Grimes DA.
Clinical Research Department, Family Health International, PO Box 13950,
Research Triangle Park, North Carolina 27709, USA. knanda@fhi.org
BACKGROUND: Women with preterm labor that is arrested with tocolytic therapy are
at increased risk of recurrent preterm labor. Terbutaline pump maintenance
therapy has been given to such women to decrease the risk of recurrent preterm
labor, preterm birth, and its consequences. OBJECTIVES: To determine the
effectiveness and safety of terbutaline pump maintenance therapy after
threatened preterm labor in preventing preterm birth and its complications.
SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials
register (searched May 2002) and the Cochrane Controlled Trials Register
(Cochrane Library Issue 2, 2002). SELECTION CRITERIA: Randomized trials
comparing terbutaline pump maintenance therapy with alternative therapy,
placebo, or no therapy after threatened preterm labor. DATA COLLECTION AND
ANALYSIS: Two reviewers independently assessed the studies for inclusion and
then extracted data from eligible studies. MAIN RESULTS: We included two
studies. Terbutaline pump maintenance therapy did not appear to offer any
advantages over the saline placebo pump or oral terbutaline maintenance therapy
in preventing preterm births by prolonging pregnancy or its complications among
women with arrested preterm labor. The weighted mean difference (WMD) for
gestational age at birth was -0.1 weeks (95% confidence interval (CI) -1.7 to
1.4) for terbutaline pump therapy compared with saline placebo pump for both
trials combined and 1.4 weeks (95% CI -1.1 to 3.9) for terbutaline pump versus
oral terbutaline therapy for the first trial. The second trial reported a
relative risk (RR) of 1.17 (95% CI 0.79 to 1.73) of preterm birth (less than 37
completed weeks) and a RR of 0.97 (95% CI 0.51 to 1.84) of very preterm birth
(less than 34 completed weeks) for terbutaline pump compared with saline placebo
pump. Terbutaline pump therapy also did not result in a higher rate of therapy
continuation or a lower rate of infant complications. No data were reported on
long-term infant outcomes, costs, or maternal assessment of therapy. REVIEWER'S
CONCLUSIONS: Terbutaline pump maintenance therapy has not been shown to decrease
the risk of preterm birth by prolonging pregnancy. Furthermore, the lack of
information on the safety of the therapy, as well as its substantial expense,
argues against its role in the management of arrested preterm labor. Future use
should only be in the context of well-conducted, adequately powered randomized
controlled trials.
Publication Types:
- Meta-Analysis
- Review
- Review, Academic
PMID: 12519621 [PubMed - indexed for MEDLINE]
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Update of:
Prophylactic antibiotics for inhibiting preterm labour with
intact membranes.
King J, Flenady V.
Department of Perinatal Medicine, Royal Women's Hospital, Carlton, Victoria,
Australia, 3053. jfking@unimelb.edu.au
BACKGROUND: The contribution of subclinical genital tract infection to the
aetiology of preterm birth is gaining increasing recognition, but the role of
prophylactic antibiotic treatment in the management of preterm labour is
uncertain. Since rupture of the membranes is an important factor in the
progression of preterm labour, it is important to see if the routine
administration of antibiotics confers any benefit, prior to membrane rupture.
OBJECTIVES: To assess the effects of prophylactic antibiotics administered to
women in preterm labour with intact membranes, on maternal and neonatal
outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth
Group's specialised register of controlled trials (May 2002), the Cochrane
Controlled Trials Register (The Cochrane Library, Issue 1, 2002), MEDLINE (1965
to May 2002). Other sources included contacting recognised experts and cross
referencing relevant material. SELECTION CRITERIA: Randomised trials which
compared antibiotic treatment with placebo or no treatment for women in preterm
labour (between 20 and 36 weeks' gestation) with intact membranes. DATA
COLLECTION AND ANALYSIS: Standard methods of the Cochrane Collaboration and the
Cochrane Pregnancy and Childbirth Group were used. Evaluation of methodological
quality and trial data extraction were undertaken independently by the authors.
Results are presented using relative risk for categorical data and weighted mean
difference for continuous data. MAIN RESULTS: This review has been updated
(2002) to include data from the 'ORACLE II 2001' trial (six times larger than
the previous 10 trials combined), which now dominates the results of this
review. Meta-analysis of the 11 included trials (7428 women enrolled) shows a
reduction in maternal infection with the use of prophylactic antibiotics
(relative risk 0.74, 95% confidence interval 0.64 to 0.87) but fails to
demonstrate a benefit or harm for any of the prespecified neonatal outcomes.
REVIEWER'S CONCLUSIONS: This review fails to demonstrate a clear overall benefit
from prophylactic antibiotic treatment for preterm labour with intact membranes
on neonatal outcomes and raises concerns about increased neonatal mortality for
those who received antibiotics. This treatment cannot therefore be currently
recommended for routine practice. Further research may be justified (when
sensitive markers for subclinical infection become available) in order to
determine if there is a subgroup of women who could experience benefit from
antibiotic treatment for preterm labour prior to membrane rupture, and to
identify which antibiotic or combination of antibiotics is most effective.
Publication Types:
- Meta-Analysis
- Review
- Review, Academic
PMID: 12519538 [PubMed - indexed for MEDLINE]
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[Management of multiple pregnancies at the Befelatanana
Antananarivo University Hospital Center (Madagascar): report of 143 cases]
[Article in French]
Andriamady RC, Rasoarinavalona AR, Ranjalahy RJ.
Centre Hospitalier Universitaire d'Antananarivo, BP 8394, 101 Antananarivo,
Madagascar.
Multiple pregnancies (MP) outcomes are often complicated. They deliver premature
infants and provoke high blood pressure. A retrospective study was carried out
in 1998 at the Maternity Hospital of Befelatanana, Antananarivo in order to
assess MP frequency and to specify the most important favourising factors and
difficulties during labor and the quality of the labor management. All
pregnancies with a MP were included in this survey. 143 MP were registered: 142
twin pregnancies and 1 triplet pregnancy. 2.0 per cent of cases were recurrent
MP. The average age of pregnancies was 26 years old. Among these 143 MP, 48.0
per cent were primiparas. Poor quality of prenatal visits is frequently
encountered. As antecedents there are abortion, hormonal contraceptive taking,
preterm delivery, gravidic toxemia, cicatricial uterus, ectopic pregnancy. 6.3
per cent of the first twin had breech presentation, 2.0 per cent transversal
labor presentation. As events during labor 40.0 per cent dynamic dystocia, 26.0
per cent acute fetal suffering, 27.0 per cent hyperthermia, 23.0 per cent high
blood pressure, some of them as eclampsia or pre-eclampsia were noted. 60.0 per
cent of the first twin delivery were easy. Whatever his labor presentation,
version by internal manipulations following by breech extraction was performed
on the second twin (67.0 per cent of cases). 18.2 per cent of parturient women
had cesaretomy. 11 maternal deaths were noted. Infant perinatal mortality rate
was of 35.7 per cent. Infant morbidity and mortality are essentially due to
infections. The authors conclude that complications prevention will be obtained
by improvement of standard of living of all female able to procreate. It needs
also correct cares at prenatal visits and during labor. Health education must be
focalized on strict and correct surveillance of pregnancies and intergenesic
periods by the reinforcement of planning family.
PMID: 12478972 [PubMed - indexed for MEDLINE]
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[Premature deliveries at the maternity hospital of
Befelatanana, Antananarivo in 1997]
[Article in French]
Andriamady RC, Rasamoelisoa JM, Rakotonoel H, Ravaonarivo H, Ranjalahy RJ,
Razanamparany M.
Hopital general de Befelatanana, Centre Hospitalier Universitaire
d'Antananarivo, BP 14 bis, 101 Antananarivo, Madagascar.
Preterm deliveries (PT) produce new-borns whose prognosis is generally very
dark. Prematurity is the first cause of neonatal death. A retrospective study
was carried out at the Maternity Hospital of Befelatanana, Antananarivo in order
to specify causes and difficulties of PT and to draw up strategy for their
better management so that premature infants have chance to survive. The survey
concerned 1394 patients: all pregnancies whose gestational age are between 22
and 36 weeks and those who delivery viable infants discharged home whose weights
are between 500 and 2,500 grams. PT occur frequently among teenagers and more
than 35-year old women. Risk factors and determinative causes of PT are mothers'
toxic habits, gyneco-obstetrical history as PT, abortion, cicatricial uterus,
urogenital infections. 12 maternal deaths were noted. Infant perinatal mortality
rate was of 47.3 per cent. The authors conclude that difficulties were in labor
and both antepartum and intrapartum periods. Preventive measures must surpass
curative therapy. They will be based on the improvement of standard of living,
the reinforcement of planning family and a strict pregnancy surveillance.
PMID: 12478969 [PubMed - indexed for MEDLINE]
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[Cushing's syndrome during pregnancy]
[Article in French]
Lubin V, Gautier JF, Antoine JM, Beressi JP, Vexiau P.
Service d'endocrinologie et nutrition et maladies metaboliques, Hopital
Saint-Louis, 1, avenue Claude Vellefaux, 75010 Paris. vanessa.lubin@free.fr
The rare association of Cushing's syndrome and pregnancy is explained by the
amenorrhea and sterility inherent to the syndrome. In the literature, 125 cases
have been reported: 30 cases of early diagnosis and 95 others diagnosed in the
second half of pregnancy. AT THE START OF PREGNANCY: When hypercorticism exists
before pregnancy it is hardly secretory. Its diagnosis, at an early stage, is
not hindered by the hormone modifications of pregnancy. Its aetiological
treatment raises the problem of the compatibility in pursuing the latter. IN THE
SECOND HALF OF PREGNANCY: The positive and aetiological diagnoses of Cushing's
syndrome are difficult and its prevalence may therefore be underestimated. The
evocative clinical signs are unspecific: excessive weight gain, hypertension of
pregnancy and gestational diabetes. The 24-hour free hypercortisoluria and the
absence of dexamethasone inhibition are of little diagnostic value after the
14th week of amenorrhea. The positive diagnosis therefore relies essentially on
the abolition of the circadian rhythm of cortisol. The biological
hyperandrogenia commonly observed is not discriminating. Adrenal aetiologies are
frequent. Imaging must be performed to eliminate an adrenocortical tumor.
PROGNOSIS: The maternal prognosis depends on the hypertension, preeclampsia,
diabetes and the complications of Cushing's syndrome. It depends on the activity
of the hypercorticism and its early aetiological treatment, which must not be
delayed after pregnancy. The foetal prognosis depends on the maternal prognosis.
It is represented by preterm delivery, hypotrophy and death of the foetus in
utero. The therapeutic management must be symptomatic and aetiologic, maternal
and obstetrical.
Publication Types:
PMID: 12467153 [PubMed - indexed for MEDLINE]
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[Special management for threatened preterm delivery in
multiple pregnancies]
[Article in French]
Vayssiere C.
SIHCUS-CMCO, 19, rue Louis-Pasteur, 67303 Schiltigheim, France.
vayssierec@club-internet.fr
Spontaneous prematurity is more frequent in multiple than singleton pregnancies.
It is estimated that 72% of the multiple pregnancies delivered before 33 weeks
are spontaneous births, compared with 58% among singletons (NP3). As in
singleton pregnancies, uterine contractions, close together, often precede
preterm delivery by several days (NP2). The benefits of home tocodynamometry for
patients who have already been hospitalized for threatened preterm delivery
(TPD) (NP4) is difficult to assess from the data currently available, but it has
not been shown to provide any benefits in a population of asymptomatic twin
pregnancies (NP1). Cervical ultrasound appears to have good predictive value for
preterm delivery when performed for TPD (NP3), although again few data are
available. The efficacy of tocolysis appears similar to that for singleton
pregnancies (NP3). Although the lack of data prevents us from judging the
efficacy of tocolytics such as calcium channel blockers or oxytocin antagonists,
it seems logical to use them as first-line drugs, especially because of the
increased risk of pulmonary edema in multiple pregnancies with Bmimetics (NP3).
Antenatal corticosteroid therapy appears to be less beneficial in multiple than
singleton pregnancies (NP3). Pharmacological studies suggest that the dose
currently used may be insufficient for multiple pregnancies (NP3). While
awaiting results from clinical studies comparing the efficacy of higher doses,
we must for now recommend antenatal corticosteroid therapy only at the usual
doses. While the rate of in utero transfers to level III facilities is nearly
85% in the case of severe TPD (NP4), this practice must be encouraged still more
in view of the benefits of inborn status compared with postnatal transfer.
Finally, delayed-interval delivery is a relatively rare obstetrical practice
that should be considered on a case-by-case basis when the first fetus is born
before 26 weeks. This approach requires tocolysis and antibiotic therapy. The
usefulness of cerclage in this situation has yet to be demonstrated. A
delayed-interval delivery can prolong the pregnancy by an average of 15 to 30
days (NP4).
Publication Types:
PMID: 12454633 [PubMed - indexed for MEDLINE]
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[Management of threatening preterm labor with intact
membranes: indications for antibiotics]
[Article in French]
Winer N.
Service d'Obstetrique et Medecine Foetale, CHU de Nantes, Hopital Mere-Enfant,
44093 Nantes, France. norbert.winer@chu-nantes.fr
OBJECTIVE: To analyse the benefits and disadvantages of systematic antibiotic
therapy in patient presenting a preterm labor with intact membranes. METHODS: We
reviewed French and English reports on Medline using to the following key words:
"antibiotic therapy and preterm labor, preterm labor, streptococcus B, vaginose,
mycoplasma, antenatal infection". RESULTS: The systematic prescription of
antibiotics is not recommended for patients presenting preterm labor who have
intact membranes and no symptoms of infection. The benefit of antibiotics is
small and shows a tendency to prolong the pregnancy and the reduction of
maternal infection. No benefit has been shown for neonatal results. When
early-onset neonatal sepsis develops in a case in which antepartum
chemoprophylaxis was used, the isolated bacteria will present an increasing risk
of bacterial drug resistance. Local treatment (cream or pessary) do not belong
in the treatment of threatening preterm labor and are not recommended for the
prevention of prematurity or materno fetal infection. Risk groups of patients
who present a positive vaginal colonization are subject to discussion. Studies
do not allow us to ascertain that antibiotics have a beneficial effect on
prematurity in these groups. Antibiotics are recommended for the treatment of
asymptomatic bacteriuria. This treatment reduces prematurity and maternal
infections. Despite poor consensus criteria, if threatening preterm labor is
associated with a bacteriuria, experts usually recommend treatment.
Publication Types:
PMID: 12454629 [PubMed - indexed for MEDLINE]
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[Home care for preterm labor]
[Article in French]
Dreyfus M, Durin L.
Service de Gynecologie-Obstetrique et Medecine de la Reproduction, CHU, avenue
Clemenceau, 14033 Caen Cedex, France. dreyfus-m@chu-caen.fr
OBJECTIVE: To analyze the different modalities of home care management for women
hospitalized for preterm labor. METHODS: We reviewed all reports in French and
English on Medline using the following key-words: home uterine activity
monitoring, home care management, midwives follow-up. Reports were categorized
by level of proof (LP 1 to 5). For each study, method, results and
authors'conclusions were recorded. We gave our comments for each report.
RESULTS: We could not find any report concerning indications of leaving hospital
after treatment for preterm labor. We only could find expert recommendations.
Concerning home uterine activity monitoring, the results demonstrated that there
were no arguments to recommend this method for early detection of preterm labor
or to avoid preterm delivery. Most of these studies had weak power and multiple
methodological biases. Very few studies reported about home care midwives
follow-up. Some rare randomized studies demonstrated the non efficient effect of
this management on the reduction of prematurity rates. The rates of
hospitalization did not decrease. Conversely, patients satisfaction was
increased. CONCLUSION: Home uterine activity monitoring seems to be unnecessary,
having no incidence on early diagnosis of preterm labor or rates of prematurity
(LP2 or 3). Home care follow-up by midwives for patients treated for preterm
labor did not reduce rates of prematurity (LP1). It slightly increased the
women's satisfaction.
Publication Types:
PMID: 12454627 [PubMed - indexed for MEDLINE]
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[Prognostic and therapeutic value of biologic signs of
infection in the management of preterm labor (amniocentesis excepted)]
[Article in French]
Subtil D.
Clinique de Gynecologie, Obstetrique et Neonatalogie, Hopital Jeanne-de-Flandre,
CHRU de Lille, 1, rue Eugene-Avinee, 59037 Lille Cedex, France.
d-subtil@chru-lille.fr
During threatened preterm delivery, both general and local signs of infection
increase the risks of amniotic infection, premature rupture of membranes,
preterm delivery, and neonatal and/or maternal morbidity of infectious origin.
Nonetheless, as antibiotics have not been sufficiently studied to be proved of
benefit in chorioamnionitis with intact membranes, search for these general (C
Reactive Protein, hyperleucocytosis) or cervical/vaginal (Group B Streptococcus,
Escherichia Coli, bacterial vaginosis) signs of infection have not been proved
to be really necessary. We have to except Group B Streptococcus, which have to
be searched during weeks that precede delivery: in those cases where it is shown
to be present in the cervix or the vagina, antibiotics must be prescribed during
delivery (ANAES recommendation). Finally, it must be emphasized that these
recommendations are mainly based on the absence of studies specifically done to
prove the benefits or risks of antenatal antibiotics - or fetal extraction - in
case of chorioamnionitis with intact membranes. Systematic vaginal and blood
samples (CRP, leukocytes, vaginal micro-organisms) would be helpful in
determining the appropriate option in those situations.
Publication Types:
PMID: 12454625 [PubMed - indexed for MEDLINE]
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Cost-effectiveness of induction after preterm premature
rupture of the membranes.
Grable IA.
Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center,
Boston, MA 02215, USA. igrable@caregroup.harvard.edu
OBJECTIVE: Our purpose was to design a decision analytic model to evaluate the
optimal length of time for expectant management after preterm premature rupture
of the membranes between 32 and 36 weeks' gestation. STUDY DESIGN: Five models
were created for 32 to 36 weeks' gestation. Probabilities for outcomes were
obtained from medical center databases. Cost data were collected from the Health
Care Microsystem database and were based on 1996 dollars. RESULTS: The optimal
time of delivery to minimize major morbidity was 34 to 36 weeks' gestation,
depending on the time of rupture. When only major morbidity was considered, the
most cost-effective approach between 32 to 34 weeks was to deliver 1 week after
rupture. At 35 to 36 weeks, the most cost-effective approach was to deliver at
presentation. CONCLUSION: The current method of treating all patients with
ruptured membranes similarly and delivery at 34 weeks' gestation is not risk
minimizing or cost-effective. By delivery 1 week after rupture at 32 to 34 weeks
and immediately at 35 to 36 weeks, significant morbidity can be avoided.
PMID: 12439494 [PubMed - indexed for MEDLINE]
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The management of preterm labor.
Goldenberg RL.
Department of Obstetrics and Gynecology, University of Alabama at Birmingham,
Birmingham, Alabama 35294-0021, USA. rlg@uab.edu
Preterm birth is the leading cause of neonatal mortality and a substantial
portion of all birth-related short- and long-term morbidity. Spontaneous preterm
labor is responsible for more than half of preterm births. Its management is the
topic of this review. Although there are many maternal characteristics
associated with preterm birth, the etiology in most cases is not clear,
although, for the earliest cases, the role of intrauterine infection is assuming
greater importance. Most efforts to prevent preterm labor have not proven to be
effective, and equally frustrating, most efforts at arresting preterm labor once
started have failed. The most important components of management, therefore, are
aimed at preventing neonatal complications through the use of corticosteroids
and antibiotics to prevent group B streptococcal neonatal sepsis, and avoiding
traumatic deliveries. Delivery in a medical center with an experienced
resuscitation team and the availability of a newborn intensive care unit will
ensure the best possible neonatal outcomes. Obstetric practices for which there
is little evidence of effectiveness in preventing or treating preterm labor
include the following: bed rest, hydration, sedation, home uterine activity
monitoring, oral terbutaline after successful intravenous tocolysis, and
tocolysis without the concomitant use of corticosteroids.
Publication Types:
PMID: 12423870 [PubMed - indexed for MEDLINE]
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[Nifedipine first choice in management of threatening preterm
labor]
[Article in Dutch]
Papatsonis DN, Timmerman CC, Oei SG, van Geijn HP.
VU Medisch Centrum, afd. Verloskunde en Gynaecologie, Amsterdam. hoog.pap@wxs.nl
Preterm birth is the most important cause of perinatal mortality in Europe and
North America. Tocolytic agents named beta 2-sympathicomimetics postpone
delivery for 24-48 hours, but do not reduce perinatal mortality or morbidity.
Calcium antagonists, in particular nifedipine, are more effective tocolytic
agents than beta 2-sympathicomimetics in terms of delaying delivery.
Meta-analyses have found that calcium antagonists statistically significantly
reduced perinatal morbidity and that the number of maternal side effects was
statistically significantly lower compared with beta 2-sympathicomimetics.
Nifedipine also has the benefit of oral administration, in contrast with beta
2-sympathicomimetics which are administered intravenously. Nifedipine is
therefore the first choice in the management of threatening preterm labour.
Publication Types:
PMID: 12420423 [PubMed - indexed for MEDLINE]
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Comment in:
Mechanisms of term and preterm birth.
Gibb W, Challis JR.
Department of Obstetrics and Gynaecology, and Cellular and Molecular Medicine,
University of Ottawa; Ottawa Hospital Research Institute, Ottawa, ON, Canada.
Labour at term and preterm results from activation and then stimulation of the
myometrium. Activation can occur through mechanical stretch of the uterus, and
by endocrine pathways resulting from increased activity of the fetal
hypothalamic-pituitary-adrenal axis. In women and in experimental animals,
cortisol likely contributes to increased prostaglandin production in fetal
tissues through up-regulation of the type 2 prostaglandin H2, synthase-2
(PGHS-2) and down-regulation of 15-OH prostaglandin dehydrogenase. Cortisol
increases expression of prostaglandin dehydrogenase in the chorion by reversing
the stimulatory effect of progesterone, and may represent "progesterone
withdrawal" in the primate. By competing with progesterone inhibition, cortisol
also increases expression of placental corticotropin-releasing hormone. Other
agents, such as pro-inflammatory cytokines, similarly up-regulate PGHS-2 and
decrease expression of prostaglandin dehydrogenase. Oxytocin, produced locally
within the intrauterine tissues, is also thought to be involved in parturition,
and there is a marked increase in oxytocin receptor expression at term. There
are thus several mechanisms by which labour at term or preterm may be initiated.
These different mechanisms need to be considered in the development of
strategies for the detection and management of women in preterm labour. Ongoing
studies are investigating the use of oxytocin receptor antagonists, PGHS-2
inhibitors, and nitric oxide to prevent or regulate preterm labour. The presence
of fibronectin in vaginal secretions, and elevated maternal serum levels of
corticotropin-releasing hormone, estrogens, and cytokines have been examined as
possible markers of preterm labour. However, at the present time, we do not have
the ability to accurately predict or diagnose preterm labour, nor do we have
specific or efficient methods to inhibit labour once it has started.
Publication Types:
PMID: 12417902 [PubMed - indexed for MEDLINE]
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Is 34 weeks an acceptable goal for a complicated singleton
pregnancy?
Jones JS, Istwan NB, Jacques D, Coleman SK, Stanziano G.
McLeod Regional Medical Center, McLeod Medical Park-East, 901 E. Cheves St.,
Ste. 430, Florence, SC 29506, USA. jonescpob@aol.com
PURPOSE: To examine neonatal risk and associated nursery costs for infants with
delivery following untreated preterm labor at 34, 35, or 36 weeks' gestation, by
assessing the incidence of neonatal intensive care unit (NICU) admission,
respiratory distress syndrome (RDS), and need for ventilatory assistance.
DESIGN: Infants with preterm birth at 34, 35, or 36 weeks were identified from a
database of prospectively collected clinical information and pregnancy outcomes
of women receiving outpatient preterm-labor management services, in addition to
routine prenatal care. Cases of singleton gestations with delivery related to
spontaneous preterm labor were analyzed. Data were divided into three groups by
gestational week at delivery. METHODOLOGY: Descriptive and statistical methods
were used to compare maternal demographics, pregnancy outcome, and nursery
costs. A cost model was utilized. PRINCIPAL FINDINGS: 2849 infants were studied.
Risk of NICU admission decreased by 47.4 percent from weeks 34 to 35 and 41.8
percent from weeks 35 to 36. Risk of RDS decreased by 25.4 percent from weeks 34
to 35, and 40.7 percent from weeks 35 to 36. Mean nursery costs per infant
delivering at 34, 35, and 36 weeks were $11,439 +/- $19,774, $5,796 +/- $11,858,
and $3,824 +/- $9,135, respectively (p < .001). CONCLUSION: Rates of NICU
admission, RDS, ventilator use, and nursery-related costs decreased
significantly with each week gained. The data indicate that benefit is derived
in prolonging pregnancy beyond 34 weeks.
PMID: 12415908 [PubMed - indexed for MEDLINE]
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Severe pre-eclampsia remote from term: what to expect of
expectant management.
Blackwell SC, Redman ME, Tomlinson M, Berry SM, Sorokin Y, Cotton DB.
Department of Obstetrics and Gynecology, Wayne State University, Detroit,
Michigan, USA.
OBJECTIVE: To describe the duration of expectant management and the indications
for termination of expectant management of pregnancies complicated by severe
pre-eclampsia remote from term. STUDY DESIGN: We identified pregnancies
complicated by severe pre-eclampsia diagnosed between 24 weeks and 31 weeks 6
days at our institution in 1991-98. Pertinent clinical data were obtained from
review of maternal and neonatal charts. Comparison of patients was based on the
duration of time from admission to delivery: < 48 h (group 1), 48 h to 7 days
(group 2), and > or = 7 days (group 3). RESULTS: A total of 142 women met all
study criteria. Seventy-nine (55.6%) women were delivered within 48 h, 42
(29.6%) between 48 h and 7 days, and 21 (14.8%) at > or = 7 days from diagnosis.
Of group 1 patients (< 48 h), 59 (74.7%) were delivered for maternal indications
while 20 (25.3%) were delivered for fetal indications. Of group 2 patients (48 h
to 7 days), 35 (83.3%) were delivered for maternal indications while seven
(16.7%) were delivered for fetal indications. Of group 3 patients (> or = 7
days), 16 (76.2%) were delivered for maternal indications while five (23.8%)
were delivered for fetal indications. There were no significant differences in
the indications for delivery based on the duration from admission to delivery.
CONCLUSIONS: Despite an aggressive approach towards expectant management of
preterm pregnancies complicated by severe pre-eclampsia, most patients were
delivered within 48 h for maternal indications.
PMID: 12389673 [PubMed - indexed for MEDLINE]
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Uterine electromyography and light-induced fluorescence in
the management of term and preterm labor.
Garfield RE, Maul H, Maner W, Fittkow C, Olson G, Shi L, Saade GR.
Reproductive Sciences, Department of Obstetrics and Gynecology, University of
Texas Medical Branch, Galveston, Texas 77555-1062, USA. rgarfiel@utmb.edu
OBJECTIVE: Understanding the physiology of the uterus and cervix during term and
preterm parturition is crucial for developing methods to control their function
and is essential to solving clinical problems related to labor. To date, only
crude, inaccurate, and subjective methods are used to assess changes in uterine
and cervical function in pregnancy. METHODS: In the past several years, we have
developed noninvasive methods to quantitatively evaluate the uterus and cervix
based on recording of uterine electrical signals from the abdominal surface
(uterine electromyography) and measurement of light-induced fluorescence (LIF)
of cervical collagen (Collascope), respectively. Both methods are rapid and
allow immediate assessment of uterine contractility and cervical ripening.
RESULTS: Studies in animals and humans indicated that uterine and cervical
performance can be monitored successfully during pregnancy using those
approaches and that these techniques can be used during labor to better define
management in a variety of conditions associated with labor. CONCLUSION: The
potential benefits of the proposed instrumentation and methods include reducing
the rate of preterm delivery, improving maternal and perinatal outcome,
monitoring treatment, decreasing cesarean rate and providing research methods to
understand uterine and cervical function.
Publication Types:
PMID: 12383910 [PubMed - indexed for MEDLINE]
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Patients with prior second-trimester loss: prophylactic
cerclage or serial transvaginal sonograms?
Berghella V, Haas S, Chervoneva I, Hyslop T.
Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology,
Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pa.,
USA.
OBJECTIVE: To compare management with prophylactic cerclage versus serial
transvaginal sonograms of the cervix in patients with prior second-trimester
loss. STUDY DESIGN: Singleton pregnancies with prior second-trimester
spontaneous loss between 14 and 24 weeks' gestation were retrospectively
reviewed. At the obstetricians' discretion, some were managed with prophylactic
cerclage and some with serial transvaginal sonograms of the cervix, starting at
14 weeks, and cerclage only if cervical length was <25 mm or funneling was >25%
before 24 weeks. All cerclages were McDonald. Primary outcome was preterm
delivery at <35 weeks. RESULTS: Of 177 patients with singleton pregnancies who
had prior second-trimester loss identified, 66 received prophylactic cerclage
and 111 were followed up with transvaginal sonography, of which 36% (40/111) had
therapeutic cerclage because of cervical changes. The two management groups of
prophylactic cerclage versus transvaginal sonography of the cervix did not
differ in any measure of obstetric outcome, including preterm delivery at <35
weeks (23% vs 30%; P =.3), preterm delivery at <33 weeks (21% vs 26%; P =.5), or
gestational age at delivery (34.6 +/- 6.8 weeks vs 34.4 +/- 6.8 weeks; P =.8).
CONCLUSION: In patients with prior second-trimester loss, serial transvaginal
sonography of the cervix, with cerclage only if indicated by cervical changes,
is a valuable alternative to a policy of uniform prophylactic cerclage.
PMID: 12237658 [PubMed - indexed for MEDLINE]
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Perinatal care improves the outcome of triplets.
Skrablin S, Kuvacic I, Kalafatic D, Peter B, Gveric-Ahmetasevic S,
Letica-Protega N, Polak-Babic J.
Department of Perinatal Medicine, University Medical School of Zagreb, Petrova
13, 10000 Zagreb, Croatia.
OBJECTIVE: To compare pregnancy complications and neonatal outcome of 85 triplet
gestations cared for during the 15 years in a single perinatal unit. METHODS:
Pregnancies were divided in two groups according to the differences in the
management plan and their outcomes were compared. Group I (N = 44) consisted of
pregnancies cared from 1986 to 1995, using standard model of care: preventive
hospitalization from the early second trimester or home bed rest with routine
hospitalization after 28-32 weeks of pregnancy, routine clinical and ultrasound
examinations, biophysical profile and non-stress tests starting at 28 weeks,
expert neonatal care without free access to surfactant or to parenteral
nutrition. Group II (N = 41) consisted of pregnancies cared for from 1986 to
2000 using modified care: preventive hospitalization from early second trimester
or home bed rest with routine hospitalization after 32 weeks of pregnancy,
biophysical profile, non-stress tests and pulsed doppler analysis of fetal
umbilical artery, fetal aorta and middle cerebral artery blood flow from as
early as 26 weeks, and neonatal care improved by free access to surfactant and
parenteral nutrition. RESULTS: The mean gestational age, mean birth weight, the
proportion of growth-retarded infants, the incidence of various maternal
complications and immediate neonatal conditions as judged by APGAR scores did
not differ between the groups. The incidence of deliveries up to 28 weeks was
lower in the group II in comparison to group I, but the proportion of term and
near term deliveries was lower. The incidence of cesarean sections was high
(91.8%), but significantly increased cesarean delivery rate because of fetal
distress was observed in the group II (P = 0.014). Infants in the group II had
less frequently uneventful early neonatal period, mainly due to significantly
increased conatal infection (P = 0.007) and neonatal encephalopathy rate (P =
0.001). However, perinatal mortality was decreased from 235% in the group I to
142% in the group II for newborns that reached 24 weeks of gestation or more.
The decrease of perinatal mortality was observed also in the newborns born after
28 weeks of gestation (123% in the group I and 99% in the group II). None of the
children weighing <1000 g died in utero in the group II. Early neonatal death of
infants weighing >1500 g was significantly reduced in the group II (P = 0.048).
CONCLUSION: Advances in neonatal care, but also the delivery of infants in
better overall condition must be the explanation for improved outcome of triplet
gestations managed by modified care. A higher cesarean section rate because of
imminent fetal jeopardy as judged by not only fetal heart rate tracings, but
also umbilical, aortic and middle cerebral artery flow analysis, could be the
explanation for lowered perinatal mortality and significantly improved outcome
in very preterm infants from triplet gestations.
PMID: 12222157 [PubMed - indexed for MEDLINE]
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ACOG Practice Bulletin: Clinical Management Guidelines for
Obstetrcian-Gynecologists: Number 38, September 2002. Perinatal care at the
threshold of viability.
The American College of Obstetricians and Gynecologists.
The survival rate for extremely preterm or extremely low-birth-weight (LBW)
newborns born at the threshold of viability (25 or fewer completed weeks of
gestation) improved in the early 1990s, largely as the result of a greater use
of assisted ventilation in the delivery room and surfactant therapy. Increased
use of antenatal and neonatal corticosteroids also may have influenced survival
rates. However, this improvement in survival has not been associated with an
equal improvement in morbidity. The incidence of chronic lung disease, sepsis,
and poor growth remains high and may even have increased. There is concern that
the treatment of extremely preterm and extremely LBW newborns may result in
unforeseen effects into adulthood, and that the neurodevelopmental outcome and
cognitive function of extremely preterm and extremely LBW infants may be
suboptimal. The purpose of this document is to describe the potential
consequences of extremely preterm birth and to provide clinical management
guidelines based on the best available data.
Publication Types:
- Guideline
- Practice Guideline
PMID: 12220792 [PubMed - indexed for MEDLINE]
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Prevention of perinatal group B streptococcal disease.
Revised guidelines from CDC.
Schrag S, Gorwitz R, Fultz-Butts K, Schuchat A.
Group B streptococcus (GBS) remains a leading cause of serious neonatal
infection despite great progress in perinatal GBS disease prevention in the
1990s. In 1996, CDC, in collaboration with other agencies, published guidelines
for the prevention of perinatal group B streptococcal disease (CDC. Prevention
of perinatal group B streptococcal disease: a public health perspective. MMWR
1996;45[RR-7]:1-24). Data collected after the issuance of the 1996 guidelines
prompted reevaluation of prevention strategies at a meeting of clinical and
public health representatives in November 2001. This report replaces CDC's 1996
guidelines. The recommendations are based on available evidence and expert
opinion where sufficient evidence was lacking. Although many of the
recommendations in the 2002 guidelines are the same as those in 1996, they
include some key changes: * Recommendation of universal prenatal screening for
vaginal and rectal GBS colonization of all pregnant women at 35-37 weeks'
gestation, based on recent documentation in a large retrospective cohort study
of a strong protective effect of this culture-based screening strategy relative
to the risk-based strategy * Updated prophylaxis regimens for women with
penicillin allergy * Detailed instruction on prenatal specimen collection and
expanded methods of GBS culture processing, including instructions on
antimicrobial susceptibility testing * Recommendation against routine
intrapartum antibiotic prophylaxis for GBS-colonized women undergoing planned
cesarean deliveries who have not begun labor or had rupture of membranes * A
suggested algorithm for management of patients with threatened preterm delivery
* An updated algorithm for management of newborns exposed to intrapartum
antibiotic prophylaxis Although universal screening for GBS colonization is
anticipated to result in further reductions in the burden of GBS disease, the
need to monitor for potential adverse consequences of intrapartum antibiotic
use, such as emergence of bacterial antimicrobial resistance or increased
incidence or severity of non-GBS neonatal pathogens, continues, and intrapartum
antibiotics are still viewed as an interim strategy until GBS vaccines achieve
licensure.
Publication Types:
- Guideline
- Practice Guideline
PMID: 12211284 [PubMed - indexed for MEDLINE]
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Characterising doctor-parent communication in counselling for
impending preterm delivery.
Zupancic JA, Kirpalani H, Barrett J, Stewart S, Gafni A, Streiner D, Beecroft
ML, Smith P.
Department of Neonatology, Beth Israel Deaconess Medical Center, Harvard Medical
School, Boston, Massachusetts, USA.
OBJECTIVE: To examine the counselling of women admitted to hospital in preterm
labour. Such women and their partners are often asked to participate in
difficult decisions including mode of delivery, fetal monitoring, and
resuscitation. STUDY DESIGN: Questionnaire based descriptive study. STUDY
SETTING: A tertiary level perinatal referral centre. PATIENTS: Forty-nine women
in preterm labour at 22-30 weeks gestation, admitted in two separate periods
between March 1997 and May 1999. INTERVENTION AND OUTCOME MEASURE: Within 24
hours of counselling, parents were asked to complete a questionnaire assessing
recall of the management plan, desire for involvement in decision making,
anxiety, and feelings of control over their health. A parallel questionnaire was
completed by the clinicians. RESULTS: Parents and clinicians on recall agreed
well about obstetric issues but poorly about neonatal issues. Overall 27% of
parents felt: "I would prefer to have the doctors advise me, rather than asking
me to decide". In 79% of cases, clinicians believed parents preferred advice
rather than to make decisions, but in 45% of these, they misidentified those who
wished to make their decisions. Anxiety levels for one third of the mothers were
high, and associated with poorer concordance of recall between parents and
clinicians. CONCLUSIONS: Serious deficiencies exist in parent-clinician
encounters during extremely preterm labour. Concordance between parents and
clinicians is poor and anxiety very high. A quarter of parents appear to prefer
to relinquish decision making autonomy, but clinicians cannot correctly identify
this subgroup. Standardised counselling in the perinatal period, using formal
decision aids, should be investigated.
PMID: 12193517 [PubMed - indexed for MEDLINE]
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Development and clinical experience with the new
evidence-based tocolytic atosiban.
Husslein P.
Department of Obstetrics and Gynecology, University of Vienna Medical School,
Austria. peter.husslein@akh-wien.ac.at
The incidence of preterm birth has remained unchanged for the last few decades.
This is due, in part, to the complex etiology of preterm labor, and the limited
ability of tocolytic agents to prolong pregnancy as a result of limited efficacy
and poor safety profiles. The recent introduction of the oxytocin antagonist,
atosiban, represents a new generation of uterine-specific tocolytics, which are
associated with more favorable safety profiles. This paper discusses the
rationale behind the development of the oxytocin antagonists and provides a
review of the phase II and III trials that have investigated atosiban. Also
included is a retrospective analysis of 83 women assessed in the Vienna Medical
School, providing an insight into the benefits associated with atosiban in the
everyday clinical setting. The introduction of a safer tocolytic agent offers
the potential to change the current approach to the management of preterm labor.
This includes a prolonged period of treatment at earlier or later gestational
ages and possibly an extended use to women with contraindications who would
normally have been excluded from treatment, e.g. preterm premature rupture of
the membranes.
Publication Types:
PMID: 12190838 [PubMed - indexed for MEDLINE]
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-
Acyclovir treatment of primary herpes in pregnancy
complicated by second trimester preterm premature rupture of membranes with term
delivery: case report.
Dietrich YM, Napolitano PG.
Department of Obstetrics and Gynecology, David Grant Medical Center, Travis AFB,
California, USA.
Primary genital herpes simplex virus (HSV) infection in pregnancy is associated
with an increased risk of vertical transmission to the fetus, especially with
rupture of membranes. Two cases of primary herpes and two cases of recurrent
herpes in pregnancy with preterm premature rupture of membranes and expectant
management have been reported, all delivering preterm. We report a case of
primary maternal genital HSV infection with preterm premature rupture of
membranes at 24 weeks' gestation who subsequently went on to deliver at term.
This case was managed with intravenous acyclovir. Neonatal serology for HSV I
(immunoglobulin M [IgM] and IgG) and HSV II (IgM) were negative. Antibodies for
HSV II (IgG) were positive. Subsequent 6-month follow-up titers were negative
for all herpes antibodies. On the basis of an extensive search of the English
literature from 1966 to 2001, this is the first reported case of primary herpes
in pregnancy associated with preterm premature rupture of membranes with a
subsequent term delivery.
PMID: 12152140 [PubMed - indexed for MEDLINE]
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Infection and preterm birth.
Andrews WW, Hauth JC, Goldenberg RL.
Department of Obstetrics & Gynecology and The Center for Research in Women's
Health, University of Alabama at Birmingham, 35249-7333, USA.
Preterm birth complicates 11% of all pregnancies in the United States and
remains a leading cause of infant mortality and long-term neurological handicap.
The majority of this morbidity and mortality is concentrated among the small
subset of infants born before 32 weeks' gestational age and that have birth
weights < 1500 g. Although the survival of these preterm infants has improved
over the last 20 years, the rate of long-term handicap has not. Despite
widespread use of preventive strategies, the rate of preterm birth is
increasing. Therefore, the prevalence of long-term handicap attributed to
preterm birth also is increasing. Considerable data implicate a clinically
silent upper genital tract infection as a key component of the pathophysiology
of a majority of early spontaneous preterm births, but a minority of preterm
births that occur near term. This report reviews the current status of our
understanding of the relationship between genital tract microbial infection and
spontaneous preterm birth, the availability and usefulness of markers to
identify women with such infections, and the results of recent prospective
randomized clinical trials of antibiotic therapy to prevent preterm birth.
Strengths and limitations of the trials are reviewed in relationship to their
value for guidance in clinical management strategies and directions for future
research are discussed.
Publication Types:
PMID: 12141522 [PubMed - indexed for MEDLINE]
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Probiotics for urogenital health.
Reid G.
University of Western Ontario, 268 Grosvenor Street, London, Ontario, N6A 4V2,
Canada. gregor@uwo.ca
Bacterial vaginosis, urinary tract infection, and yeast vaginitis afflict an
estimated 1 billion women each year. Once investigation has ruled out
complicated underlying causes, the only therapeutic option is antimicrobial
agents. In many cases, this is effective at clearing infection. However,
recurrences, side effects, and secondary infections are frequent. Coinciding
with infection is a disruption of the normal commensal microflora in the vagina,
primarily a loss of lactobacilli. The exogenous application of lactobacilli to
the host as probiotic agents appears to offer hope as an alternative management
regimen to antimicrobial treatment and prophylaxis. Although commercial
probiotics specifically selected and proven to be effective for urogenital
infections are not yet available, there is growing in vitro and human data to
suggest that certain strains could confer health benefits on a large number of
women. Given that depleted vaginal lactobacilli and recurrent infection is
associated with increased risk of sexually transmitted diseases and preterm
labor, multiple antibiotic resistance, and significant reduction in quality of
life, the need for probiotic therapeutics has never been greater.
Publication Types:
PMID: 12134717 [PubMed - indexed for MEDLINE]
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Trends and characteristics of induced labour in the United
States, 1989-98.
MacDorman MF, Mathews TJ, Martin JA, Malloy MH.
Division of Vital Statistics, National Center for Health Statistics, Centers for
Disease Control and Prevention, 6525 Belcrest Road, Room 820, Hyattsville, MD
20782, USA. mmacdorman@cdc.gov
Induction of labour is one of the fastest growing medical procedures in the
United States. In 1998, 19.2% of all US births were a product of induced labour,
more than twice the 9.0% in 1989. Induction of labour has been efficacious in
the management of post-term pregnancy and in expediting delivery when the mother
or infant is sufficiently ill to make continuation of the pregnancy hazardous.
However, the recent rapid increase in induction, and particularly the doubling
of the induction rate for preterm pregnancies (from 6.7% in 1989 to 13.4% in
1998), has generated concern among some clinicians. The present study uses vital
statistics natality data to examine the epidemiology of induced labour in the
US. Multivariable analysis is used to examine the probability of having an
induced delivery in relation to a wide variety of socio-demographic and medical
characteristics, and also in relation to relative indications and
contraindications for induced labour as outlined by the American College of
Obstetricians and Gynecologists (ACOG). Induction rates were higher for women
who were non-Hispanic white, college educated, born in the US, primaparae and
those with intensive prenatal care utilisation. Induction rates were also higher
for women with various medical conditions including hypertension, eclampsia and
renal disease. For non-Hispanic white women with singleton births, 59% of the
increase in the preterm birth rate from 1989 to 1998 can be accounted for by the
increase in preterm inductions. The adjusted odds ratio for neonatal mortality
among preterm births with induced labour was 1.20 [95% confidence interval 1.11,
1.31]. The rapid increase in induction rates, particularly among preterm births,
marks a shift in the obstetric management of pregnancy. More detailed studies
are needed to examine physician decision-making protocols, particularly for
preterm induction, and to assess the impact of these practice changes on patient
outcomes.
PMID: 12123440 [PubMed - indexed for MEDLINE]
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Recurrent obstetric complications: how placental pathology
can contribute to cost-effective clinical evaluation and a rational clinical
care plan.
Salafia CM.
EarlyPath Diagnostics, 86 Edgewood Avenue, Larchmont, NY 10538, USA.
salafiacm@aol.com
When a pregnancy is delivered with unexpected outcomes and the potential for
newborn risk (growth restriction, preterm birth, preeclampsia) or a pregnancy
fails, this fact carries risks for future obstetric complications. There is an
ever-expanding range of laboratory tests for patients with "obstetric
compromise, not otherwise specified." How can you interpret these test results
to give surveillance and treatment only to those patients who will benefit? Four
major patterns of placental tissue injury may be distinguished reliably by
routine microscopy (acute inflammation, chronic inflammation,
maternal/uteroplacental vascular pathology, and clotting problems). For the
clinician, this information may serve as a guide to cost-effective and rational
patient evaluation and next-pregnancy management.
Publication Types:
PMID: 12112985 [PubMed - indexed for MEDLINE]
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Implementing preterm labor guidelines: a collaborative care
improvement process.
Goering M, Wilson W.
The Birth Center, United Hospital, St Paul, Minnesota, USA.
Health care organizations today are being challenged to deliver care that is
cost-effective, satisfying to patients, and based on quality outcomes. Urgency
created by inadequate bed capacity as well as financial opportunity prompted
United Hospital's Birth Center to launch care improvement activities aimed at
assessing appropriateness of antepartal length of stay. Collaboration between
all members of the health care team enabled a steering committee to implement
evidence-based provider practice guidelines targeting variance around preterm
labor management. Other multidisciplinary strategies implemented include a home
care prescreening process, case management, and establishment of a peer review
process. Within the 1-year care improvement process, the Birth Center
successfully decreased the length of stay for preterm labor patients from 6.9
days to 5.3 days. This article describes one institution's efforts to improve
care by implementing guidelines for the inpatient management of preterm labor.
PMID: 12083294 [PubMed - indexed for MEDLINE]
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Delivery outcomes following loop electrosurgical excision
procedure for microinvasive (FIGO stage IA1) cervical cancer.
Paraskevaidis E, Koliopoulos G, Lolis E, Papanikou E, Malamou-Mitsi V,
Agnantis NJ.
Department of Obstetrics and Gynecology, Ioannina University Hospital, Greece.
OBJECTIVE: The goal of this study was to report the delivery outcomes in women
who had loop electrosurgical excision procedure (LEEP) for microinvasive
cervical cancer (stage IA1 without lymphovascular invasion) and became pregnant
and progressed beyond 24 weeks. METHODS: A case-control study was performed.
Twenty-eight women who were managed exclusively with LEEP for microinvasive
cervical carcinoma had at least one pregnancy beyond 24 weeks and were the
cases. Each case was matched with one woman who delivered at the same department
without prior treatment of her cervix (controls) and their delivery outcomes
were compared with those of the cases. Known risk factors for preterm delivery
were used as matching factors. RESULTS: There was no statistically significant
difference (P > 0.05) between cases and controls in the duration of pregnancy
(37.6-38.4 weeks respectively), birth weight (3212-3315 g), cesarean section
rate (17.8-32.1%), neonatal unit admission rate (21.4-10.7%), and precipitate
labor rate (13-10.5%). The duration of labor was significantly shorter in cases
(5.5-7.1 h, P = 0.032). After LEEP the relative risk for preterm delivery is
3.67 (95% confidence interval, 0.97-20.27), for low birth weight infant 0.67
(0.06-5.8), for precipitate labor 1 (0.05-3.88), and for delivery by cesarean
section 0.5 (0.17-4.46). CONCLUSIONS: Women treated for microinvasive cancer
with LEEP did not have significantly more delivery complications compared with
controls apart from shorter duration of labor. There was a possible
non-statistically significant trend toward shorter duration of pregnancy in
cases. While caution should be advised when selecting and treating women with
microinvasive carcinoma by LEEP, the apparent safety of the management and the
satisfactory delivery outcome seem to justify this approach in many cases. (c)
2002 Elsevier Science (USA).
PMID: 12079292 [PubMed - indexed for MEDLINE]
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Multifetal gestation--maternal and perinatal outcome of 112
pregnancies.
Strauss A, Paek BW, Genzel-Boroviczeny O, Schulze A, Janssen U, Hepp H.
Department of Obstetrics and Gynecology-Grosshadern, University Hospital,
University of Munich, Marchioninistrasse 15, D-81377 Munich, Germany.
Alexander.Strauss@helios.med.uni-muenchen.de
PURPOSE: Multifetal pregnancy reduction is a widespread "therapy" to diminish
the risk of prematurity and adverse outcome for the survivors in higher order
multiple gestation. The aim of our study was to determine the maternal and
neonatal outcome of multifetal pregnancies under a conservative pregnancy
management. STUDY DESIGN: A retrospective review of 112 multifetal pregnancies
is presented. All higher order multiple pregnancies delivered after 25 weeks of
gestation and managed at a single institution between 1982 and 1999 are
included. RESULTS: Triplets, quadruplets and quintuplets were delivered at a
mean gestational age of 31 + 5, 29 + 5 and 28 + 4 weeks, respectively. The
perinatal mortality was 14 for triplets and 36 for quadruplets. No quintuplet
died in the perinatal period. Respiratory distress syndrome occurred in 23% of
triplets, 65% of quadruplets and 75% of quintuplets, intracranial hemorrhage was
diagnosed in 14% of triplets, 15% of quadruplets and 10% of quintuplets and
retinopathy of prematurity was found in 10% of triplets, 9% of quadruplets and
25% of quintuplets. DISCUSSION: Despite a low neonatal mortality, morbidity of
higher order multiple gestations remains significant. Mortality and morbidity
are related to preterm delivery but do not exceed the rates of singletons or
twins of an identical gestational age. Favorable prognostic landmarks are a
gestational age >30 weeks and a number of fetuses per pregnancy < or =4.
CONCLUSION: The risks of multifetal pregnancies are significant. Therefore,
evidence-based counseling of couples seeking treatment for infertility and
prevention of higher order multiple pregnancies through the prudent use of
reproductive techniques attains paramount importance. Copyright 2002 S. Karger
AG, Basel
PMID: 12065948 [PubMed - indexed for MEDLINE]
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Hospitalization vs. outpatient care in the management of
triplet gestations.
Skrablin S, Kuvacic I, Jukic P, Kalafatic D, Peter B.
Department of Perinatal Medicine, School of Medicine, University of Zagreb,
Petrova 13, Croatia. ivan.kuvacic@zg.hinet.hr
OBJECTIVE: To compare the course and outcome of triplet gestations under a
preventive care strategy that includes hospitalization, surveillance, bed rest,
and daily specialized care from the beginning of the second trimester, with
pregnancies managed according to the Croatian standard outpatient care protocol
for multiplets. METHODS: A retrospective study of 79 triplet pregnancies.
Preventive hospitalization from the beginning of the second trimester, with
complete bed rest and all necessary interventions, was chosen by 55 women (Group
I). The remaining 24 women (Group II) elected the standard outpatient protocol
for multiple pregnancies. Outpatient management with prophylactic bed rest was
initiated at home as soon as the multiple pregnancy was diagnosed. After 28
weeks of gestation, all outpatients were hospitalized until delivery
irrespective of symptoms. RESULTS: There was no difference between the groups
regarding maternal age, race, pre-pregnancy weight and height, weight gain
during the first 24 weeks of pregnancy, or the proportion of pregnancies
achieved with assisted reproductive technology. Four out of 55 women (7.2%) from
Group I and 4 out of 24 women (12.5%) from Group II had monochorionic triplet
pregnancies (P=n.s.). Nulliparity was more frequent in Group I than in Group II
(P=0.006). Elective cesarean delivery was significantly more frequent in Group I
(46 out of 55 gestations, 72.7%) than in Group II (9 out of 24 gestations,
37.5%), P=0.024. Gestational age at delivery and mean birth weight were
significantly higher in Group I than in Group II (P<0.001). Deliveries up to 28
weeks of pregnancy were infrequent in Group I (P=0.02). Thirty-three gestations
in Group I (60%) and 6 (25%) in Group II had a duration of 33-36 weeks
(P<0.001). Two out of 55 triplet gestations in Group I (3.6%) and 4 out of 24 in
Group II (16.7%) ended in spontaneous abortion (P=0.053). The survival of the
three triplets was more frequent in Group I than in Group II (P=0.048). For
gestations reaching 24 weeks or more, the fetal and perinatal death rate was
significantly lower in Group I (P<0.001). In Group I the intrauterine death rate
for fetuses weighing 1500 g or less was also significantly lower (P=0.007), and
the early neonatal death rate was almost half (15.8 vs. 28.9%, P=0.157). There
were no differences in other pregnancy complications between the two groups
except significantly more frequent preterm premature rupture of membranes and
preterm labor requiring parenteral tocolysis in Group II (P=0.042 and 0.036,
respectively), and significantly more frequent fetal growth retardation in Group
I (P<0.001). CONCLUSION: Preventive hospitalization offers a better outcome for
triplets even though prolonged hospitalization and all other procedures
necessary to achieve optimal pregnancy outcome are also offered in the Croatian
standard outpatient care protocol for multiplet pregnancies.
PMID: 12065133 [PubMed - indexed for MEDLINE]
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-
Risk factors for preterm delivery in women with placenta
praevia and antepartum haemorrhage: retrospective study.
Lam CM, Wong SF.
Department of Obstetrics and Gynaecology, Princess Margaret Hospital, 2-10
Princess Margaret Hospital Road, Hong Kong.
OBJECTIVE: To identify risk factors for preterm delivery in women with placenta
praevia and antepartum haemorrhage. DESIGN: Retrospective study. SETTING:
Regional obstetric unit, Hong Kong. SUBJECTS AND METHODS: Women delivered at
Princess Margaret Hospital between 1 January 1990 and 31 December 1997. Possible
risk factors for preterm delivery among women with placenta praevia and
antepartum haemorrhage including onset, pattern, and severity of vaginal
bleeding; presence of uterine contractions on admission; and type of placenta
were assessed. RESULTS: Three risk factors for preterm delivery were identified
from univariate analysis. These included second trimester vaginal bleeding (odds
ratio=4.19; 95% confidence interval, 1.29-13.66), the presence of uterine
contractions on admission (odds ratio=4.00; 95% confidence interval,
1.57-10.19), and a haemoglobin decrease of more than 20 g/L (odds ratio=3.00;
95% confidence interval, 1.00-9.04). Using the logistic regression model, second
trimester vaginal bleeding and the presence of uterine contractions were found
to be independent risk factors for delivery before 36 weeks. CONCLUSION: Preterm
delivery is increased in women with placenta praevia and antepartum haemorrhage
who have second trimester vaginal bleeding or the presence of uterine
contractions. This high-risk group may benefit from close in-patient monitoring
and more aggressive management.
PMID: 12055359 [PubMed - indexed for MEDLINE]
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-
Early-onset neonatal group B streptococcal infections in New
Zealand 1998-1999.
Grimwood K, Darlow BA, Gosling IA, Green R, Lennon DR, Martin DR, Stone PR.
Department of Paediatrics and Child Health, Wellington School of Medicine and
Health Sciences, Wellington, New Zealand. grimwood@wnmeds.ac.nz
OBJECTIVE: To determine in New Zealand infants the attack rates, risk factors,
preventive policies, strain serotype and antibiotic susceptibilities of
early-onset neonatal group B streptococcus (GBS) infection. METHOD: A 2-year
prospective active surveillance study was conducted in New Zealand's 19 neonatal
units. Cases had to present within 48 h of delivery, be unwell, possess abnormal
haematological indices and have GBS isolated from sterile sites. RESULTS: Of the
112 402 infants born in New Zealand during 1998-1999, 56 had early-onset GBS
infection, an attack rate of 0.5 per 1000 live births (95% confidence interval
[CI] 0.38, 0.65). Seven had meningitis and there was one death (case fatality
rate of 1.8%; upper 95% CI 9.5%). Univariate analysis identified young maternal
age, parity, preterm labour, prolonged membrane rupture, maternal fever and
assisted delivery as risk factors. Preventive policies for GBS were reported by
14 (74%) obstetric centres associated with neonatal units. Of the 56 cases, five
(9%) were born to mothers receiving intrapartum antibiotics, 32 (57%) had
mothers with risk factors but were not treated with antibiotics, and 19 (34%)
were born to mothers without identifiable risk factors for GBS prevention.
Serotypes Ia and III predominated, while two isolates were resistant to
erythromycin and/or clindamycin. CONCLUSIONS: Rates of early-onset GBS infection
are similar to other countries following the introduction of prevention
policies. Further reductions are possible with full implementation of these
guidelines. Meanwhile, emergence of antibiotic resistance complicates the
management of women with penicillin allergy. Vaccine development therefore
remains a priority.
PMID: 12047696 [PubMed - indexed for MEDLINE]
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[Endocrine, paracrine and electrophysiologic regulation of
human labor]
[Article in Serbo-Croatian (Roman)]
Skrablin S, Kalafatic D, Goluza T, Zagar L.
Klinika za zenske bolesti i porode KBC-a Zagreb i Medicinskog fakulteta
Sveucilista u Zagrebu, Petrova 13, 10000 Zagreb.
The problem of labor and delivery, either at term or occurring prematurely, are
among the greatest problems facing physicians nowadays. The understanding of the
process of preparation and initiation of active labor is of utmost importance.
Currently, the clinical methods to assess the changes of the uterus and cervix
are still subjective, inaccurate and crude. Fortunately, a noninvasive method of
transabdominal uterine muscle electrical activity analysis (electromiography,
EMG) is digitalized and standardized in recognizing uterine contractility, and
biochemical changes, as well as ultrasound and fluorescent methods, are emerging
to estimate cervical preparation prior to active labor. Studies in humans
indicate that uterine and cervical function an be accurately monitored during
pregnancy and during the preparation for labor. In the review article all
aspects of uterine muscle and uterine cervix architecture, preparation for labor
and control of these processes are presented. The development of new methods of
diagnosis for the patient in labor will improve our ability to diagnose preterm
labor early enough to undertake all kinds of scientifically based methods and
strategies specifically for the management of this condition.
Publication Types:
PMID: 12038097 [PubMed - indexed for MEDLINE]
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-
Placental abruption.
Hladky K, Yankowitz J, Hansen WF.
University of Iowa College of Medicine, University of Iowa Hospital and Clinic,
Iowa City, Iowa 52242-1080, USA.
Placental abruption complicates approximately 1% to 2% of all pregnancies and
remains a significant cause of both maternal and fetal morbidity. Proposed
pathophysiology of both acute placental abruption and the more common partial
placental separation are discussed. The contribution of placental abruption to
both preterm labor and preterm premature rupture of membranes is discussed.
Recent evidence supporting maternal hypertensive disorders, maternal tobacco and
cocaine use, age and parity, multiple gestations, maternal thrombophilias, and
an unexplained elevated maternal serum alphafetoprotein as risk factors for
abruption is reviewed. Emergency management of acute abruption is outlined.
Finally, particular emphasis is given to the management of partial placental
separation, including both immediate and delayed delivery and the use of
tocolysis. TARGET AUDIENCE: Obstetricians and Gynecologists, Family Physicians.
LEARNING OBJECTIVES: After completion of this article, the reader will be able
to define the condition of placental abruption, list the conditions associated
with abruption, and outline potential management options for patients with
placental abruption.
Publication Types:
PMID: 11997676 [PubMed - indexed for MEDLINE]
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Elective cerclage vs. ultrasound-indicated cerclage in
high-risk pregnancies.
To MS, Palaniappan V, Skentou C, Gibb D, Nicolaides KH.
Harris Birthright Research Centre for Fetal Medicine, King's College Hospital,
London, UK.
OBJECTIVE: To compare pregnancy outcome after elective vs. ultrasound-indicated
cervical cerclage in women at high risk of spontaneous mid-trimester loss or
early preterm birth. METHODS: This was a retrospective study comparing two
management strategies in women with singleton pregnancies who had at least one
previous spontaneous delivery at 16-33 weeks of gestation. One group was managed
by the placement of an elective cerclage at 12-16 weeks and the other group had
transvaginal ultrasound examinations of the cervix at 12-15+6, 16-19+6, and
20-23+6 weeks and cervical cerclage was carried out if the cervical length was
25 mm or less. RESULTS: A total of 90 patients were examined, including 47 that
were managed expectantly and 43 treated by elective cerclage. In the expectantly
managed group, 59.6% (28/47) required a cervical cerclage. We excluded from
further analysis three patients who were lost to follow-up and three because of
fetal death or iatrogenic preterm delivery. Miscarriage or spontaneous delivery
before 34 weeks' gestation occurred in 14.6% (6/41) of the elective cerclage
group, compared with 20.9% (9/43) in the expectantly managed group (chi2 =
0.219, P = 0.640). CONCLUSION: In women at increased risk of spontaneous
mid-trimester or early preterm delivery, a policy of sonographic surveillance
followed by cervical cerclage in those with a short cervix reduces the need for
surgical intervention without significantly increasing adverse pregnancy
outcome.
PMID: 11982981 [PubMed - indexed for MEDLINE]
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Surgical treatment of primary hyperparathyroidism during the
third trimester.
Schnatz PF.
Departments of Obstetrics and Gynecology and Internal Medicine, The University
of Connecticut School of Medicine, Farmington, and Hartford Hospital, Hartford,
Connecticut, USA. pschnat@harthosp.org
BACKGROUND: Primary hyperparathyroidism is a rare diagnosis in the third
trimester of pregnancy. A 58% fetal complication rate, including perinatal death
and preterm labor, following late gestation parathyroidectomy has been reported.
These statistics, however, are based on small sample sizes and were reported
when our current technology was unavailable. CASE: A 30-year-old woman presented
in the early third trimester with primary hyperparathyroidism. Despite
conservative management, her ionized calcium level increased to 1.88 mmol/L
(normal 1.17-1.33 mmol/L). At 3447 weeks, she had an uncomplicated
parathyroidectomy. At 3837 weeks she delivered a 3182-g female infant. Neither
the mother nor baby had complications. CONCLUSION: This supports the contention
that pregnant women with hyperparathyroidism not controlled by conservative
measures can be treated successfully with parathyroidectomy, regardless of
gestational age.
PMID: 11975976 [PubMed - indexed for MEDLINE]
-
[Current clinical implications of transvaginal ultrasound
measurement of the cervix during pregnancy]
[Article in French]
Kayem G, Cabrol D.
Maternite Port-Royal, Hopital Cochin-APHP-Universite Rene Descartes, 123,
boulevard Port-Royal, 75014 Paris. g.kayem@mageos.com
Transvaginal ultrasound measurement of the cervix is increasingly used for the
prediction of preterm labor. In comparison to clinical vaginal examination, it
has the advantages of being highly reproducible, with a low inter-observer
variability, and of offering an evaluation of the entire cervical canal,
including the internal os. The sensitivity and specificity of transvaginal
ultrasound have been validated by several studies in women with symptoms of
preterm labor, however its clinical applications and its limits have yet to be
fully determined. It is likely to be of benefit in the management of multiple
gestations, but it appears unlikely to be of use in low-risk pregnancies.
Finally, whether it can be applied to estimate the risk of cervical
incompetence, or to determine the need for cervical cerclage placement has not
yet been determined by methodologically satisfactory clinical studies.
Publication Types:
PMID: 11973520 [PubMed - indexed for MEDLINE]
-
Data mining methods for improving birth outcomes prediction.
Goodwin LK, Iannacchione MA.
Health Systems and Primary Care, Duke University School of Nursing, USA.
linda.goodwin@duke.edu
Data mining is a research method that is increasingly being used to predict
clinical outcomes, for example, cancer or AIDS survival, diagnostic accuracy in
abdominal pain or brain tumors, and much more. In clinical practice, predicting
which patients will deliver preterm versus full term remains a complex clinical
problem for families and the healthcare system. Exploratory data mining was used
for predicting birth outcomes in a racially diverse sample (n = 19,970). Duke
University provided data (1622 variables) for data mining methods that found 7
demographic variables yielded .72 area under the curve for receiver operating
characteristic (ROC) analyses, suggesting that a parsimonious set of preterm
birth outcomes predictors may be possible. Improved prediction is needed for
interventions to be appropriately targeted for improved birth outcomes
management.
PMID: 11949518 [PubMed - indexed for MEDLINE]
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-
Routine cervical cerclage in higher order multiple gestation
-- does it prolong the pregnancy?
Strauss A, Heer IM, Janssen U, Dannecker C, Hillemanns P, Muller-Egloff S.
Department of Obstetrics and Gynecology - Grosshadern, University of Munich,
Germany. Alexander.Strauss@helios.med.uni-muechen.de
Preterm birth following cervical dilatation is the greatest threat to infants of
a multiple pregnancy. Lacking reliable data concerning the effect of
prophylactic cerclage, we compared a study group to controls for maternal and
perinatal outcome. Sixteen of 94 triplet-, 9 of 18
quadruplet/quintuplet-pregnancies, treated with prophylactic cerclage, were
retrospectively compared to those without cervical cerclage respectively.
Kruskal-Wallis test and Mann-Whitney-U test were performed as non-parametric one
way analysis of variance. For the analysis of frequencies Chi Square test or
Fisher's exact test were performed. Odds ratio with 95% confidence interval was
used to compare the need for intravenous tocolysis as well as perinatal
morbidity and mortality. Gestational age at delivery was not different from the
controls in all studied groups. Birth weight revealed a 200 g dominance for the
"no cerclage-triplets", while this significant difference was inverted for
quadruplets/quintuplets (1245 g vs. 1069 g). With respect to gestational age at
birth, need for hospitalisation or medical intervention no benefit was achieved.
Moreover, perinatal outcome analysed by arterial pH, APGAR-Score and perinatal
mortality was not altered by a prophylactic cerclage. Perinatal morbidity for
quadruplets and quintuplets was even higher in cerclage pregnancies. Therefore,
these retrospective results disclaim a positive impact of cervical cerclage on
pregnancy management or perinatal outcome in multifetal pregnancies.
Publication Types:
PMID: 11931683 [PubMed - indexed for MEDLINE]
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-
Cervical screening for preterm delivery.
Welsh A, Nicolaides K.
Harris Birthright Research Centre for Fetal Medicine, King's College Hospital,
London SE5 9RS, UK.
The ability of sonographic cervical length screening to detect those at risk of
spontaneous preterm delivery has been extensively explored over the past few
years. This applies both to high-risk and low-risk groups. Cervical length
measurement appears to be superior to biochemical, microbiological or hormonal
methods of screening. The screening technique has been standardized, but the
cervical length for intervention and the timing and nature of intervention have
not been defined. Cervical cerclage appears to be of use to prevent or arrest
the progress of cervical dilation in high-risk cases, but the management of the
screen-positive low-risk case has yet to be determined. Future management may be
stratified according to actual cervical length, and prospective randomized
trials of treatment for the short cervix are needed.
Publication Types:
PMID: 11914698 [PubMed - indexed for MEDLINE]
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-
New therapies for the pregnant patient with diabetes.
El-Sayed YY, Lyell DJ.
Department of Gynecology and Obstetrics, Stanford University, California, USA.
yasser.el-sayed@stanford.edu
Gestational diabetes complicates 3-5% of pregnancies. Of diabetes seen during
pregnancy, 10% is pregestational and the remaining 90% represents gestational
diabetes. (1,2) Pregnancy in women with pregestational diabetes is especially
high risk. Spontaneous abortion, preterm labor, congenital malformations,
preeclampsia, macrosomia, birth injury, and cesarean section are all increased
in these pregnancies. Deterioration of maternal health during pregnancy,
especially in the setting of diabetes-induced end-organ disease, is a real
concern. Vigilant surveillance and management of associated disorders such as
retinopathy, nephropathy, and chronic hypertension are required. During the
preinsulin era, maternal and perinatal mortality in pregnancies complicated by
pregestational diabetes was approximately 50%. (1,2) Although modern obstetrical
management and the appropriate use of insulin have dramatically improved
maternal-fetal outcomes, pregnant patient with diabetes remains at increased
risk for complications. There is no doubt that optimizing maternal glucose
control is a key element in avoiding established perinatal risks. The most
effective means to accomplish this control are topics of active research.
Further, hormonal changes during pregnancy can make glycemic control difficult
even for the most compliant and educated patient. This paper discusses several
new approaches, either currently in practice or under consideration, to
pregnancies complicated by diabetes, including oral hypoglycemic agents, lispro,
the insulin pump, and transplantation.
Publication Types:
PMID: 11911177 [PubMed - indexed for MEDLINE]
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Transvaginal sonographic examination of the cervix in
asymptomatic pregnant women: review of the literature.
Rozenberg P, Gillet A, Ville Y.
Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital,
University Paris V, France. prozenberg@chi-poissy-st-germain.fr
Different strategies have been developed to refine the prediction of the risk of
preterm delivery in asymptomatic patients. Transvaginal sonography has been used
for this reason to measure and examine the length and shape of the cervix. In
this review, we focus on clinical studies involving transvaginal sonographic
assessment of the cervix in asymptomatic women at high risk of preterm delivery
and in the general pregnant population. Three ultrasound signs are suggestive of
cervical incompetence, namely, dilatation of the internal os, sacculation or
prolapse of the membranes into the cervix (with shortening of the functional
cervical length) either spontaneously or induced by transfundal pressure, and
short cervix in the absence of uterine contractions. Transvaginal sonography has
clearly demonstrated that cerclage leads to a measurable increase in cervical
length which may contribute to the success of this procedure in reducing the
risk of preterm delivery. Several non-randomized interventional studies among
patients with cervical incompetence have been published. They have defined a new
group of patients requiring cerclage when the women show progressive cervical
modifications on transvaginal sonography, while in other studies, cerclage
performed on the basis of cervical changes on transvaginal sonography did not
prevent premature delivery. One prospective randomized trial in asymptomatic
high-risk women has shown two benefits of cerclage following indications for
transvaginal sonography: (1) it would generate fewer prophylactic cerclages in
high-risk women; (2) therapeutic cerclage before 27 weeks may reduce the
incidence of premature delivery before 34 weeks. The risk of preterm delivery is
inversely correlated with cervical length. Routine transvaginal sonography of
the cervix performed between 18 and 22 weeks can help identify patients at risk
of preterm delivery. However, given the low prevalence of preterm births,
screening would generate either a high false-positive rate or a low sensitivity.
One non-randomized interventional study among patients with a short cervix on
routine ultrasound examination found a lower risk of delivery before 32 weeks in
the cerclage group than in the expectant management group. However, to date,
there have been no prospective randomized trials in a general population.
Although evidence is still lacking, there does appear to be a benefit in
performing a cerclage rather than continuing with expectant management in cases
with sonographic appearance of cervical incompetence in asymptomatic women at
high risk of preterm delivery. Ultrasound can be offered to reduce the
indications of cerclage for cases in which the situation is uncertain. Within
the general obstetric population, transvaginal sonography might help in the
selection of asymptomatic but high-risk women. However, the benefit associated
with cerclage for sonographic indication has not been demonstrated.
Publication Types:
PMID: 11896957 [PubMed - indexed for MEDLINE]
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-
Transvaginal sonographic cervical length changes during
normal pregnancy.
Gramellini D, Fieni S, Molina E, Berretta R, Vadora E.
Department of Obstetrics, Gynecology, and Neonatology, University of Parma,
Italy.
OBJECTIVE: To examine the relationship between cervical length and gestational
age in normal pregnancy in nulliparous versus parous women. METHODS: We studied
a cross-sectional sample of 321 pregnant women, including 185 nulliparous and
136 multiparous women. The inclusion criteria were sonographic confirmation of
gestational age within the 12th week, the absence of any risk factors for
preterm birth, and uncomplicated pregnancy with expected delivery during the
38th to 42nd weeks. Cervical length was measured in a straight line if the
cervix did not show any curvature; in the presence of cervical curvature, the
measurement was broken down into 2 or more segments. RESULTS: There was a
relationship between gestational age and cervical length, which could be
described with a linear function (R = 0.92; R2 = 0.85; P < .001). Moreover,
there was no statistically significant difference between multiparous and
nulliparous women. CONCLUSIONS: Our study shows that cervical length is
comparable in nulliparous and multiparous women throughout pregnancy. In both
groups, it actually shows a progressive, linear reduction between the 10th and
40th weeks. Reference ranges constructed for the whole gestational period might
be more useful than a single cut-off value for more efficient prevention and
management of preterm birth.
PMID: 11883533 [PubMed - indexed for MEDLINE]
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[Management and outcome of preterm labor in department of
obstetrics and pathology of pregnancy school of medicine in Lublin]
[Article in Polish]
Kraczkowski J, Skoczynski M, Robak M, Krzyzanowski A, Sawulicka-Oleszczuk H,
Brzozowski I, Semczuk M.
Kliniki Poloznictwa i Patologii Ciazy AM w Lublinie.
OBJECTIVES: We present data of three years experience of management and outcome
of preterm labour. MATERIALS AND METHODS: The study comprised 335 pregnant women
with preterm labour. We analyzed the pharmacological therapy and way of labour.
There were two groups of patients: I group--180 patients who had cesarean
delivery, II group--155 patients who had vaginal delivery. RESULTS: It has been
found 7.54% more cesarean delivery than vaginal delivery of preterm labour.
PMID: 11883216 [PubMed - indexed for MEDLINE]
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Nifedipine versus terbutaline in management of preterm labor.
Weerakul W, Chittacharoen A, Suthutvoravut S.
Department of Obstetrics and Gynecology, Ramathibodi Hospital, Mahidol
University, Bangkok, Thailand.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 11880137 [PubMed - indexed for MEDLINE]
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Drugs in pregnancy. Drugs for obstetric conditions.
Peek MJ.
University of Sydney, Level 5 South Block, Spurrett Building, Nepean Hospital,
Penrith, New South Wales, Australia 2752.
For many reasons, including the fear of fetal anomaly, the recognition of
pregnancy being a normal physiological process and maternal choice, few drugs
are prescribed and used during pregnancy. Nevertheless, there are certain common
obstetric conditions that are associated with significant maternal and perinatal
morbidity and mortality where drugs play an important and necessary part in
treatment. These conditions include termination of pregnancy, threatened preterm
labour, induction of labour and post-partum haemorrhage. This chapter deals with
the role of drug therapy in these obstetric scenarios. A large amount of
obstetric clinical trial research has been dedicated to the management of these
conditions. Copyright 2001 Harcourt Publishers Ltd.
Publication Types:
PMID: 11800538 [PubMed - indexed for MEDLINE]
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The diagnosis and management of preterm labor.
Shellhaas CS, Iams JD.
Department of Obstetrics and Gynecology, The Ohio State University College of
Medicine and Public Health, Columbus 43210, USA.
Accurate diagnosis of preterm labor remains a problematic issue. New techniques
such as transvaginal cervical sonography and fetal fibronectin are increasingly
important in diagnosis and intervention planning. Neither test can, at present,
be recommended for screening of the general population since there is no
effective intervention for a positive test. Future directions in research
include development of new tocolytic agents such as COX-2 inhibitors and
clarification of the best use of adjunctive therapies such as betamethasone for
lung maturity.
Publication Types:
PMID: 11794815 [PubMed - indexed for MEDLINE]
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-
Primary infertility associated with isolated cervical
collecting diverticulum.
Seoud M, Awwad J, Adra A, Usta I, Khalil A, Nassar A.
Department of Obstetrics and Gynecology, American University of Beirut Medical
Center, Beirut, Lebanon. mike@aub.edu.lb
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.
PMID: 11779612 [PubMed - indexed for MEDLINE]
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Telemedicine: cost-effective management of high-risk
pregnancy.
Morrison J, Bergauer NK, Jacques D, Coleman SK, Stanziano GJ.
Dept. of Ob/Gyn, University of Mississippi Medical Center, 2500 N. State St.,
Jackson, MS 39216, USA. jmorrison@ob-gyn.umsmed.edu
PURPOSE: To evaluate the cost-effectiveness of telemedicine services in patients
diagnosed with preterm labor (PTL). DESIGN: Women hospitalized with a diagnosis
of PTL during a 3-year study period were identified within a health maintenance
organization. Inclusion criteria: singleton gestation, stabilized after
tocolysis and discharged from the hospital, and participation in the HMO's
preterm-birth prevention program. After a PTL diagnosis, telemedicine services
(home uterine activity monitoring with daily telephonic nursing contact) were
authorized by the payer. The decision to prescribe telemedicine services was
made by each patient's individual physician. Two groups of patients were
identified: those who received telemedicine services (telemedicine group), and
those who received standard care without the adjunctive outpatient service
(control group). METHODS: Descriptive and statistical methods were used to
compare maternal demographics, pregnancy outcome, antepartum hospitalization,
delivery, nursery, and outpatient services. PRINCIPAL FINDINGS: One hundred
women were identified: 60 in the telemedicine group and 40 in the control group.
Gestational age at diagnosis of PTL was similar at 29.4 +/- 3.8 weeks,
telemedicine group vs. 28.0 +/- 7.4 weeks, control group (P = 0.252). The
telemedicine group had a significantly later mean gestational age at delivery
(38.2 +/- 1.4 vs. 35.3 +/- 3.8), higher mean birth weight (3224 +/- 588 vs. 2554
+/- 911), fewer mean total nursery days (2.4 +/- 1.8 vs. 14.9 +/- 26.4), and
less frequent admission to the neonatal intensive care unit (6.7 percent vs. 40
percent) than the control group (all P < 0.005). The total mean cost per
pregnancy was $7,225 for the telemedicine group and $21,684 for the control
group. This represented average savings of $14,459 per pregnancy using
telemedicine services. CONCLUSION: Following an episode of PTL, use of
telemedicine services can be a cost-effective tool to improve pregnancy outcome.
PMID: 11761593 [PubMed - indexed for MEDLINE]
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-
Premature rupture of the membranes: an evidence-based
approach to clinical care.
Naylor CS, Gregory K, Hobel C.
Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine,
Cedars-Sinai Medical Center, Burns and Allen Research Institute, Los Angeles,
California, USA.
Management of the patient with premature rupture of membranes is a relatively
common but often perplexing problem frequently faced by the obstetrician.
Despite the recent advances in perinatal care, premature membrane rupture,
especially in the preterm patient, remains a potentially serious complication
with important maternal and fetal implications. This review will address the
important questions concerning the management of premature rupture of membranes
and will attempt to provide comprehensive answers as they appear in the medical
literature.
Publication Types:
PMID: 11731894 [PubMed - indexed for MEDLINE]
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Fetal heart rate patterns in normal and ritodrine-treated
pregnancies, detected by magnetocardiography.
Anastasiadis PG, Anninos P, Assimakopoulos E, Koutlaki N, Kotini A, Galazios
G.
Department of Obstetrics and Gynecology, Medical School, Democritus University
of Thrace, Thrace, Greece.
OBJECTIVE: The aim of the present study was to test the validity of
magnetocardiography in the diagnosis of fetal heart rate arrhythmias in normal
pregnancies, as compared to the number of arrhythmias reported in other series,
which were detected by use of other diagnostic techniques. We also evaluated the
influence of ritodrine on the fetal heart rhythm in pregnancies treated for the
risk of preterm labor by means of magnetocardiography, in order to provide
preliminary results that could be utilized in the future establishment of
magnetocardiography as a screening procedure in the diagnosis and management of
fetal arrhythmias. METHODS: We performed a prospective study on two subgroups of
pregnant women: one of 84 women with normal healthy singleton pregnancies and
one of 68 pregnant women treated with ritodrine for the risk of preterm labor.
RESULTS: The prevalence of fetal arrhythmias in the first subgroup was 3.5%
(3/84), while in the second subgroup the prevalence was 16% (11/68).
CONCLUSIONS: The incidence of fetal arrhythmias detected in our population of
normal pregnancies was comparable to that reported in previous studies by use of
other techniques. Results gained from the second subgroup, although not
comparable to others, owing to lack of similar reports, led us to believe that
magnetocardiography's advantages over conventional methods of fetal cardiac
surveillance could highlight the technique as a useful screening procedure for
the detection of preterm fetuses, which should be submitted to closer
investigation, because of the arrhythmias caused by ritodrine infusion.
Publication Types:
PMID: 11730500 [PubMed - indexed for MEDLINE]
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Risk and prediction of preterm delivery in pregnancies
complicated by antepartum hemorrhage of unknown origin before 34 weeks.
Leung TY, Chan LW, Tam WH, Leung TN, Lau TK.
Department of Obstetrics and Gynecology, The Chinese University of Hong Kong,
Prince of Wales Hospital, Shatin, Hong Kong, China. tyleung@cuhk.edu.hk
OBJECTIVE: To assess the timing and risk factors of preterm delivery in
pregnancies complicated by antepartum hemorrhage of unknown origin (APHUO)
before 34 weeks of gestation, and to formulate a clinical management protocol.
METHODS: A retrospective study involving singleton pregnancies with APHUO
occurring before the 34th week of gestation was performed over a 4-year period
at a university teaching hospital. RESULTS: Seventy-five cases were identified.
Fifty-nine (78.7%) did not have any associated uterine contractions, 74.7 and
90.7% of the cases were classified as having mild bleeding according to history
and physical examination, respectively. The number of cases delivering before 37
weeks of gestation and before 34 weeks were 28 (37.3%) and 22 (29.3%),
respectively. Eighteen cases (24%) delivered within the first week of APHUO, and
4 (5.3%) within the first day. The number of cases delivering within the first
week was significantly higher when there were uterine contractions (62.5 vs.
13.6%, p < 0.001). The severity of bleeding was not shown to be related to the
time of delivery. CONCLUSION: APHUO that occurs before 34 weeks is associated
with a high risk of preterm delivery before 34 weeks (29.3%). The chance of
delivery within the first week is 62.5% when there are coexisting uterine
contractions. Even if contractions are absent, the risk is still high (13.6%)
and persists beyond the first week. We suggest that this group of patients
should be managed with a course of steroid injection and hospitalization for 4
days. Copyright 2001 S. Karger AG, Basel
PMID: 11729334 [PubMed - indexed for MEDLINE]
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[Fetal surgery for severe congenital abnormalities]
[Article in German]
Danzer E, Schier F, Paek B, Harrison MR, Albanese CT.
Abteilung fur Kinderchirurgie, Friedrich Schiller Universitat Jena.
edanzer@gmx.de
BACKGROUND: Over the past two decades the diagnosis of life threatening
congenital malformations has evolved rapidly. Sophisticated and powerful new
imaging and sampling techniques have stripped the veil of mystery from the once
secretive fetus. Early detection and close follow-up of the fetus with
congenital malformations have allowed us to define their natural history,
determine the clinical features that affect clinical outcome, and plan
management approaches to improve prognosis. Fetal surgical intervention is the
logical culmination of the progress in fetal diagnosis. The purpose of this
article is to describe the current techniques and recent advances in prenatal
diagnosis and fetal intervention of severe congenital malformation. MATERIAL AND
METHODS: A complete review of the literature and our own experience concerning
fetal surgery was performed. RESULTS: Although most prenatally diagnosed
malformations are best managed by appropriate medical and surgical therapy after
maternal transport and planned delivery at a tertiary care center, an expanding
number of simple anatomical abnormalities with predictable, lethal consequences
have been successfully corrected before birth. A malformation amenable to
prenatal surgical intervention must fulfill a number of conditions. It must be
severe enough to warrant the risks associated with in utero treatment and must
be reliably detectable before birth. Additionally, the pathophysiology must be
reversible by fetal surgery, significantly improving the prognosis over
post-natal treatment. Many technical intricacies of open fetal surgery have been
solved, but pre-term labor and premature rupture of membranes remain a
omnipresent risks to both the mother and the fetus. To reduce maternal morbidity
and the risk of prematurity we developed minimally invasive techniques to treat
the fetus prenatally. Current indications of fetal surgery include the treatment
of congenital diaphragmatic hernia, cystic adenomatoid malformation of the lung,
sacrococcygeal teratoma, obstructive uropathy, twin-to-twin-transfusion-syndrome
and myelomeningocele. Minimally invasive surgical techniques (FETENDO) have
significantly lessened the incidence of preterm labor and promise to extend the
indications for fetal surgical intervention. CONCLUSIONS: Fetal surgical therapy
for severe congenital malformations may improve the outcome of selected
patients. The development of FETENDO will in all probability reduce the
importance of open fetal surgery in the future.
Publication Types:
PMID: 11727664 [PubMed - indexed for MEDLINE]
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Safety and timing of nonobstetric abdominal surgery in
pregnancy.
Visser BC, Glasgow RE, Mulvihill KK, Mulvihill SJ.
Department of Surgery, University of California at San Francisco, San Francisco,
Calif, USA.
BACKGROUND/AIMS: Abdominal disorders occurring during pregnancy pose special
difficulties in diagnosis and management to the obstetrician and surgeon. The
advisability of nonobstetric abdominal surgery during pregnancy is uncertain.
Our objective was to evaluate the safety and timing of abdominal surgery during
pregnancy. METHODS: We retrospectively reviewed 77 consecutive gravid patients
undergoing nonobstetric abdominal surgery from 1989 to 1996 at an urban academic
medical center and a large affiliated community teaching hospital. Medical
records were evaluated for clinical presentation, perioperative management,
preterm labor, and maternal and fetal morbidity and mortality. RESULTS: The rate
of nonobstetric abdominal surgery during pregnancy was 1 in every 527 births.
Among the 77 patients, the indications for surgery were adnexal mass (42%),
acute appendicitis (21%), gallstone disease (17%) and other (21%). There was no
maternal or fetal loss or identifiable neonatal birth defect. Preterm labor
occurred in 26% of the second-trimester patients and 82% of the third-trimester
patients. Preterm labor was most common in patients with appendicitis and after
adnexal surgery. Preterm delivery occurred in 16% of the patients, but appeared
to be directly related to the abdominal surgery in only 5%. CONCLUSION: Surgery
during the first or second trimester is not associated with significant preterm
labor, fetal loss or risk of teratogenicity. Surgery during the third trimester
is associated with preterm labor, but not fetal loss. Copyright 2001 S. Karger
AG, Basel
PMID: 11721118 [PubMed - indexed for MEDLINE]
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Alternative approaches to preterm labor.
Maxwell CV, Amankwah KS.
Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and
Women's Hospital, Harvard Medical School, Boston, MA, USA.
Alternative approaches to the management of preterm labor have included home
uterine activity monitoring, long-term tocolysis, bed rest, and intravenous
hydration. Current evidence in the literature does not support improved
pregnancy outcomes with these various therapies.
Publication Types:
PMID: 11707018 [PubMed - indexed for MEDLINE]
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New developments in the management of preterm labor.
Bukowski R, Saade GR.
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,
The University of Texas Medical Branch, Galveston, USA.
Current management of preterm labor has not changed the incidence of preterm
delivery; therefore, significant research effort has been concentrated on the
search for new methods of management. New tocolytics like inhibitors of
cyclooxygenase 2 and nitric oxide donors have been tested in animal models and
in preliminary clinical trials with promising results. Inhibition of cervical
ripening may be one alternative to tocolysis. This new approach has a potential
to be a valuable method of management of preterm labor if human studies confirm
the promising results reported in animals. Growing evidence suggests that
premature delivery may be associated with infection or fetal growth
abnormalities, with dire consequences to the fetus. If these associations are to
be included in risk and benefit assessment, then inhibition of preterm labor may
prove to be detrimental to the fetus.
Publication Types:
PMID: 11707016 [PubMed - indexed for MEDLINE]
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Delayed interval delivery in multiple pregnancies.
Van der Straeten FM, De Ketelaere K, Temmerman M.
Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent,
Belgium.
Preterm delivery remains the most important complication of multiple
pregnancies. We describe six cases of successful delay of the subsequent
child(ren) after very preterm birth of the first-born, with intervals ranging
between 14 and 117 days.Based on our findings and on the available literature,
we propose a set of guidelines for the management of early preterm multiple
birth deliveries, including tocolysis, antimicrobial therapy and
corticosteroids.
PMID: 11604191 [PubMed - indexed for MEDLINE]
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Understanding preterm labor.
Challis JR, Lye SJ, Gibb W, Whittle W, Patel F, Alfaidy N.
Department of Physiology, University of Toronto, CIHR Institute of Human
Development, Child and Youth Health, Canada. j.challis@utoronto.ca
Increased uterine contractility at term and preterm results from activation and
then stimulation of the myometrium. Activation can be provoked by mechanical
stretch of the uterus and by an endocrine pathway resulting from increased
activity of the fetal hypothalamic-pituitary-adrenal (HPA) axis. In fetal sheep,
increased cortisol output during pregnancy regulates prostaglandin H synthase
type 2 (PGHS2) expression in the placenta in an estrogen-independent manner,
resulting in increased levels of PGE2 in the fetal circulation. Later increases
in maternal uterine expresssion of PGHS2 require elevations of estrogen and lead
to increased concentrations of PGF2alpha in the maternal circulation. Thus,
regulation of PGHS2 at term is differentially controlled in fetal (trophoblast)
and maternal (uterine epithelium) tissue. This difference may reflect expression
of the glucocorticoid receptor (GR), but not estrogen receptor (ER), in
placental trophoblast cells. In women, cortisol also contributes to increased PG
production in fetal tissues through upregulation of PGHS2 (amnion and chorion)
and downregulation of 15-OH PG dehydrogenase (chorion trophoblasts). The effect
of cortisol on chorion expression of PGDH reverses a tonic stimulatory effect of
progesterone, potentially through a paracrine or autocrine action. We have
interpreted this interaction as a reflection of "progesterone withdrawal" in the
primate, in relation to birth. Other agents, such as proinflammatory cytokines,
similarly upregulate PGHS2 and decrease expression of PGDH, indicating the
presence of several mechanisms by which labor at term or preterm may be
initiated. These different mechanisms need to be considered in the development
of strategies for the detection and management of the patient in preterm labor.
Publication Types:
PMID: 11594542 [PubMed - indexed for MEDLINE]
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Methods and devices for the management of term and preterm
labor.
Garfield RE, Maul H, Shi L, Maner W, Fittkow C, Olsen G, Saade GR.
Department of Obstetrics & Gynecology, University of Texas Medical Branch,
Galveston 77555-1062, USA. rgarfiel@utmb.edu
In this review, we outline studies showing that the uterus (myometrium) and
cervix pass through a conditioning step in preparation for labor. This step is
not easily identifiable with present methods designed to assess the uterus or
cervix. In the uterus, this seemingly irreversible step consists of changes in
the electrical properties that make muscle more excitable and responsive and
produce forceful contractions. In the cervix, the step consists of softening of
the connective tissue components. Progesterone and nitric oxide appear to have
important roles in these processes. The progress of labor can be assessed
noninvasively using electromyographic (EMG) signals from the uterus (the driving
force for contractility) recorded from the abdominal surface. Uterine EMG bursts
detected in this manner characterize uterine contractile events during human and
animal pregnancy. A low uterine EMG activity, measured transabdominally
throughout most of pregnancy, rises dramatically during labor. EMG activity also
increases substantially during preterm labor in humans and rats and may be
predictive of preterm labor. A quantitative method for assessing the cervix is
also described. A collascope estimates cervical collagen content from a
fluorescent signal generated when collagen crosslinks are illuminated with an
excitation light of about 340 nm. The system has proved useful in rats and
humans at various stages of pregnancy and indicates that cervical softening
occurs progressively in the last one-third of pregnancy. In rats, collascope
readings correlate with resistance measurements made in the isolated cervix,
which may help to assess cervical function during pregnancy and indicate
controls and treatments.
Publication Types:
PMID: 11594541 [PubMed - indexed for MEDLINE]
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ACOG Practice Bulletin. Assessment of risk factors for
preterm birth. Clinical management guidelines for obstetrician-gynecologists.
Number 31, October 2001. (Replaces Technical Bulletin number 206, June 1995;
Committee Opinion number 172, May 1996; Committee Opinion number 187, September
1997; Committee Opinion number 198, February 1998; and Committee Opinion number
251, January 2001).
American College of Obstetricians and Gynecologists.
Preterm birth is the second leading cause of neonatal mortality in the United
States (1) (second only to birth defects), and preterm labor is the cause of
most preterm births (2). Neonatal intensive care has improved the survival rate
for babies at the cusp of viability, but it also has increased the proportion of
survivors with disabilities. The incidence of multiple births also has increased
along with the associated risk of preterm delivery (4). Interventions to delay
preterm delivery in these settings have not shown conclusive effectiveness.
Because the morbidity of babies born after 34-35 weeks of gestation has
diminished, most efforts to identify preterm deliveries have focused on
deliveries before this age. This document describes the various methods proposed
for predicting preterm birth and the evidence for their roles in clinical
practice.
Publication Types:
- Guideline
- Practice Guideline
PMID: 11592272 [PubMed - indexed for MEDLINE]
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A systematic approach to the management of preterm labor.
Norwitz ER, Robinson JN.
Department of Obstetrics, Gynecology and Reproductive Biology, Brigham & Women's
Hospital, Harvard Medical School, Boston, MA 02115, USA.
Preterm birth occurs in 7% to 12% of all deliveries, but accounts for over 85%
of all perinatal morbidity and mortality. Although the ability of obstetric care
providers to identify women at risk for preterm delivery has improved, the
overall incidence of preterm birth has remained unchanged for the past 30 years.
Preterm birth remains the single greatest challenge for physician-researchers in
the field of maternal-fetal medicine in the 21st century. This article reviews
in detail the current state of the literature as regards the etiology,
pathophysiology, prevention, and treatment of premature labor and preterm birth.
A better understanding of the molecular mechanisms responsible for the process
of labor, both at term and preterm, will improve our ability to identify and
manage women at risk of premature delivery.
Publication Types:
PMID: 11561910 [PubMed - indexed for MEDLINE]
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Comment in:
A comparison of sonographic cervical parameters in predicting
spontaneous preterm birth in high-risk singleton gestations.
Guzman ER, Walters C, Ananth CV, O'Reilly-Green C, Benito CW, Palermo A,
Vintzileos AM.
Department of Obstetrics, Gynecology and Reproductive Sciences, University of
Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Saint
Peter's University Hospital, New Brunswick, New Jersey, USA. guzmaner@umdnj.edu
OBJECTIVES: To assess the role of cervical sonography and to compare various
sonographic cervical parameters in their ability to predict spontaneous preterm
birth in high-risk singleton gestations. DESIGN: A prospective cohort of 469
high-risk gestations were longitudinally evaluated between 15 and 24 weeks'
gestation on 1265 occasions with transvaginal cervical sonography and
transfundal pressure. The cervical parameters obtained were funnel width and
length, cervical length, percent funneling and cervical index. The information
obtained was used for patient management. Restriction of physical activities was
initiated at cervical lengths of < or = 2.5 cm with cerclage as an option for
cervical lengths of < or = 2.0 cm. RESULTS: Receiver operating characteristic
curve analyses showed that a cervical length of < or = 2.5 cm between 15 and 24
weeks' gestation was equal to the other sonographic cervical parameters in its
ability to predict spontaneous preterm birth. The sensitivities for delivery at
< 28, < 30, < 32 and < 34 weeks' gestation were 94%, 91%, 83% and 76%,
respectively, while the negative predictive values were 99%, 99%, 98% and 96%,
respectively. The placement of a cerclage did not influence the positive and
negative predictive values. In comparison to women with other risk factors,
cervical length was best in the prediction of preterm birth in women with a
prior mid-trimester loss; an optimal cut-off of < or = 1.5 cm had sensitivities
for delivery at < 28, < 30, < 32 and < 34 weeks' gestation of 100%, 100% 92% and
81%, respectively. The rate of preterm delivery at < 34 weeks' gestation
increased dramatically when the cervical length was < or = 1.5 cm. Cervical
length was the only independent variable that entered the logistic regression
model for the prediction of preterm delivery at < 34 weeks' gestation.
CONCLUSIONS: In high-risk singleton gestations a cervical length of < or = 2.5
cm was equal to other sonographic cervical parameters in its ability to predict
spontaneous preterm birth and was better for the prediction of earlier forms of
prematurity (at < 28 and < 30 weeks) than later forms (at < 32 and < 34 weeks).
The optimal cervical lengths and their performance for predicting prematurity
may be influenced by obstetric risk factors.
PMID: 11555447 [PubMed - indexed for MEDLINE]
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Chloride channel blockers 5-nitro-2-(3-phenylpropylamino)
benzoic acid and anthracene-9-carboxylic acid inhibit contractions of pregnant
rat myometrium in vitro.
Yarar Y, Cetin A, Kaya T.
Department of Obstetrics and Gynecology, Cumhuriyet University School of
Medicine, 58140 Sivas, Turkey.
OBJECTIVE: We compared in vitro relaxant effect of chloride channel modulators,
such as 5-nitro-2-(3-phenylpropylamino) benzoic acid (NPPB) and
anthracene-9-carboxylate (9-AC), and beta(2)-adrenergic agonists, such as
ritodrine, in pregnant rat myometrium. METHODS: Isolated myometrial strips were
obtained from eight pregnant rats, and the strips were mounted in organ baths
for recording isometric tension. The effects of 10(-8)-10(-4) M ritodrine,
10(-6)-3 x 10(-4) M NPPB, and 10(-6)-10(-3) M 9-AC on spontaneous contractions
were recorded. RESULTS: Ritodrine (10(-8)-10(-5) M) completely inhibited the
amplitude and frequency of spontaneous contractions in myometrial strips
isolated from pregnant rats in a concentration-dependent manner, but the
relaxant effect of ritodrine at 10(-4) M concentration resulted in
tachyphylaxis. The chloride channel blocker NPPB (10(-6)-3 x 10(-4) M) and the
chloride transport inhibitor 9-AC (10(-5)-10(-3) M) decreased the amplitude of
spontaneous myometrial contractions in a concentration-dependent manner; the
maximum inhibition produced by the highest tested concentration of each drug was
43.8% and 42.1% of the original degree of spontaneous contractions,
respectively. The frequency of myometrial contractions was significantly
inhibited by NPPB and 9-AC beginning with the concentration of 10(-4) M.
CONCLUSION: NPPB and 9-AC appear to be effective relaxants of pregnant rat
myometrium. These effects of NPPB and 9-AC might be therapeutically advantageous
in clinical management of preterm labor.
PMID: 11525895 [PubMed - indexed for MEDLINE]
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-
Rebound perioperative hyperkalemia in six patients after
cessation of ritodrine for premature labor.
Kotani N, Kushikata T, Hashimoto H, Muraoka M, Tonosaki M, Matsuki A.
Department of Anesthesiology, University of Hirosaki School of Medicine,
Hirosaki 036-8562, Japan. nao@cc.hirosaki-u.ac.jp
IMPLICATIONS: This report describes six patients who had marked hyperkalemia
60-150 min after cessation of intravenous ritodrine, which had been administered
for management of preterm labor. Abnormal electrocardiographic findings are very
important clues for a prompt diagnosis of hyperkalemia.
Publication Types:
PMID: 11524345 [PubMed - indexed for MEDLINE]
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Comment in:
Impairment of growth in fetuses destined to deliver preterm.
Bukowski R, Gahn D, Denning J, Saade G.
Department of Obstetrics and Gynecology, The University of Texas Medical Branch,
Galveston, 77555-0587, USA.
OBJECTIVE: The objective of this study was to test the hypothesis that fetuses
destined to deliver preterm do not reach their individual growth potential.
STUDY DESIGN: In a case control design, data on 44 preterm deliveries at < or
=34 weeks were compared with data on a control group of next consecutive term
deliveries. Criteria for inclusion were dating by ultrasonography at <20 weeks
and no medical or obstetric complications. For each fetus, GROW v.2 software was
used to generate an individual optimal growth curve and to calculate the
percentile of achieved growth potential for birth weight based on 6 independent
factors (maternal weight, height, parity, ethnicity, fetal sex, and gestational
age) identified as determining fetal weight from multivariate logistic
regression analysis of 40,000 uncomplicated term pregnancies. Birth weight
percentiles based on standard norms were also calculated for each fetus.
RESULTS: The number of fetuses with birth weight below the 5th, 10th, and 25th
percentile of their growth potential was significantly higher in the preterm
group (10, 13, and 18) compared with that in the control group (2, 2, and 6; P
<.008, P <.001, and P <.008, respectively). There were no significant
differences in variables defining growth potential between the case and control
groups. The number of fetuses below the 5th and 10th percentile based on
standard birth weight norms was not significantly different between preterm and
term pregnancies (3 vs 1 and 5 vs 2; P =.37 and P =.27). Among preterm
deliveries, those preceded by preterm premature rupture of the membranes had
significantly fewer fetuses >75th percentile of their growth potential (2 vs 8;
P =.025). Fetuses with lower gestational ages at preterm delivery achieved lower
median percentiles of their growth potential. CONCLUSION: A significant
proportion of fetuses destined to deliver preterm do not reach their individual
growth potential compared with those delivered at term. This finding challenges
our concept of preterm delivery and management strategy aimed at tocolysis.
PMID: 11518910 [PubMed - indexed for MEDLINE]
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[Delayed birth of the second child in multiple gestation]
[Article in Dutch]
Weemhoff M, van Meir CA, Walther FJ, Twaalfhoven FC, van Roosmalen J.
Medisch Centrum Haaglanden, locatie Antoniushove, afd. Gynaecologie en
Obstetrie, Leidschendam.
Five case histories illustrate the issue of delayed interval deliveries. In the
first two cases, the first child was born at a gestational age of 20 and 18
weeks, respectively. The first woman (40 years old) gave birth to the second
child after successful prolongation of pregnancy to a gestational age of 38
weeks. In the second case (28 years old), the attempt to delay delivery failed
and the second child was born at 19 weeks of gestation. The third case (32 years
old), illustrates the enormous differences in neonatal course between a child
born at 26 weeks of gestation, who had to be treated at length for respiratory
distress syndrome, hypotension and patent ductus arteriosus, and his twin
brother born two weeks later and who recovered more quickly. The fourth case (24
years old) describes delayed delivery to allow administration of antenatal
glucocorticoids. The last case (32 years old) deals with a serious maternal
complication of placental abruption during an attempt to delay the birth of the
second twin. Early tocolytic and antibiotic therapy may delay delivery and, in
combination with antenatal glucocorticoids to stimulate lung maturation, may
thereby improve the condition of the second twin. The role of cervical cerclage
remains controversial. There is an important publication bias in the literature
due to under-reporting of the failed attempts of delayed deliveries. In multiple
gestation with imminent very preterm birth, delayed delivery of the second child
is a feasible management option.
Publication Types:
PMID: 11494684 [PubMed - indexed for MEDLINE]
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The efficacy and safety of asthma medications during
pregnancy.
Schatz M.
Department od Allergy, Kaiser-Permanente Medical Center, San Diego, CA 92111,
USA.
Asthma may be the most common potentialy serious medical problem to complicate
pregnancy. Because severe uncontrolled asthma may cause both maternal and fetal
morbidity and mortality, pharmacological asthma therapy is often necessary
during pregnancy. Only 1 published randomized controlled clinical trial has
evaluated the efficacy of an asthma medication (inhaled beclomethasone) during
pregnancy. Human data bearing on the safety of medications during pregnancy are
usually limited to observational studies, because experimental studies on the
use of medications during human pregnancy would generally be unethical. Existing
observational cohort data do not associate an increased risk of preeclampsia,
total congenital malformations, preterm birth, or low birth weight infants with
maternal exposures to inhaled beta agonists, theophylline, cromolyn, or inhaled
corticosteroids. Maternal use of oral corticosteroids has been associated with
reduced birth weight, an increased risk of preeclampsia, and an increased risk
of oral clefts (first trimester use). Based on this information, benefit-risk
considerations suggest that inhaled asthma medications and theophylline should
be used when indicated for the treatment of asthma during pregnancy. Moreover,
although some increased risks may be associated with the gestational use of oral
corticosteroids, these risks are probably still less than the potential risks to
the mother and the fetus of severe uncontrolled asthma. This articles describes
recently published consensus recommendations regarding the pharmacological
management of asthma during pregnancy.
Publication Types:
PMID: 11453610 [PubMed - indexed for MEDLINE]
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