Vaginal delivery from the persistent occiput posterior position. Influence on maternal and neonatal morbidity

We performed a retrospective study of 564 vaginal occiput posterior (OP) deliveries to investigate the influence of this position on maternal and fetal morbidity. The cases were compared to 1,068 controls matched for race, parity and delivery method. The OP group had a higher incidence of severe perineal laceration and episiotomy than the occiput anterior (OA) group. Within the OP group, operative delivery was associated with a higher incidence of severe perineal laceration, vaginal laceration and episiotomy than was spontaneous delivery. Similarly, the OP group delivered by forceps had a higher incidence of severe perineal lacerations, vaginal lacerations and episiotomy than those delivered by vacuum extraction. Mediolateral episiotomy was associated with a lower incidence of severe perineal lacerations than median episiotomy during delivery from the OP position. The infants delivered from the OP position had a higher incidence of Erb's and facial nerve palsy than did those delivered from the OA position. All these injuries occurred following forceps delivery. Vaginal delivery from the persistent OP position is associated with increased maternal morbidity, and operative vaginal delivery from this position is associated with increased neonatal morbidity.     

The influence of progesterone on the antidiuretic and oxytocic activities of the posterior pituitary lobe of female rats

The course of delivery and labor, the post partum period and the postpartal condition of the newborn were reviewed in 315 obese patients with a bodyweight of 90 kg or more at delivery. The results were compared with those of a group of 315 patients with a body-weight of less than 90 kg, choosed by random and evaluated by statistic (t-test, x2-test). In the group of obese gravidae we found a significant higher rate of cases with induction of labor, protracted deliveries, breech presentation and operative deliveries. Also the rate of manual removal of the placenta, post partum uterine infections and disorders in the milk secretion was significant higher in this group. Post partum abnormal glucose tolerance tests ocurred abnormal more frequently in the obese patients. The weight of the infants of obese mothers was higher as in the control group. Significant higher were the perinatal mortality and the cases of fetal death in utero in the obese group compared to the non obese group.     

Low birth weight: some considerations in a Zambian population

A retrospective analysis of 2401 consecutive births revealed a lowbirth weight rate of 11.4 percent of all births and 14.2 percent all live borns. Sixty-five percent of late fetal and first week neonatal deaths were low birthweight babies. The cause of low birthweight labour was unknown in 48.2 percent of cases. The major known associations with low birthweight labour and delivery were twin birth, antepartum haemorrhage, premature rupture of the membranes and toxaemia of pregnancy. Nutritional factors were considered to be of significance in the incidence of low birthweight. The earlier attendance of mothers at ante-natal clinics and the availability of experienced medical and nursing personnel with adequate facilities are necessary for perinatal mortality to be significantly reduced in the low birthweight group.     

Teenage primigravidae: a comparative study

A review of history sheets of obstetric cases recorded in a district hospital in 1992 was done to compare the obstetric outcome in 200 teenage first pregnancies (Study group) with that in Control group i.e. 20 years to 29 years. It revealed that incidence of complications of pregnancy like anaemia, pregnancy induced hypertension (PIH) and preterm labour were significantly higher among teenage mothers. The normal mode of delivery was commoner in teenagers (82.5%) in comparison to control group (76.5%), probably because of higher number of low birth weight babies. The fetal outcome was significantly worse in teenage mothers with high incidence of perinatal mortality (8%) and low birth weight babies (35%). There was not a single newborn with birthweight above 3500 gms, in teenage group, whereas, control group had 5 babies (2.5%) in the category.     

Vesico-sigmoidal fistulas of diverticular origin

OBJECTIVE: To evaluate the course and outcome of expectantly managed twin pregnancies with single fetal death in the second half of gestation. DESIGN: Case-controlled study of 29 consecutive pregnancies from 1973 to 1993, with sonographic evidence of a twin at 20 weeks gestation with antenatal demise later in pregnancy, matched for maternal parity with 58 twin pregnancies without fetal death and delivered in the same year as the index case. Outcome measures included the incidence of complications of pregnancy, gestational age and mode of delivery, placentation, and perinatal outcome. SETTING: University Hospital Rotterdam. RESULTS: The frequency and severity of pregnancy-induced hypertensive disorders was significantly higher in the study group than in controls. We found no differences between the study group and controls with regard to median gestational age at delivery (33 weeks versus 34 weeks) and median birthweight of liveborn infants (1880 g versus 2160 g). No consumptive coagulopathy was apparent in our 29 patients. The main cause of neonatal death was prematurity; multicystic encephalomalacia was not observed. CONCLUSIONS: Our results support expectant management in twin pregnancies complicated by single fetal death.     

Labor and delivery in a pregnancy involving fetal macrosomia

The alleged connection between fetal magalosomia and the increased risk of maternal and perinatal morbidity justifies the lively discussion that has developed about the management problems caused by a big unborn child. The aim of this study is to offer a contribution to the definition of the more or less peculiar problems associated with labour and delivery in a pregnant women with a megalosomic fetus. The study was retrospectively carried out on a sample of 45 women who, during the period 1190-1993, delivered a fetus weighing at least 4 kg. This sample was statistically compared with a numerically identical standard sample, selected at random. The main characteristics of labour and delivery were examined in the two groups under study. The most considerable differences observed concern the length of the labour, greater in the sample than in the standard group, and the frequency of dystocic events, similarly more considerable in the pregnant women with a megalosomic fetus. Maternal and perinatal outcomes, in spite of the small number of cesarean sections performed, were anyway very good in both the examined groups. In our experience, the risks associated with fetal megalosomia were rather limited, but this is not a reason to minimize beyond measure the problem we are talking about.     

Midtrimester pregnancy termination for fetal malformations. Use of intravaginal prostaglandin E2

OBJECTIVE: To compare outcome differences and responses to treatment in pregnancies complicated by either major fetal malformations or previous fetal death in the second trimester. STUDY DESIGN: Data were analyzed from a computerized perinatal database and individual hospital records for singleton gestations between 14 and 23 weeks undergoing labor induction with prostaglandin E2 (PGE2) suppositories (20 mg intravaginally every three to five hours). RESULTS: Between January 1993 and June 1995, 65 pregnancies underwent induction of labor for either a lethal fetal malformation (38) or death (27). As compared with the fetal death group, the malformation group required more suppositories (median 4, range 1-10, versus median 3, range 1-6; P < .05) and needed a greater total dosage (77.5 +/- 38.5 mg versus 61.8 +/- 37.8 mg, P < .05). The mean time from initiation of treatment until delivery was two hours longer in the malformation group. There were no significant differences between the two treatment groups in incidence of maternal side effects or of retained placentas requiring operative intervention. CONCLUSION: Patients who undergo second-trimester induction of labor for major fetal malformations using intravaginal PGE2 should be counseled that the dosage of the drug is greater and that labor may last longer than in pregnancies complicated by a previous fetal death.     

Prevalence of fetal heart rate decelerations in self-referred low-risk patients in the third trimester

We tested the hypotheses that fetal heart rate decelerations are present during the third trimester in most low risk pregnant women, the prevalence of decelerations is a function of the length of time fetal heart rate monitoring occurs and their presence is not associated with an adverse prognosis. We performed a retrospective chart review of 114 self-referred low-risk pregnant patients who presented to the labor and delivery triage area of a tertiary care hospital at 26-41 weeks gestation. None required admission to the hospital. The control group consisted of patients who delivered immediately before and after the delivery of the study patient. Normal long-term variability and fetal baseline heart rate were found in all electronic fetal monitoring tracings. Accelerations were present in 91% and decelerations in 65% of patients. There was no correlation between length of time of monitoring and the incidence of decelerations. At delivery, there were no differences in birthweight, gestational age, 5-min Apgar scores or cord pH between the control and study patients. Variable decelerations were a common finding in the third trimester of low-risk pregnant patients who self referred to labor and delivery triage. They were not prognostic of an adverse perinatal outcome.     

Comparison of stature growth curves in children and adolescents

During the period 1988-1966, 737 pregnancies, in which the infant birth weight was > or = 4000 grams were studied. During the same period there were 11,631 newborns, and 6.3% of them were infants with a birth weight > or = 4000 grams. Normal vaginal delivery occurred in 583 cases (79.1%), vacuum extraction in 24 cases (3.3%) and caesarean section in 130 cases (17.6%). Regarding the caesarean section, 38 (29.2%) of them were elective and 92 (70.8%) were done in different periods of the labour. In these macrosomic babies perinatal death never occurred, but different pathological neonatal outcomes were observed and the majority of these were clavicle abruptions (39 cases: 5.3%). Maternal morbidity observed in the 607 (82.4%) cases with vaginal delivery is characterized by: 60 cases (9.8%) of vaginal and perineal tears, 4 cases (0.6%) of cervical tears, and 2 cases (0.3%) of pubic symphysis traumatic diastasis. Shoulder dystocia is the most likely outcome in fetal macrosomic delivery; for this reason we considered the diagnostic and therapeutic management of this obstetrical complication. Because the normal outcome of neonatal births actually encourages the preference for normal vaginal delivery, we concluded that mothers with macrosomic fetuses can safely be managed expectantly unless there is a high maternal and fetal risk.     

Umbilical artery blood flow velocity in pregnancies complicated by systemic lupus erythematosus

PURPOSE: We evaluated the role of umbilical artery Doppler velocimetry in the surveillance of pregnancies complicated by systemic lupus erythematosus (SLE). METHODS: We retrospectively studied 56 women with SLE whose pregnancies were managed at our perinatal center between 1988 and 1995. RESULTS: Absent or reversed end-diastolic flow velocity was detected in 6 (11%) of 56 patients. This sub-group of patients had an increased risk of pre-eclampsia, intrauterine growth restriction, cesarean section, and preterm delivery. CONCLUSIONS: A high incidence (11%) of abnormal umbilical artery waveforms was detected. This finding was associated with an increased risk of maternal and fetal complications.     

Inducing labor with intracervical prostaglandin (PG) gel administration. A comparative analysis of 171 patients with 2 different preparations of PGE2 with regard to course of labor and fetal outcome

In the present study we examined whether the difference in viscosity of two prostaglandins applied intracervically for induction of labour influences course of labour and fetal outcome. A comparative analysis was carried out in 171 patients, which received either Cerviprost (n = 85) or Prepidil (n = 86) at 6 hour intervals. The results show that the viscosity of the PG E2 has no influence on the course of induction of labour, the mode of delivery or on fetal outcome. The low viscosity does also not present an increased risk for uterine overstimulation, even in case of intracervical application.     

Obstetric outcome of teenage pregnancies

A retrospective cohort study was performed in a tertiary centre to determine if teenage nulliparas (aged alpha19 years, study group) had higher incidences of instrumental and Caesarean deliveries compared with nulliparas aged 20-34 years (control group) selected from the first women in the birth registry who delivered after each study case and satisfying the criteria for controls. The hospital records of the study and control cases were retrieved for review. Comparison was made in the maternal demographics, major antenatal complications, outcome of labour, mode of delivery, and perinatal outcome. In the study group, maternal height was similar but the body mass index was lower. Although the mean birthweight was lower and the incidences of preterm labour and small-for-gestational-age infants higher, there were also increased incidences of large-for-gestational-age and macrosomic infants. While there was no difference in the types of labour, there were fewer Caesarean and instrumental deliveries, a finding that persisted even after excluding the preterm deliveries. Lastly, teenage mothers aged <17 years had similar outcomes to those aged 17-19 years. These results indicated that teenage mothers had better obstetric outcomes, despite the higher incidence of preterm labour, and that young adolescents (<17 years) performed as well as their older peers.     

The diagnosis of "pathological hyperglycaemia' in gestational diabetes in a high risk obstetric population

In order to define a level of "pathological hyperglycaemia', i.e. glucose intolerance that predicts perinatal morbidity among the obstetric population, 100 g glucose tolerance tests (GTTs) were performed in 660 patients attending for antenatal care at the University Hospital in Jeddah. The results were analysed in two ways: (1) patients were stratified according to the number of abnormal glucose values on the GTTs and (2) patients were placed into one of three groups according to the 100 g GTT diagnostic criteria, i.e. normal (non-GDM), abnormal with fasting blood glucose (FBG) > or = 5.8 mmol l-1 (GDM), and abnormal with FBG < 5.8 mmol l-1 (gestational induced hyperglycaemia, GIH). Although there was a stepwise association between fetal/maternal morbidity with increasing number of abnormal glucose values, no level of glucose intolerance could be defined as a threshold level for normal response. However, when stratified by FBG, GDM patients were significantly heavier (78.5 kg +/- SD 14.9), had a higher incidence of both macrosomia (27.5%) and operative delivery (25.3%) than the other two groups (14.7%, 14.3%, and 15.4%, 12.8% in the non-GDM and GIH, respectively). It is suggested that among patients with abnormal GTT results a FBG > or = 5.8 mmol l-1 identifies a threshold for true "pathological hyperglycaemia'.     

The obstetric implications of teenage pregnancy

A retrospective review was performed on the obstetric outcome of teenage pregnancies delivered in 1 year in a tertiary centre. The results were compared with the rest of the obstetric population in the same hospital in the same year. The teenage mothers (n = 194) had increased incidence of sexually transmitted diseases (5.2 versus 1.0%, P < 0.05), and preterm labour (13.0 versus 7.0%, P < 0.01), but decreased incidence of gestational glucose intolerance (3.1 versus 11.4%, P < 0.001), when compared with the non-teenage mothers (n = 4914). There was no difference in the types of labour, while the incidence of Caesarean section was lower (4.1 versus 12.6%, P < 0.001) in the teenage mothers. Although the incidence of low birthweight was higher in the teenage mothers (13.5 versus 6.5%, P < 0.001), there was no significant difference in the mean birthweight, gestation at delivery, incidence of total preterm delivery, or perinatal mortality or morbidity. The results indicate that the major risk associated with teenage pregnancies is preterm labour, but the perinatal outcome is favourable. The good results accomplished in our centre could be attributed to the free and readily available prenatal care and the quality of support from the family or welfare agencies that are involved with the care of teenage mothers.     

Epidemiological studies on 321 children with congenital diaphragmatic hernia in China]

Perinatal babies delivered in hospitals with gestation of 28 weeks to seven days after birth were monitored by National Birth Defects Monitoring Network from September 1986 to December 1993 to study the prevalence of congenital diaphragmatic hernia in China and the risk factors contributing to their prognosis. Results showed that 321 cases of congenital diaphragmatic hernia in 4,777,220 perinatal babies were detected with an incidence of 0.7 per ten thousand, a case-fatality ratio of 84.1 percent and, fetal death and stillbirth accounting for 28.1 percent of the total perinatal deaths. There was significant difference in birth weight between perinatal deaths and survival perinatal. And, 54.4 percent of the cases complicated with other congenital deformities and severe deformities in heart, lung and central nervous system accounted for the most proportion of them, which were the most important factors contributing to death. A case-fatality ratio of cases with single malformation was 74.7 percent and that of those with multiple malformation 92 percent, with a statistically significant difference. The cases diagnosed antenatally accounted for 11.3 percent of the total, and multiple malformation accounted for a large proportion of them. It indicated that proportion of antenatal diagnosis for congenital diaphragmatic hernia deformity was lower, and their perinatal case-fatality ratio was higher and their prognosis worse.     

Positive association between the GABRA5 gene and unipolar recurrent major depression

The authors describe a case with double perinatal survival of a monoamniotic twin pregnancy and give a survey on the literature regarding this rare and riskful kind of twinning. The importance of accurate antenatal diagnosis, intensive fetal surveillance and operative delivery is discussed.     

Electrophysiological studies in the follow-up of children with perinatal asphyxia history

OBJECTIVES: The objective of this study was to analyze the usefulness of electrophysiological studies [electroencephalogram (EEG) and auditory-evoked potential (AEP)] during the follow-up of children with perinatal asphyxia antecedents. PATIENTS AND METHODS: A prospective epidemiological study of perinatal asphyxia in term neonates born at the University Hospital San Juan (Alicante, Spain) between November 1991 and February 1995 was performed. Perinatal asphyxia was graded as non-severe (1 minute Apgar score < or = 6 and/or umbilical artery pH < 7.20, with abnormal fetal heart patterns and/or meconium-stained amniotic fluid and the need for immediate neonatal resuscitation) and severe (1 minute Apgar score < or = 3 and umbilical artery pH < 7.10). The incidence of hypoxic-ischemic encephalopathy (classification of Levene and Sarnat & Sarnat) during the neonatal period and neurological sequelae (classification of Finer and Amiel-Tison) during the follow-up period were studied. Electrophysiological studies (EEG and AEP) were made mainly between 12 and 18 months of life. RESULTS: During the study period there were 156 cases of perinatal asphyxia in full-term live births (31 severe and 125 non-severe). Hypoxic-ischemic encephalopathy was present in 25.6% of asphyxiated newborn infants, being mild in 30 cases, moderate in 5 and severe in 5. The incidence of neurological sequelae in 115 asphyxiated newborns followed for 24 month was 16.5%. This included mainly motor disabilities. We did not find any case of epilepsy, but there were 4 children with febrile seizures and one case of benign myoclonic seizures. EEG was performed in 88 cases during follow-up, and only was abnormal in two infants without seizures. AEP was performed in 82 cases during follow-up and hearing loss was detected in 4 children with neurosensorial hypoacusia (3 unilateral and 1 bilateral). CONCLUSIONS: Rutinary EEG is not useful during follow-up of children with antecedents of perinatal asphyxia. However, AEP is a hearing screening procedure for infants at risk of deafness, such as in perinatal asphyxia, and the cases of neurosensorial hearing loss detected by AEP in our population were clinically unapparent.     

Lennox-Gastaut syndrome--clinical course and therapy

Clinical course and results of therapy were analysed in the group of 92 children, aged between 3 and 9 years, with diagnosed Lennox-Gastaut syndrome. The obtained results of an analysis have shown that Lennox-Gastaut syndrome origin is not clear--causative factor can not be established in 1/3 of patients whereas in 1/2 of them abnormal course of pregnancy and perinatal period is noted. Together with seizures of various origin, other focal neurological symptoms, mental retardation and abnormalities in CT scans of the brain are frequently seen in patients with Lennox-Gastaut syndrome. Clinical course, prognosis and results of therapy are largely dependent on the degree of mental development before the onset of epileptic seizures, course of pregnancy and perinatal period, and the time of therapy. Children with Lennox-Gastaut syndrome require relative polytherapy in which valproic acid derivatives are predominating together with benzodiazepines, and temporary corticosteroids. An improvement was achieved in about 30% of the treated children. Prognosis in the remaining 70% of children is rather poor. Irregular administration of drugs, frequent changes of anti-epileptic agents, too low doses and abnormal environmental effects (abnormal parental attitudes) affect the results of therapy. An emphasis is on the poor prognosis in Lennox-Gastaut syndrome proceeded with West syndrome.