Long bone fractures in extreme low birth weight infants at birth: obstetrical considerations

BACKGROUND: Cesarean section is a common delivery route for breech fetuses < 1000 gm to prevent trauma. However, abdominal and vaginal delivery maneuvers are similar. Cesarean section avoids the risk of head entrapment but long bone trauma can still occur. CASES: We identified three neonates with femoral fractures during a one year period. All mothers were in active labor. All were premature newborns less than 32 weeks gestation, in breech presentation and delivered by a low vertical cesarean section. Review of all cesarean sections done due to mal presentation (n = 26) during that time showed 11 classic and 15 lower segment vertical incisions (both vertical and transverse). CONCLUSIONS: The interest to reduce maternal morbidity may prompt physicians to perform a low segment vertical incision for delivery of a preterm breech. This decision may increase the chances of trauma by providing less area for the required obstetric maneuvers.

Method of risk assessment affects acceptance rate of amniocentesis

Risk assessment for aneuploidy is an integral part of modern obstetrics. However, patients might choose or reject an amniocentesis, based, not on the risk, but on the screening method used. We examined records of patients referred for evaluation of aneuploidy risk from January 1999 to December 2000. Patients found to have a risk above 1/250 were offered amniocentesis. Out of 555 patients found at risk, 336 (60.5) accepted. Acceptance rate varied depending on risk factor identified: advanced maternal age 178/290 (61.4), abnormal serum screening 107/198 (54), sonographic markers 35/48 (72.9) or a previous child aneuploidy 16/19 (84.2). The risk assessment method used influences significantly the amniocentesis acceptance rate and may affect sensitivity of testing.

How does maternal age affect pregnancy planning in Puerto Rico?

Family planning is essential to most prenatal care programs. It is generally believed that maternal age influences the planning of pregnancy with younger patients having higher incidences of unplanned pregnancies. To test this hypothesis we evaluated 470 consecutive cases of pregnant patients regarding pregnancy planning in their current pregnancy. A total of 170 (36.1) were planned. The incidence of planned pregnancies was evaluated among three age groups and results were as follows: less than 20 years old, 18/60 (30.0), patients 20 to 29 years old, 105/270 (37) and more than 29 years old, 47/140 (33.6). These differences were not statistically significant. Surprisingly, no differences among age groups regarding pregnancy planning were identified in this study.

Failure of intensive fetal monitoring and ultrasound in reducing the stillbirth rate

Although highly popularized among obstetricians, there are conflicting results regarding the efficacy of high-resolution ultrasound and other fetal well-being tests on improving neonatal outcome and morbidity. To assess the impact of unrestricted fetal well-being tests and sonographic evaluations on the stillbirth rate, we evaluated a total of 1,810 pregnancies 20 weeks of gestation or more from a single private clinic serving a mixed population of high and low-risk patients. All patients were performed high-resolution sonography during each trimester of pregnancy. In addition, on each prenatal visit, fetal heart rate, position and amniotic fluid index were documented by a limited sonographic scan. Further sonographic studies were done whenever deemed necessary depending on the clinical situation. Biophysical profiles were performed in the third trimester at any time a risk factor was identified, and repeated as frequently as estimated necessary. All cases of fetal death in utero were documented and the associated maternal risk factors assessed. A total of 14 stillbirths occurred among the 1,810 patients. The stillbirth rate for this population was determined to be 7.7/1000 births (U.S. national average of 6.7-7.8/1000 births). The most common associated maternal complications were Diabetes (4 cases) and Antiphospholipid syndrome (3 cases). All except for one fetus lost at 37 weeks had at least one identifiable maternal risk factor. These results prove that intensive fetal surveillance, even when unrestricted by economic concerns, has limited effectiveness in avoiding fetal demise. This is most probably due to acute placental and cord accidents that cannot be detected promptly enough or that are simply unavoidable.

A nationwide program for the use of preconceptional folic acid to prevent the development of open neural tube defects. Who is really using folic acid?

A nationwide program directed at stimulating the preconceptional use of folic acid (FA) for the prevention of open neural tube defects has been in effect in Puerto Rico for the last 4 years. To evaluate its effectiveness, 479 questionnaires were distributed among pregnant patients. The average age was 27 (range 14-21), and 64.9 of the pregnancies were unplanned. Preconceptional use of FA was 31.5, despite 87.7 of patients reporting knowledge about the importance of FA use. Only 35.4 of patients who had knowledge about FA used it prior to conception. Among patients who planned their pregnancies and knew about the importance of FA, 92/168 (54.6) used it prior to pregnancy. With these dismal results, we believe these campaigns should re-evaluate their educational strategies and consider reduction of unplanned pregnancies as part of their goals.

High incidence of emergency cesarean section among fetuses with unrecognized chromosomal abnormalities

OBJECTIVE: To examine the incidence of obstetric complications in fetuses with unrecognized chromosomal anomalies compare with those in which the diagnosis was known before hand. METHODS: All cases followed at a private facility in San Juan, PR during the time from January 1993 through February 1997 were evaluated in terms of gestational age and method of diagnosis and eventual pregnancy outcome. RESULTS: There where 9 cases of chromosomal anomalies documented by karyotype analysis among 1377 (0.65). Among this group, 5 cases were detected by a combination of maternal serum screening, analysis of risk factors and sonography. Among these, 3 cases elected pregnancy termination, one case of trisomy 21 was delivered stillborn vaginally at 32 weeks and one case of trisomy 18 delivered vaginally at 29 weeks. Among the 4 cases not recognized prenatally, one case of trisomy 21 was delivered at 27 weeks by classical cesarean section due to malpresentation and 3 cases (2 of trisomy 18 and one trisomy 21) where delivered by emergency transverse cesarean section due to suspected fetal hypoxia. CONCLUSIONS: The very high frequency of emergency cesarean section (100) among fetuses with unrecognized major chromosomal anomalies should make us increase our efforts to obtain at prenatal diagnosis. In all of these cases, a prior diagnosis would have probably avoided a cesarean section and the associated potential maternal morbidity. PRECIS: The high incidence of emergency cesarean section among fetuses with unrecognized chromosomal anomalies should make prenatal diagnosis of these conditions a primary goal.

Reduction in the cesarean section rate in nulliparous patients after administration of intravenous propranolol

OBJECTIVE: A preliminary investigation to test the efficacy of intravenous propranolol in reducing the cesarean section rate in nulliparas in active labor and evaluate its effect on neonatal and maternal outcomes. METHODS: Fifty seven nulliparous patients admitted in active labor were randomly divided into two groups: a control group consisting of 23 patients, and a treatment group consisting of 34 patients given 2 mg of propranolol intravenously every 4 hours until delivery. Total length of labor, time from first administration of medication to delivery, incidence of cesarean section, APGAR scores, maternal and fetal morbidity were assessed. RESULTS: A total of 4 cesarean sections were performed in each group (11.7 per cent in the treatment group and 17.3 per cent in the control group). The rate of cesarean section due to dystocia was 6.25 and 13.6 per cent respectively (P = .367). Statistical significance was not reached due to the small number of subjects (students t test analysis). There was no increase in the incidence of low APGAR scores, intensive care unit admissions, abnormal heart rate patterns during labor, cesarean sections for fetal distress or maternal morbidity in the treated group. CONCLUSIONS: Intravenous administration of 2 mg of propranolol every four hours is safe and not associated to increased neonatal or maternal morbidity. A 50 per cent decrease in the incidence of cesarean sections can be documented among nulliparous patients treated with propranolol although the small numbers and overall low incidence of cesarean section in our population (14 per cent) did not permit these differences to reach statistical significance