Delayed delivery of multiple gestations: maternal and neonatal outcomes.

OBJECTIVE: The study's aims were to compare neonatal outcomes and to describe maternal complications in patients who underwent delayed delivery of twins or triplets in a preterm gestation. STUDY DESIGN: A retrospective review was performed on 5 sets of twins and 2 sets of triplets. Maternal morbidity was described. Neonatal outcomes were compared in the initial and subsequent delivery groups. RESULTS: The percentage of surviving firstborns was 57%, compared with 78% among latter-born infants. The average gestational age of the initial delivery group was 22.6 weeks (18.9-24.7 weeks); gestational age was 27.4 weeks (19.3-37.9 weeks) for the subsequent group (P <.05), a difference of 32.6 days. The average weight gain was 556.1 g. Serious neonatal complications were less frequent among the subsequently delivered siblings (P <.05), and the mean difference in neonatal hospital stay was 77.3 days, with a range of 62.5 to 139.8 (P <.5). Adverse maternal outcomes were represented by 3 patients with abruptio placentae and 3 patients with intra-amniotic infection, 2 of whom had positive blood culture results. CONCLUSION: On the basis of our experience with 7 multifetal pregnancies, delayed delivery has been demonstrated to increase the likelihood of survival and decrease morbidity among the latter-born siblings. Despite the risk of complications, these data support therapeutic interventions aimed at delayed delivery of subsequent fetuses in cases with the potential for significant morbidity and mortality.

Doppler velocimetry of growth-restricted fetuses in an ovine model of placental insufficiency.

OBJECTIVE: With an ovine model in which growth restriction was induced by exposure to heat stress, our aims were as follows: (1) to describe the normal gestational age-related changes in Doppler velocimetry in the ovine fetal aorta and umbilical artery and (2) to compare Doppler velocimetry between heat-stressed and non-heat-stressed fetuses. STUDY DESIGN: Five ewes were exposed to heat stress for 55 days beginning at 35 days' gestation. Five ewes were not exposed and served as controls. Aortic and umbilical artery pulsed Doppler velocimetry was obtained, including the systolic/diastolic ratio, pulsatility index, and resistance index. Data were obtained between 50 and 120 days' gestation. Linear regression analysis was used to analyze gestational age-related changes in velocimetry. Comparison of mean index values between heat-stressed and non-heat-stressed fetuses were made with analysis of variance. RESULTS: Heat-stressed fetuses demonstrated significantly higher systolic/diastolic ratios and pulsatility index values for both umbilical artery (p < 0.025; p < 0.033) and aorta (p < 0.017; p < 0.022) compared with controls. The umbilical artery and aortic resistance index values were not different between groups (p < 0.079; p < 0.28). The slopes for each of the Doppler index values were negative in both normal and heat-stressed fetuses. Umbilical artery and aortic end-diastolic flows remained absent through the first 70 days of gestation in both groups. CONCLUSION: Doppler velocimetry index values decrease with increasing gestational age, reflecting decreased placental bed vascular resistance. The higher Doppler index values seen in the heat-stressed group are consistent with increased placental vascular resistance. The normal absence of diastolic flow until 70 days' gestation is similar to the pattern described in humans.

Prostaglandin E2 for cervical ripening: a randomized comparison of Cervidil versus Prepidil.

OBJECTIVE: Our purpose was to compare the efficacy and safety of two standardized preparations of prostaglandin E2, Prepidil and Cervidil, for ripening of the cervix and initiation of labor. STUDY DESIGN: This was a prospective randomized study. Subjects in whom induction of labor was indicated were randomly assigned to receive either Prepidil (n = 36), an intracervical prostaglandin E2 gel, or Cervidil (n = 37), a controlled-release hydrogel pessary, as a cervical ripening agent. Inclusion criteria included (1) a Bishop score of < or = 7, (2) a cervix < 4 cm dilated, and (3) < or = 2 cm of cervical dilatation if effacement was > 70%. Each agent was administered according to the manufacturer's recommendations. RESULTS: There was no difference in Bishop scores between the two groups at the completion of the ripening process. The following mean times were shorter for the pessary group than for the gel group: (1) insertion of the ripening agent to vaginal delivery (20.6 vs 26.4 hours, p = 0.017), (2) time to achieve cervical ripening (11.1 vs 15.2 hours, p < 0.001), (3) time to achieve active labor (18.3 vs 25.5 hours, p = 0.019), and (4) hospital stay (3.7 vs 4.4 days, p = 0.03). Labor was initiated without the use of oxytocin in 24% of patients in the pessary group versus 3% of those in the gel group (p = 0.014). CONCLUSION: Both prostaglandin E2 agents are effective in achieving cervical ripening; however, the controlled-release pessary achieves ripening over a shorter time period. Furthermore, because time to achieve vaginal delivery and length of stay are shorter, the use of oxytocin is less frequent, and there is no increase in complications, the overall cost is expected to be less with the use of Cervidil as compared with Prepidil.