Epidural analgesia during labor: a retrospective cohort study on its effects on labour, delivery and neonatal outcome.

OBJECTIVES: to evaluate the impact of epidural analgesia (EA) on labor delivery and neonatal status. MATERIAL AND METHODS: retrospective, observational, cohort study comprising 5593 pregnant women who met the inclusion criteria (singleton pregnancy cephalic presentation, 37-42 weeks of gestation). Out of them, 2496 had EA and 3097 constituted the control group. MAIN OUTCOME MEASURES: incidence of labor complications and operativd deliveries in women who received EA, neonatal status assessed by Apgar score in 1- and 5-minute, and cord pH values. RESULTS: Labor complications were more frequently observed in the epidural group, with an almost 1.5-fold higher incidence in nulliparous (16.32% vs. 11.29%) and 1.4-fold in multiparous women (9.86% vs. 7.08%). Stepwise logistic regression confirmed that EA is a significant risk factor for labor complications in nulliparous women (OR 1.27, 95% CI 1.03-1.58) and for forceps delivery in multiparous women (5.20, 95% CI 3.31-8.177). Also, EA is an important risk factor for both, low cord arterial pH <7.10 (OR 1.98, 95% CI 1.28-3.09, p=0.0023) and low Apgar score at 7 minute (OR=4.55, 95% CI 2.35-8.80, p<0.0001). Crucially there was no difference in the incidence of a low Apgar score at 5 minutes. CONCLUSIONS: EA constitutes an independent risk factor for operative vaginal delivery in multiparous women, but has no effect on the incidence of cesarean sections, either in nulliparous or multiparous women. EA also increases the risk of labor complications, low 1-minute Apgar score and low umbilical cord pH, but is not associated with low 5-minute Apgar score.

48-hours administration of fenoterol in spontaneous preterm labor - Doppler blood flow assessment of placental and fetal circulation.

OBJECTIVES: The aims were to investigate whether any changes in placental and fetal circulation were observed during fenoterol tocolysis within the first 48 hours of therapy. MATERIAL AND METHODS: Doppler evaluation of placental and fetal circulation was performed prior to fenoterol administration and then after 24 and 48 hours. Maternal heart rate and pulsatility index (PI) in uterine arteries were assessed. FHR, RI and PI of umbilical artery and middle cerebral artery were measured. E/A ratio for A-V valves, the myocardial performance index (MPI) and shortening fraction (SF) were calculated for both ventricles independently. The blood flow pattern in DV was assessed using PI, S/a ratio and peak velocity index for the vein. To determine changes over time in all study variable analysis of variance (ANOVA) for repeated measurements followed by Tukey-Kramer's multiple comparison test was used. The effects of additional clinical covariates were checked. RESULTS: Uterine and fetal arterial blood flow patterns were not altered significantly during 48 hours of tocolysis. No significant changes were observed in fetal cardiac function parameters as well. The evaluation of Doppler parameters in the DV revealed a significant increase in PVIV after 48 hours. Additionally after 48 hours of successful tocolysis S/a ratio values were significantly lower. CONCLUSIONS: Short term intravenous administration of fenoterol seems not to alter uterine and fetal arterial blood flow pattern. Direct fetal cardiac function remained unaffected. However significant changes of selected Doppler parameters in DV may suggest further studies should be performed to assess more precisely fetal venous blood flow.

New onset Addison's disease presenting as prolonged hyperemesis in early pregnancy.

UNLABELLED: A 32-year-old Caucasian was admitted at 14 weeks of gestation with hypotension and weight loss. Family members noted that she appeared "tired" prior to pregnancy Past medical history included primary hypothyroidism treated with thyroxine (100 microg/day). She had a healthy daughter aged 2.5 years who had been born small for gestational age. At about 8 weeks of gestation she started to vomit several times a day. She was treated with antiemetics and intravenous fluids. Following discharge she remained nauseated, weak and lightheaded and lost about 8 kg of weight. After readmission she appeared ill and dehydrated, BMI 16.6 kg/m2, BP 90/60 mmHg supine, 70/50 mmHg upright (with faint-like sensation), normal heart sounds, chest clinically clear, abdomen soft and not tender Investigations revealed severe hyponatraemia (sodium 112 mmol/L), normal potassium level 4.3 mmol/L, normal renal function, TSH 1.31 microIU/mL (reference range (RR): 0.27-4.2), freeT4 1.99 ng/dL (RR: 0.93-1.7), freeT3 3.29 pg/mL (RR: 2.57-4.43), anti-TPO antibodies 467 IU/mL (RR: <34)). She was hyperpigmented, hypotensive and hyponatraemic despite rehydration. Cortisol & ACTH, followed by a 250 microg short Synacthen test were requested and revealed peak cortisol response of 17 nmol/L (RR: above 550 nmol/l) as well as high baseline ACTH (969 pg/mL, RR: 0-46 pg/mL). She was started on hydrocortisone and felt tremendously better A diagnosis of Addisons disease was made (in view of hypothyroidism as a part of Autoimmune Polyglandular Syndrome type II). She was discharged on hydrocortisone and fludrocortisone replacement. Further during her pregnancy there was about two-week foetal growth delay. She, however delivered a healthy female infant at 36 weeks of gestation. CONCLUSIONS: New onset Addison's disease is rare in pregnancy but may present with prolonged vomiting and weight loss. Therefore adrenal failure should be included in the differential diagnosis of hyperemesis gravidarum.

Maternal obesity as a perinatal risk factor.

OBJECTIVE: The aim of the study was to estimate the effect of maternal obesity on pregnancy course, delivery and newborn well-being. MATERIAL AND METHODS: Data about women who delivered in PMMH was analyzed and obese pregnant women (pre-pregnancy BMI > or =30) were included in the study group; the rest of the mothers constituted the control group. The pregnancy course, labor and delivery, and newborn well-being were taken into consideration. RESULTS: 4648 women were found in our delivery database, among them 208 (4.48%) were classified as obese. In this group, pregnancy-associated hypertension was common, either non-proteinuric one (8.65% vs 2.39%, p=0.001) or preeclampsia (4.81% vs 1.58 %, p<0.05). There were also more cases of gestational diabetes mellitus requiring insulin therapy (9.62% vs 1.48%, p<0.001) and polyhydramniosis (4.81% vs 2.11%, p<0.05) than in case of controls. The mean gestational age at delivery and newborn general health (estimated by Apgar score, mean umbilical cord pH and the incidence of cases with pH < or =7.10) were similar in both groups. The mean birthweight (3266 g vs 3100 g, p<0.05) and the incidence of macrosomia (20.19% vs 5.69%, p<0.001) were significantly higher in the study group. The delivery mode was comparable in both groups, with the marked tendency towards higher incidence of elective cesarean sections in case of obese mothers (27.88% vs 19.90%, p=0.01). CONCLUSION: Maternal obesity is a significant perinatal risk factor; with pregnancy-associated hypertension and gestational diabetes requiring insulin therapy in obese mothers and macrosomia in newborns as most common complications.

[Evaluation of pregnancy-associated plasma protein A (PAPP-A) and free beta subunit of human chorionic gonadotropin (beta hCG) levels and sonographic assesement of fetal nuchal translucency (NT) in singleton pregnancies between 11 and 14 weeks of gestation--Polish multi-centre research]. / Ocena poziomów osoczowego bialka ciazowego A (PAPP-A) i wolnej podjednostki beta ludzkiej gonadotropiny kosmówkowej (beta hCG) miedzy 11 a 14 tygodniem ciaiy--polskie badania wieloosrodkowe.

UNLABELLED: Evaluation of pregnancy-associated plasma protein A (PAPP-A) and free beta subunit of human chorionic gonadotropin (beta hCG) levels and sonographic assessment of fetal nuchal translucency (NT) in singleton pregnancies between 11 and 14 weeks of gestation--Poland's multi-centers research. OBJECTIVES: Pregnancy-associated plasma protein A has been reported to be low in Down syndrome affected pregnancies during the first trimester of pregnancy. Enlarged nuchal translucency (NT) is observed in about 80% of fetuses affected with chromosomal abnormalities and congenital heart defects (CHD). MATERIAL AND METHODS: The aim of this study were to determine value and the medians of free beta-human chorionic gonadotropin (beta-hCG) and pregnancy associated plasma protein-A (PAPP-A) and nuchal translucency thickness in the first trimester in a prospective study of a non-selected Polish population. RESULTS: All examinations have been performed according to the Fetal Medicine Foundation (FMF) rules. We have included 800 women between 11 weeks 0 days and 13 weeks 6 days gestation into a biochemical examination. Women booked into the clinic were offered screening, using a combination of maternal serum free beta-hCG and pregnancy-associated plasma protein-A (PAPP-A) and fetal nuchal translucency thickness. The maternal serum were measured using the Kryptor analyzer (Brahms Diagnostica). All pregnant women have been divided into 2 groups younger than (first group) and older than (second group) 35 years of age. CONCLUSIONS: Nomogrames for free beta-hCG and PAPP-A levels in physiological pregnancy between 11(+0) and 13(6) weeks were determined in the examined population. A positive correlation between PAPP-A and CRL levels, as well as a weak negative correlation between free beta-hCG and CRL, were demonstrated.

[The use of steroids in the treatment of HELLP syndrome--case report]. / Zastosowanie sterydoterapii w leczeniu zespolu HELLP--opis przypadku, przeglad pismiennictwa.

The HELLP syndrome is a variant of severe preeclampsia. Its leading symptoms are: hemolysis, increased liver enzymes and low platelet count. The treatment of the HELLP syndrome remains controversial as there are no standards of proven efficacy. The article presents a case of a 27- year-old patient, G1P0, 30 wk of gestation, reporting no fetus movements for several hours, who was admitted to The Materno-Fetal Medicine Department, Polish Mother's Memorial Hospital in Lódz, with symptoms of the onset of the HELLP syndrome. The authors present the course of the therapy based on steroids administration, with reference to the most up-to-date literature.

[Massive fetomaternal hemorrhage--case report]. / Masywne przetoczenie plodowo-matczyne--opis przypadku.

Massive fetomaternal hemorrhage is defined as a loss of more than 30-50ml of fetal blood, transferred into maternal circulation. It can lead to severe anemization of the fetus and its consequences such as fetal hydrops or stillbirth. We present a case in which the diagnosis was based on the decresased fetal movement and pathological cardiotocography record. The Kleihauer-Betke test revealed a high percentage of fetal cells and allowed to state a proper diagnosis. An immediate cesarean section was performed and the lab tests confirmed severe anemization of the newborn.

[Prenatal ultrasound findings in complete trisomy 9]. / Regularna trisomia 9 chromosomu--opis przypadku, przeglad pismiennictwa.

This case report describes a 40-year-old woman, primigravida. On 13,3 weeks of gestation we diagnosed an abnormal flow pattern in the umbilical artery and abnormal hyperechogenic structure in fetal abdomen. In next sonographic examination on 16 weeks of gestation we diagnosed ventriculomegaly and ahydramnion. We also observed spina bifida, hyperechogenic kidneys, abnormal flow pattern in the umbilical vein and pulmonary valve insufficiency. We performed genetic amniocentesis. We observed complete trisomy in cytogenetic examinations. The woman opted for an elective TOP according to the Polish Abortion Act on 20 weeks of gestation.

[Doppler assessment of the fetal asphyxia in pregnancies complicated by gestational hypertension and intrauterine growth retardation]. / Dopplerowskie cechy niedotlenienia plodu w przypadkach wspólistniejacego nadcisnienia ciazowego (GH--gestational hypertension) i wewnatrzmacicznego zahamowania wzrostu.

OBJECTIVES: Gestational hypertension is associated with a high morbidity for both mother and fetus. Doppler ultrasound has allowed the fetal circulation to be examined. Now it is possible to monitor the response of the fetal circulation to hypoxia. DESIGN: The aim of this study was to determine flow patterns in fetal circulation from pregnancies complicated by gestational hypertension and intrauterine growth restriction. MATERIALS AND METHODS: The investigation included 23 fetuses with signs of the gestational hypertension and intrauterine growth restriction. We evaluated cerebral-placental ratio (CPR) and pulsation index (PI) in the middle cerebral artery (MCA) and the umbilical artery (UA). We also evaluated flows in umbilical vein. RESULTS: We observed abnormal flow pattern in all cases of analyzing fetuses. The most common abnormal flow was vein pulsation (48%). CONCLUSIONS: All analyzing fetuses shown signs of the hypoxia. Present of the umbilical vein pulsation or decompensate of the brain sparing effect is closely related o increased perinatal mortality.

[Umbilical cord entanglement in monoamniotic twin preganacy--case presentation and literature review]. / Powiklania pepowinowe w ciazy blizniaczej jednoowodniowej--omówienie przypadków i przeglad pismiennictwa.

Monoamniotic twins are at most increased risk of perinatal complications with perinatal mortality of 28-60 % reported in literature. The most specific complication to monoamniotic twins is entanglement and (or) knotting of the cords leading to intrauterine death of both (more often) or one twin. In first presented case 1, 23-year-old primigravida in 33wks of twin monoamniotic gestation was reffered to our Institute due to intrauterine death of one co-twin caused by umbilical cord entanglement. In second case, 26-year-old multigravida in monoamniotic twin gestation was admitted to our institution. A serious umbilical cord entanglement was observed and a presence of true knot of umbilical cord was suspected. Presented cases indicate that establishing a chorionicity and amniocity in twin pregnancy is an essential part of ultrasound examination. The diagnosis of cord entanglement in monoamniotic twin pregnancy enables a forecasting of possible complications. According to the established diagnosis future protocols of perinatal management could be proposed. Due to possible complications counseling and management of monoamniotic twins should be performed in tertiary medical centers.

[Unconjugated serum estriol in the prediction of preterm delivery]. / Zastosowanie oznaczen estriolu w surowicy ciezarnych w diagnostyce porodów przedwczesnych.

OBJECTIVE: The objective was to analyze the serum estriol levels among patients with sings and symptoms of preterm labor and/or preterm rupture of membranes. STUDY DESIGN: A prospective study included pregnant women with sings and symptoms of preterm labor. The main end point of the study was the delivery <28 days from testing. RESULTS: 196 patients were included. 116 patients were included in group I (idiopathic preterm labor), 37 patients in group II (PROM) and the control group (group III) consisted of 43 patients. The incidence of preterm delivery was 31% in group I; in the PROM group all the patients delivered preterm. The mean serum estriol levels in all groups were compared regarding delivery <28 days from testing. In group I patients that delivered <28 days had statistically higher serum level of E3 (14.5 ng/ml vs. 11.1 ng/ml, p = 0.03); in group II the mean E3 serum level did not differ significantly (12.5 ng/ml, p = 0.168). The detailed analysis revealed that significant difference was observed in patients tested after completed 30 wk of gestation (15.4 ng/ml vs 12,8 ng/ml, p = 0.043), but not in patients <30 wk of gestation (9,5 ng/ml vs. 10.0 ng/ml, p = 0.842). CONCLUSIONS: The serum level of E3 seems to have prognostic value in the diagnosis of preterm delivery among symptomatic patients after 30 week of gestation.

[The pregnancy and delivery course in patients with reproductive tract anomalies]. / Przebieg ciazy i porodu u pacjentek z wadami rozwojowymi narzadu rodnego.

OBJECTIVES: The goal of our study was to analyse the course of pregnancy and delivery in women with reproductive tract anomalies. MATERIAL AND METHODS: We retrospectively analyzed the pregnancy and delivery course of 16 patients with previously diagnosed reproductive tract anomalies. The control group constisted of 200 healthy pregnant women. All patients were hospitalized in our department between January 1st 2001 and 31st May 2005. RESULTS: In the study group preterm delivery and abnornal fetal lie were more common. The incidence of cesarean sections (81%) was also statistically higher in the study group. CONCLUSIONS: The course of pregnancy and delivery in women with previous diagnosis of specific reproductive tract anomalies is more likely complicated by several obstetrical pathologies. The pregnant women with this a diagnosis should be considered as a group of high risk pregnancy and perinatal intensive care procedures should be carried out.

[Cervical ectopic pregnancy--a case report]. / Ciaza szyjkowa--opis przypadku.

Authors present a case of a viable cervical pregnancy in a 31 year old woman. Conservative management with intramuscular methotrexate and local injection of KCl was applied. We describe the ultrasound and biochemical findings in this case and discuss those reported in the literature along with the available treatment options.

[Pregnancy and delivery after bariatric surgery]. / Przebieg ciazy i porodu u pacjentek po chirurgii bariatrycznej.

The obesity in Europe is established for 15-20% of population. About 20% of women in reproductive age have accrued body weight. Obesity in this group leads to increased obstetrical risk. Preconceptional normalization of body mass is crucial. Bariatric surgery is one of the most effective methods of obesity treatment with Roux en Y gastric by pass (RYGB) as the one of its kind. In this report we present tree cases of pregnancy and delivery after RYGB.

[Pregnancy and childbirth course after IVF-ET patients admitted to KMMP ICZMP on Lodz between 1996-2002]. / Przebieg ciazy i porodu po IVF-ET u pacjentek hospitalizowanych w Klinice Medycyny Matczyno--Plodowej ICZMP w Lodzi w latach 1991-2002.

THE AIM: The evaluation of pregnancy course and the birth body weight of the infants from the women, which got pregnant as a result of IVF-ET procedures. MATERIALS AND METHODS: 72 female patients admitted to KMMP ICZMP in Lódz between January 1996 and December 2002 were put to the analysis (group I). The control group consisted of 400 random chosen female patients admitted to the Clinic during the examined period (group II). The course of the pregnancy, childbirth and the birth body weight of infants in both groups since 23rd week of the pregnancy were analysed. Mean age of the female patients in group I amounted 32 years (22-42), and in the group II 26 years (17-37). For the purposes of statistic analyse the test chi 2 was used. RESULTS: In group I the patients presented significantly elder population then in the group II. The multiple pregnancies in the group I presented 32% and they occurred significantly more often then in the group II (2%). In the group I significantly statistically more often the cholestase (6.9%), the imminent premature childbirth (36%), the premature amniorrhoea (20.8%), the premature childbirth (22%), the isthmo--cervicalis insufficiency (6.9%) and the inhibition of the intrauterine foetus growth (11%) were affirmed. Statistically significantly more often the childbirth was ended with Caesarean section in the group I (47.2%) then in group II (17.8%). The infants with birth body weight less than 2500 g statistically significantly more often were born from group I (36.4%) then from group II (8.6%). CONCLUSION: 1. The pregnancy and childbirth course after IVF-ET is burden with bigger risk of obstetric pathology occurrence. 2. The pregnant women after IVF-ET are more often giving birth to the infants with low birth body weight.

Two-step test: the combined use of fetal fibronectin and sonographic examination of the uterine cervix for prediction of preterm delivery in symptomatic patients.

PURPOSE: Our purpose was to assess the possibility of combined use of fetal fibronectin testing and sonographic examination of the uterine cervix for prediction of preterm deliveries. METHODS: We prospectively evaluated 82 patients with preterm labor. In each case fibronectin testing and sonographic examination of the cervix were performed. The primary outcome measure was preterm delivery within 28 days. RESULTS: Seventeen point one percent of the examined women delivered within 28 days. Among the analyzed sonographic parameters of the cervix only the functional canal length was significantly correlated with delivery (21.6+/-7.0 mm vs. 30.1+/-6.5 mm, p<0.001). Positive fetal fibronectin was found in 71.4% of patients delivered within 28 days and in 7.4% delivered after 28 days (p<0.001). In multiple logistic regression analysis only positive fibronectin testing (OR 11.25, p=0.005) and functional canal length < or =20 mm (OR 8.18, p=0.027) were independently associated with preterm delivery. We propose two-step testing: begin with the sonographic assessment of the cervix with functional canal length 31 mm as a negative one. The fibronectin testing should be performed only in patients with length 21-31 mm. Two step testing had overall sensitivity of 86%, specificity of 90%, positive predictive value of 63% and negative of 97% for predicting delivery within 28 days. CONCLUSIONS: The proposed combined use of the cervical sonography and fetal fibronectin testing is a practical diagnostic tool for predicting preterm delivery with higher sensitivity and negative predictive value than any of these methods alone.