Eclampsia: trends in incidence and outcomes over 30 years.

OBJECTIVE: This study set out to describe the incidence, mortality rates, and treatment of eclampsia over a 30-year period in a large urban population. STUDY DESIGN: A detailed report of all pregnancies delivered in the Dublin area from 1977 to 2006 was reviewed for incidence, mortality, and treatment of eclampsia. Almost all pregnancies in this area are managed at one of three major obstetric hospitals. All offer comprehensive antenatal care and operate a restrictive policy to magnesium sulfate prophylaxis, in which MgSO4 is reserved for patients with severe preeclampsia or who have already had an eclamptic seizure. RESULTS: During the 30-year study period, there were a total of 626,929 deliveries. Of the 247 cases of eclampsia (3.9/10,000 deliveries) and four maternal deaths (0.63/100,000 deliveries) attributed to eclampsia, none received MgSO4. The mortality rate due to eclampsia was 1.6% (4/247). The use of MgSO4 increased significantly from 11% (13/115) in the first decade of the study to 88.1% (67/76) in the last decade (p < 0.001). The incidence of eclampsia decreased from 5.4/10,000 in the first decade to 3.5/10,000 in the final decade of the study (p < 0.0001). CONCLUSION: Over the study period, MgSO4 has become the leading antiseizure medication used, and this has led to a significant decrease in rates of eclampsia.

Endothelial progenitor cells in mothers of low-birthweight infants: a link between defective placental vascularization and increased cardiovascular risk?

CONTEXT: Offspring birthweight is inversely associated with future maternal cardiovascular mortality, a relationship that has yet to be fully elucidated. Endothelial progenitor cells (EPCs) are thought to play a key role in vasculogenesis, and EPC numbers reflect cardiovascular risk. OBJECTIVE: Our objective was to ascertain whether EPC number or function was reduced in mothers of low-birthweight infants. DESIGN AND SETTING: This was a prospective cohort study in a general antenatal department of a university maternity hospital. PARTICIPANTS: Twenty-three mothers of small for gestational age (SGA) infants (birthweight < 10th centile) and 23 mothers of appropriate for gestational age (AGA) infants (birthweight ≥ 10th centile) were recruited. MAIN OUTCOME MEASURES: Maternal EPC number and function, conventional cardiovascular risk markers, and cord blood adiponectin were measured. RESULTS: Median EPC count was lower (294 vs. 367, P = 0.005) and EPC migration was reduced (0.91 vs. 1.59, P < 0.001) in SGA compared with AGA infants, with no difference in EPC adhesion (0.221 vs. 0.284 fluorescence units, P = 0.257). Maternal triglyceride levels were higher in SGA than AGA infants (0.98 vs. 0.78 mmol/liter, P = 0.006), but there was no difference in cholesterol, glucose, insulin, glycosylated hemoglobin, adiponectin, or blood pressure. There was a moderate monotone (increasing) relationship between birthweight and umbilical cord blood adiponectin (r = 0.475, P = 0.005). CONCLUSION: Giving birth to an SGA infant was associated with lower maternal EPC number and reduced migratory function. Cord blood adiponectin was significantly correlated with birthweight.

Placental pathology, birthweight discordance, and growth restriction in twin pregnancy: results of the ESPRiT Study.

OBJECTIVE: We sought to evaluate the association between placental histological abnormalities and birthweight discordance and growth restriction in twin pregnancies. STUDY DESIGN: We performed a multicenter, prospective study of twin pregnancies. Placentas were examined for evidence of infarction, retroplacental hemorrhage, chorangioma, subchorial fibrin, or abnormal villus maturation. Association of placental lesions with chorionicity, birthweight discordance, and growth restriction were assessed. RESULTS: In all, 668 twin pairs were studied, 21.1% monochorionic and 78.9% dichorionic. Histological abnormalities were more frequent in placentas of smaller twins of birthweight discordant pairs (P = .02) and in placentas of small for gestational age infants (P = .0001) when compared to controls. The association of placental abnormalities with both birthweight discordance and small for gestational age was significant for dichorionic twins (P = .01 and .0001, respectively). No such association was seen in monochorionic twins. CONCLUSION: In a large, prospective, multicenter study, we observed a strong relationship between abnormalities of placental histology and birthweight discordance and growth restriction in dichorionic, but not monochorionic, twin pregnancies.

Changes in vaginal breech delivery rates in a single large metropolitan area.

OBJECTIVE: Vaginal breech delivery rates have been accepted widely to be in decline and the Term Breech Trial (TBT) has recommended delivery of a breech-presenting infant by elective cesarean section delivery. Our aim was to examine the rate of vaginal delivery of term breech pregnancies in the 8 years before and after the publication of the TBT. STUDY DESIGN: We retrospectively examined vaginal delivery rates of breech presentations over a 16-year period in 3 large tertiary maternity hospitals that serve a single large metropolitan population. All 3 hospitals are of similar size and serve a population with similar risk profile. We also examined rates of perinatal mortality in the 3 hospitals over the study period. RESULTS: During the 16-year study period, there were 344,259 deliveries among the 3 hospitals; 11,913 of which were breech deliveries. There were 5655 breech deliveries in the 8 years before the publication of the TBT, with a cesarean delivery rate of 76.9%. There were 6258 breech deliveries in the 8 years since publication of the TBT, and the cesarean delivery rate increased to 89.7% (P < .0001). During the 8 years since publication, the rate of vaginal delivery in nulliparous women decreased from 15.3-7.2% (P < .0001). The vaginal breech delivery rate in multiparous women decreased from 32.6-14.8% (P < .0001). The rates of corrected perinatal mortality showed a significant decrease in the last 4 years of the study. CONCLUSION: Our study demonstrates that the results and recommendations of the TBT have contributed to decreasing vaginal breech delivery rates, which were already in decline before its publication.

Early and late preterm delivery rates - a comparison of differing tocolytic policies in a single urban population.

OBJECTIVE: Preterm delivery results in neonatal morbidity and mortality. We set out to estimate the difference in rates of preterm delivery in two institutions, serving a single population, with differing policies regarding use of tocolytic drugs for the prevention of preterm delivery. STUDY DESIGN: A retrospective study comparing preterm delivery rates between 2002 and 2007 in two large tertiary hospitals serving a single urban population with similar risk factor profile located less than 2 miles from each other. During the study period Hospital A routinely used tocolytic therapy, Hospital B operates a policy of never using any tocolytic drugs. Rates of delivery prior to 26, 30, 34 and 37 weeks were compared for each hospital. RESULTS: During the study period there were 90,843 deliveries between the two hospitals. The overall rates of preterm delivery at less than 37 weeks gestation were comparable with 6.62% (2794/42,232) in Hospital A and 6.15% (2989/48,611) in Hospital B (p = 0.99). There was no significant difference in the numbers delivering at less than 34 weeks, 995/42,232 (2.36%) versus 1134/48,611 (2.33%), p = 0.59, less than 30 weeks, 403/42,232 (0.95%) versus 429/48,611 (0.88%), p = 0.87 or prior to 26 weeks, 126/42,232 (0.29%) versus 121/48,611 (0.25%), p= 0.08. CONCLUSION: In this large population routine use of tocolytic drugs in the treatment of threatened preterm labor does not alter rates of early or late preterm delivery. While this study is limited by its retrospective nature, it calls into question the practice of tocolysis.

Placental cord insertion and birthweight discordance in twin pregnancies: results of the national prospective ESPRiT Study.

OBJECTIVE: The purpose of this study was to evaluate the impact of noncentral placental cord insertion on birthweight discordance in twins. STUDY DESIGN: We performed a multicenter, prospective trial of twin pregnancies. Placental cord insertion was documented as central, marginal, or velamentous according to a defined protocol. Association of the placental cord insertion site with chorionicity, birthweight discordance, and growth restriction were assessed. RESULTS: Eight hundred sixteen twin pairs were evaluated; 165 pairs were monochorionic, and 651 pairs were dichorionic. Monochorionic twins had higher rates of marginal (P = .0068) and velamentous (P < .0001) placental cord insertion. Noncentral placental cord insertion was more frequent in smaller twins of discordant pairs than control pairs (29.8% vs 19.1%; P = .004). Velamentous placental cord insertion in monochorionic twins was associated significantly with birthweight discordance (odds ratio, 3.5; 95% confidence interval, 1.3-9.4) and growth restriction (odds ratio, 4; 95% confidence interval, 1.1-14.3). CONCLUSION: Noncentral placental cord insertion contributes to birthweight discordance in monochorionic twin pregnancies. Sonographic delineation of placental cord insertion may be of value in antenatal assessment of twin pregnancies.