Previous cesarean section and the risk of postpartum maternal complications and adverse neonatal outcomes in future pregnancies.

OBJECTIVE: To assess maternal postpartum and neonatal outcomes associated with previous method of delivery. STUDY DESIGN: We analyzed prospectively collected maternal and neonatal data from July 2002 to December 2003. Data were collected from dedicated perinatal database and neonatal database from discharge and procedure codes. Groups were: (i) multiparous, prior vaginal delivery (VD), and (ii) multiparous, prior cesarean (CS). This group was subdivided by subsequent pregnancy trial or no trial of labor (No TOL). Results were compared with chi (2)-analysis; significance P<0.05. RESULTS: There were 17 406 births. Prior CS patients without trial of labor (TOL) required more blood transfusions, intensive care unit admissions and hospital readmissions than women with a prior VD. Prior CS patients with TOL required more aminoglycosides for postpartum infection. Term neonates of (CS) mothers without a TOL were more likely to have prolonged hospitalization and require ventilatory support. CONCLUSIONS: In their subsequent delivery, women with a prior CS delivery are at significant risks for postpartum maternal and neonatal morbidities compared with parous patients who experienced a prior VD.

Dynamic cervical change: is real-time sonographic cervical shortening predictive of preterm delivery in patients with symptoms of preterm labor?

OBJECTIVES: To determine prospectively if dynamic cervical change (spontaneous real-time cervical shortening) is predictive of preterm delivery at < 37 weeks' gestation in patients with symptoms of preterm labor. METHODS: This was a prospective study of patients at 23-34 weeks' gestation who were symptomatic for preterm labor. Patients underwent a 10-min real-time sonographic cervical length assessment with measurements taken at 1-min intervals. The presence or absence of dynamic cervical change, defined as real-time changes in cervical length observable to the naked eye of the sonologist during the examination, was recorded. Gestational age at delivery was obtained from medical records. Preterm delivery was defined as delivery at < 37 weeks' gestation. Dynamic cervical change and initial and minimum cervical lengths were assessed for prediction of preterm delivery. RESULTS: Seventy-six patients were enrolled, and 66 were available for outcome analysis. Thirty-one patients (47%) exhibited dynamic cervical change. Patients with dynamic change had shorter initial cervical lengths (27 mm vs. 36 mm, P = 0.001), shorter minimum cervical lengths (20 vs. 33 mm, P < 0.001) and larger changes in cervical length during the examination period (10 vs. 4 mm, P < 0.001). In the subgroup of patients with an initial cervical length > 30 mm, those with dynamic change delivered earlier than did those without dynamic change (36.8 vs. 38.6 weeks, P = 0.02), and a higher percentage delivered preterm (27% vs. 11%, odds ratio (OR), 3.0 (0.5-17.0)). Multivariate analysis showed that minimum cervical length was a better predictor of preterm delivery than was initial cervical length. CONCLUSIONS: Dynamic cervical change occurs frequently in association with shortened cervical length. In patients with longer initial cervical lengths, dynamic change may increase the risk for preterm delivery. When dynamic change is noted in a patient with preterm labor symptoms, use of the minimum cervical length observed may be better compared with initial cervical length for determining preterm delivery risk.

Dynamic cervical change during real-time ultrasound: prospective characterization and comparison in patients with and without symptoms of preterm labor.

OBJECTIVES: To compare the incidence of dynamic cervical change (spontaneous real-time cervical shortening) in singleton patients with and without symptoms of preterm labor (PTL). METHODS: A total of 109 patients between 23 and 34 weeks' gestation with and without PTL symptoms underwent cervical length ultrasound and contraction monitoring over a 10-min period. Cervical length measurements were taken at 1-min intervals. Exclusion criteria included ruptured membranes, dilation > 3 cm or cerclage. Following the examination, the sonographer made a subjective assessment as to whether noticeable dynamic cervical change had occurred. A measurement was then made during the application of fundal pressure. The initial cervical length, shortest length, maximum change in length and incidence of dynamic change were compared between patients with and without PTL symptoms. The shortest cervical length was compared to the presence and timing of uterine contractions and the measurement during the application of fundal pressure. RESULTS: A total of 43 asymptomatic patients and 66 symptomatic patients were studied. Compared to asymptomatic patients, patients with PTL symptoms had shorter initial lengths, nadir lengths and mean lengths over time as well as a greater amount of maximum change. Dynamic cervical change was more frequently seen in symptomatic patients (48% vs. 9%, P < 0.001) and was associated with uterine contractions (odds ratio 4.6, 95% CI 1.9-10.8). Fundal pressure was not able to reproduce the shortest cervical length that occurred spontaneously during the observation period. CONCLUSIONS: Dynamic cervical change (real-time cervical shortening) is common in patients with PTL symptoms and is associated with uterine contractions. Whether this finding enhances the ability to predict preterm delivery remains to be elucidated.

A proposed role for hCG in clinical obstetrics.

The role of human chorionic gonadatropin (hCG) in the maintenance of early pregnancy is well known. Recent data suggests that hCG may play a role in the maintenance of the later stages of pregnancy as well, by directly and indirectly promoting uterine quiescence. If hCG acts as an endogenous tocolytic in normal pregnancy, then it may be an ideal candidate for therapy of preterm labor as well. We present compelling in vitro as well as in vivo data, which support the role of hCG in the maintenance of normal uterine quiescence. Additionally, we will present in vivo and in vitro data that confirms the ability of hCG to directly promote relaxation of uterine contractions. This review provides a basis for future study of the use of hCG in clinical obstetrics. Given the limited effectiveness of tocolytic therapies available at the time, hCG may provide a promising pharmacological approach to the pervasive problem of preterm labor in human pregnancy. While further work is needed, initial data strongly support this novel use of hCG in clinical obstetrics.

Human chorionic gonadotropin exhibits potent inhibition of preterm delivery in a small animal model.

OBJECTIVE: The purpose of this study was to test the capability of human chorionic gonadotropin to inhibit prostaglandin-induced preterm delivery in a murine model. STUDY DESIGN: A preterm delivery model was developed by using intraperitoneal injection of 20 microgram of prostaglandin F(2)(alpha) to induce preterm labor in C3H/HeN inbred mice. Mice were then pretreated with human chorionic gonadotropin 4 hours before administration of prostaglandin F(2)(alpha), and time to delivery of the first pup was recorded. After initial promising results, mice were then given increasing intraperitoneal doses of human chorionic gonadotropin (100 IU, 250 IU, or 1000 IU or sodium chloride solution vehicle) 4 hours after administration of prostaglandin F(2)(alpha). The specificity of the human chorionic gonadotropin effect was assessed by treating mice with whole human chorionic gonadotropin, an equal mass dose of the beta-subunit or the alpha-subunit of human chorionic gonadotropin, or an equal mass dose of luteinizing hormone 4 hours after administration of prostaglandin F(2)(alpha). Delivery times between groups were compared by using the Mann-Whitney U test and the log-rank test. Survival estimates were computed by using the Kaplan-Meier method. RESULTS: Pilot studies in 52 mice confirmed that a single intraperitoneal injection of 20 microgram of prostaglandin F(2)(alpha) on day 16 (80% gestation) consistently induced preterm delivery compared with the effect of sodium chloride solution on control mice (prostaglandin F(2)(alpha), 19.3 +/- 2.9 hours; sodium chloride solution, 53.5 +/- 13.6 hours; P <.0001). Mice pretreated with human chorionic gonadotropin (1000 IU) demonstrated significant delays in delivery times compared with the prostaglandin-only group (prostaglandin F(2)(alpha) only, 21.9 +/- 2. 0 hours; human chorionic gonadotropin pretreatment plus prostaglandin F(2)(alpha), 48.5 +/- 20 hours; P <.0001; n = 17). Mice treated with human chorionic gonadotropin (100 IU, 250 IU, 1000 IU) 4 hours after administration of prostaglandin F(2)(alpha) demonstrated significant dose-dependent inhibition of preterm delivery compared with the prostaglandin-only group (P <.00005; n = 34). Mice treated with the alpha-subunit or the beta-subunit of human chorionic gonadotropin after prostaglandin administration did not demonstrate delays in delivery times (P =.46; n = 27). Administration of luteinizing hormone delayed delivery compared with the effect of prostaglandin F(2)(alpha) on control animals (P <.05; n = 17); however, the effect was less pronounced than that seen with a mass equivalent of human chorionic gonadotropin. CONCLUSIONS: Human chorionic gonadotropin exhibits potent inhibition of prostaglandin-induced preterm delivery in mice. The effect is dose-dependent, and whole human chorionic gonadotropin is required to elicit inhibition. Further studies are needed to determine the safety and efficacy of human chorionic gonadotropin as a potential therapy for preterm labor inhibition in human pregnancy.

Predictive value of fetal ultrasonography in the diagnosis of a lethal skeletal dysplasia.

BACKGROUND: Certain ultrasonographic findings identified in a fetus suspected of having a skeletal dysplasia may be predictive of a lethal outcome. METHODS: We evaluated 27 fetuses suspected of having a skeletal dysplasia using targeted ultrasonography between 16 and 31 weeks' gestation. Clinical examination and skeletal radiography were done after delivery. RESULTS: A skeletal dysplasia was confirmed and a diagnosis established in all but one case. The skeletal dysplasia was lethal in 23 cases and, in each case, the outcome was accurately predicted prenatally; however, three of the infants survived several months. In 11 of the 23 cases (48%), the specific diagnosis was correctly determined before birth. Ultrasonographic findings not considered to reflect a lethal outcome, were accurately predicted in two other cases. In an additional two, sonographic examination suggested a lethal osteochondrodysplasia, though both survived. Findings consistent with a lethal skeletal dysplasia included a femur length < 1st centile, combined with either a bell-shaped thorax, decreased bone echogenicity, or both. Using these criteria provided a positive-predictive value for neonatal deaths of 80% (20/25), and 92% (23/25) if the three that died in infancy were included. CONCLUSIONS: In the fetus suspected of having a skeletal dysplasia, certain findings on targeted ultrasonography frequently are predictive of a lethal outcome; the ability to predict this appears greatest when more than one of these abnormalities is present.

Transvaginal versus transperineal ultrasonography: a blinded comparison in the assessment of cervical length at midgestation.

OBJECTIVE: The study's objective was to determine the correlation and agreement between transperineal ultrasonography and transvaginal ultrasonography in the assessment of cervical length in gravid patients. STUDY DESIGN: After a pilot, unblinded series of transperineal and transvaginal cervical length measurements in 200 gravid patients, 206 study patients between 14 and 34 weeks' gestation with intact membranes and cervical dilatation of < or = 2 cm underwent transperineal and transvaginal cervical length assessment under a blinded, 2-sonographer protocol. The Pearson correlation coefficient, Lin concordance coefficient, and Bland-Altman plot were used. Acceptable concordance was defined as > 0.82, with an acceptable correlation of > 0.9 and an acceptable difference between the means of < 3 mm. The power of the study to detect this degree of concordance was estimated to be 95% at this sample size. RESULTS: Paired ultrasonographic measurements were obtained for all 206 study patients. Transperineal mean cervical length was 35 +/- 8.6 mm. Transvaginal mean cervical length was 35.9 +/- 8.8 mm. The Pearson correlation coefficient was 0.959, and the Lin concordance coefficient was 0.955, with a 95% confidence lower bound of 0.949. Close agreement between transperineal and transvaginal measurements was observed across the full range of cervical lengths (1-5 cm). The estimated difference between the paired means was 1 mm. The 95% tolerance interval for any given paired observation (Transperineal length - Transvaginal length) was -5.7 to +4 mm. CONCLUSIONS: Cervical length measured by transperineal ultrasonography demonstrates close correlation and agreement with transvaginal measurements. With sonographer experience and optimal technique, approximately 95% of transperineal cervical length observations can be expected to be within 5 mm of a given paired transvaginal measurement. Transperineal ultrasonography may be a preferred method of cervical length assessment for situations in which vaginal placement of instruments should be minimized.

HIV infection in women: an escalating health concern.

The proportion of women infected with the human immunodeficiency virus (HIV) continues to increase. Over one-half of women acquire the virus through heterosexual contact. The diagnoses that define the acquired immunodeficiency syndrome and the use of antiretroviral therapy are similar in men and women, except in pregnancy. However, management decisions differ significantly regarding contraceptive and gynecologic care. Besides abstinence, use of the latex condom continues to be the most effective way of preventing transmission of HIV. The management of human papillomavirus-associated disease, pelvic inflammatory disease and vaginal candidiasis is especially challenging in women with HIV infection. A positive status for the virus does not appear to affect pregnancy outcome. Each year, up to 2,000 infants are born infected with HIV. Transmission can occur by transplacental or intrapartum spread or through breast milk. Since 1994, prophylaxis with zidovudine has been shown to be an effective method of limiting transmission to infants. It is important to offer all pregnant women a test for HIV, with counseling provided both before and after the test, even if testing does not become mandatory under the law.

Estrogen mediates the pregnancy-enhanced cardiotoxicity of cocaine in the isolated perfused rat heart.

OBJECTIVE: To determine whether pregnancy enhances cocaine toxicity in the isolated perfused whole rat heart model and whether this enhanced toxicity can be simulated by pre-treatment with either estrogen or progesterone. METHODS: Hearts excised from 65 female Sprague-Dawley rats were attached to a Langendorff apparatus for measurement of left ventricular systolic pressure, heart rate, and contractility. Before excision, the animals were assigned to one of five groups: 1) nonpregnant, 2) pregnant, 3) nonpregnant pretreated with progesterone, 4) nonpregnant pretreated with estrogen, and 5) nonpregnant pretreated with estrogen and progesterone. Each group was exposed serially to the following cocaine concentrations: 5 x 10(-6), 1 x 10(-5), and 6 x 10(-5) mol/L. RESULTS: Heart rate declined at all doses of cocaine (9.2, 6.9, and 31.0%, respectively). The lowest dose of cocaine had positive inotropic effects, with a 23.2% increase in left ventricular pressure and a 15.3% increase in contractility. Exposure to the two higher doses resulted in negative inotropic effects (a 24.8% decrease in left ventricular pressure and a 39.7% decrease in contractility for the highest dose). Although pre-treatment with estrogen, alone or with progesterone, resulted in responses similar to those seen in pregnant animals, progesterone pre-treatment alone failed to do so. CONCLUSIONS: Cocaine displayed cardiotoxicity in isolated rat hearts similar to that in other animal models. This toxicity was enhanced by pregnancy. We were able to simulate changes by pretreating the animals with estrogen. Perhaps the enhanced cardiotoxicity of cocaine in pregnancy is partially mediated by estrogen.

Central hemodynamic effects of cocaine and ritodrine in the isolated, perfused rat heart.

OBJECTIVE: To explore the cardiac interactions of cocaine and ritodrine in pregnancy. METHODS: Using the isolated, perfused rat-heart model, hearts from pregnant Sprague-Dawley rats were exposed to increasing concentrations of ritodrine: 25, 50, 100, and 250 ng/mL. Hearts of half of the animals, the experimental group, were exposed to cocaine (5 x 10(-6) mol/L). Left ventricular systolic pressure, heart rate, and contractility were measured. RESULTS: Ritodrine had marked positive inotropic and chronotropic effects. Cocaine exposure resulted in smaller increases in all indices. CONCLUSION: Cocaine blunted but did not obliterate the cardiac stimulatory effects of ritodrine in this model.

Fetal death from chlamydial infection across intact amniotic membranes.

We report a case of a fetal death at 34 weeks' gestation with intact membranes. An autopsy confirmed intrauterine pneumonia as a result of Chlamydia trachomatis. Staining of the lung tissue with a direct fluorescein-conjugated Chlamydia-specific monoclonal antibody assay revealed a pattern typical of a Chlamydia trachomatis infection. This case supports the thesis that Chlamydia crosses fetal membranes and produces disease.