The impact of prenatal maternal stress and optimistic disposition on birth outcomes in medically high-risk women.

A sizable body of evidence indicates that prenatal maternal stress (PNMS) has an adverse impact on birth outcomes, including birth weight and gestational age at delivery. The authors hypothesized that effects of PNMS are attributable in part to dispositions such as pessimism that lead women to view their lives as stressful and that effects of PNMS and disposition on birth outcome are mediated by prenatal health behaviors. Using structural equations modeling procedures, the authors examined prospective impact of PNMS and dispositional optimism on birth weight and gestational age in a medically high-risk sample (N = 129), controlling for effects of risk and ethnicity. After its strong inverse association with optimism was accounted for, PNMS had no impact on birth outcomes. Women who were least optimistic delivered infants who weighed significantly less, controlling for gestational age. Optimists were more likely to exercise, and exercise was associated with lower risk of preterm delivery. Results suggest that chronic stress in pregnancy may be a reflection of underlying dispositions that contribute to adverse birth outcomes.

Indications for and outcomes of emergency peripartum hysterectomy. A five-year review.

OBJECTIVE: To review risk factors, management and outcomes of emergency peripartum hysterectomy performed in the last five years at Stony Brook University Hospital. STUDY DESIGN: Retrospective descriptive and cohort analyses from January 1990 to January 1995. Incidences of emergency peripartum hysterectomy and placenta accreta were determined. Relative risks of hysterectomy for specified risk factors were calculated. RESULTS: There were 39 cases of emergency peripartum hysterectomy, for an overall incidence of 2.7/1,000 births. Indications for emergency hysterectomy were placenta accreta, unspecified bleeding, uterine rupture, myomas and atony with placenta accreta, the most common. The crude relative risk of emergency hysterectomy was 46.9 (n = 37) for cesarean delivery, 15.24 (n = 31) for prior cesarean delivery and 110.83 (n = 21) for placenta previa. CONCLUSION: Cesarean delivery, prior cesarean delivery, placenta accreta and uterine atony were identified as risk factors for emergency peripartum hysterectomy, and abnormal placentation was the primary cause of cesarean hysterectomy.

Peripartum hemorrhage.

This article has reviewed the causes and potential therapies for PPH. These include both predictable and unpreventable causes and methods of differential diagnosis. Triage of therapeutic interventions and prompt diagnosis are critical in reducing morbidity and mortality caused by PPH.

Preliminary experience with a prospective protocol for planned vaginal delivery of triplet gestations.

OBJECTIVE: The objective of the study was to evaluate a protocol for vaginal delivery of triplet gestations. STUDY DESIGN: All women with triplet gestations managed between January 1, 1995, and December 31, 1997, by University Medical Center's perinatal practice were offered enrollment in our vaginal delivery protocol. Our protocol offered attempt of vaginal delivery if triplet A was in vertex presentation, fetal monitoring was possible, and there were no other obstetric contraindications. Twenty-three triplet gestations were identified; 8 achieved vaginal delivery. Outcome parameters investigated included neonatal mortality, Apgar scores, neonatal intracranial hemorrhage, arterial cord pH, neonatal weight, and length of postpartum hospital stays of mother and neonates. All parameters were analyzed with analysis of variance and the Student t test as appropriate with the JMP 3.1 statistics program (Cary, NC). RESULTS: Twenty-three sets of triplets were enrolled. Eight sets were delivered vaginally. Eight of 9 patients (88.9%) who attempted trial of labor were delivered vaginally, 1 of which was a vaginal birth after cesarean section. The remaining triplet gestation failed to progress at 4-cm dilation. Twelve sets of triplets had a nonvertex-presenting triplet and were delivered by the cesarean route. The remaining 2 triplet gestations were delivered by the cesarean route because of inadequate fetal monitoring. Neonatal survivals were 100% for both groups. No significant differences in neonatal mortality, Apgar scores, intracranial hemorrhage, arterial cord blood pH, hospital or neonatal intensive care unit stay of neonate, neonatal weight, and change in maternal or neonatal blood cell count were noted. There were no cases of grade III or IV intraventricular hemorrhage in either group. A significant reduction in postpartum hospital stay of mother was noted in the vaginal delivery group (2.8 vs 4.5 days, P <.001). The mean gestational age at delivery was significantly lower for the vaginal delivery group (31.3 vs 34.0 weeks, P <.02). The mean neonatal weight for the vaginal delivery group was significantly lower (1758 +/- 473 vs 2022 +/- 407 g, P <.02). There were no significant differences in outcome parameters for the first, second, and third triplets within each group when compared with each other or with the other study group. One patient who underwent vaginal delivery had retained products of conception and required curettage. A single fetal death occurred at 22 weeks' gestation from twin-twin transfusion, with the remaining triplets being delivered vaginally at 35 weeks' gestation. Cesarean hysterectomy was required in 1 case for uncontrollable bleeding at the time of cesarean delivery. Perinatal complications occurred in a large number of patients, with the incidence of premature labor 47. 8% (n = 11), that of preterm premature rupture of membranes 26.1% (n = 6), and that of preeclampsia 34.8% (n = 8). CONCLUSION: In selected cases vaginal delivery of triplet gestations can be accomplished without increased maternal or neonatal morbidity and mortality and may significantly decrease maternal hospital stay and postoperative morbidity.

Accuracy of portable glucose meters for rapid determination of amniotic fluid glucose levels.

This study was designed to evaluate the accuracy and feasibility of use of three commercially available portable blood glucose meters to measure amniotic fluid glucose(AFG) levels as compared to an accepted laboratory standard. A prospective study of amniotic fluid from 101 consecutive amniocenteses was performed. Glucose concentration in the amniotic fluid was assessed by hexokinase method in our hospital laboratory (control) and by using three portable meters: Advantage (ADV) (Boehringer Mannheim), Glucometer Elite (ELT) (Bayer), and One Touch II Hospital (T-2) (Lifescan). Twenty consecutive amniotic fluid samples were sent to the laboratory in two vials, the first without additive and the second with potassium oxalate to prevent metabolic activity, to assess the effect of cellular metabolism and time delay on amniotic fluid glucose concentrations. Data are reported as mean +/-SE and were assessed by one-way ANOVA. Of the 101 patients studied, 29 were of gestational age > or = 20 wks. The remaining 72 patients were < 20 wks. All three ambulatory meters demonstrated a linear relationship with control (all P < 0.001). Given a slope of almost 1.0 (m = 0.94) and a y-intercept approaching zero (b = 4.3), the OT2 proved to correlate best with control. ELT: (r2 = 0.55, m = 0.79, b = 22.2) and ADV: (r2 = 0.74, m = 1.45, b = 16.9) both overestimated amniotic fluid glucose. When AFG was < 30 mg/dl via laboratory standard, OT2: (r2 = 0.78, m = 1.05, and b = -2.20, P < 0.001), ADV: (m = 1.02, b = 24.1, r2 = 0.12, P = 0.133). The One Touch II Hospital accurately predicted amniotic fluid glucose at the bedside with excellent correlation including with laboratory standard glucose levels < 30 mg/dl. ADV and ELT proved too inaccurate for clinical use. Control samples were not affected by additives or time delay. These findings confirm that AFG determinations can be obtained rapidly with the OT2 meter at the bedside.

Fetal vascular responses to maternal glucose administration in streptozocin-induced ovine diabetes mellitus.

OBJECTIVE: To assess the impact of administration of a glucose load to the pregnant diabetic ewe on fetal biochemistry and umbilical-placental perfusion. METHODS: Six pregnant ewes were rendered glucose intolerant by the administration of streptozocin at 85-90 days gestation. An intravenous glucose load was administered to the 6 diabetic ewes and 4 control animals at 125-130 days gestation. Assessment of the fetal responses to this glucose load was made by cardiovascular monitoring, biochemical evaluation and measurement of fetal blood flows by the radioactive microsphere technique. RESULTS: In the fetus of the diabetic ewe the arterial pH progressively decreased from 7.36 +/- 0.04 to 7.10 +/- 0.09 (p < 0.05) 180 minutes after the maternal glucose load. These fetuses displayed a consistent and significant reduction in arterial oxygen tension compared to controls, with a decrease in pO2 from 14.9 +/- 3.3 mmHg at baseline to 11.3 + 3.7 mmHg after 180 minutes. Umbilical-placental blood flow did not alter significantly in the fetus of the diabetic ewe following glucose administration, although in the control fetuses there was a significant reduction from baseline after 60 minutes. Blood flow to the fetal brain and kidney were significantly elevated in the fetus of the diabetic ewe compared to control at all times, suggesting a metabolic adaptation to preserve oxygen delivery may be present. CONCLUSIONS: Maternal hyperglycemia produces profound metabolic alterations in the ovine fetus which are unaccompanied by significant alterations in umbilical-placental blood flow. In the chronically hyperglycemic pregnant ewe, a glucose load produces a major disturbance of fetal homeostasis.

A training program to improve domestic violence identification and management in primary care: preliminary results.

Domestic violence as encountered in day-to-day practice is greatly underidentified. It is estimated that only 3% of cases are presently being identified, and practitioners are uncertain of what to do if a case is discovered. In this paper, a training program to improve identification and management of domestic violence (DV) in primary care and the providers' responses to the program are described. A multimodal training program was undertaken to demonstrate and practice the incorporation of didactic content into practice for the health care teams. Two medical centers from a large staff-model HMO were chosen at random from five volunteering for training. The entire adult health care medical center teams, including physicians, physician assistants, RNs, LPNs, medical assistants, and receptionists, were the recipients of the training. Assessment of provider valuation of the components of the training program was performed by administering a standardized 5-point Likert-scaled questionnaire 9 months after the training. This time interval was chosen because we were interested in lasting program effects. Core didactic content, such as the epidemiology of DV, identification and management of victims and batterers, and legal issues, was highly rated. Delivery of the content through role-playing, start-stop videos and presentations by former victims received lesser but solid support. Follow-up assessment 9 months post training demonstrates solid support for many components of the program: highest for specific information content areas, but strong for techniques and processes. The training program appears to be a promising method to improve provider skills in DV management.

Health assessment for partners of pregnant women: a pilot study of four survey methods.

BACKGROUND: Health assessment for partners of pregnant women has not been routinely offered. Work in the area of smoking cessation suggests that a partner's health habits have a strong influence on the health habits of a pregnant woman. Smoking, alcohol abuse, depression, battering, and household firearms cab adversely affect the health of the expectant mother and the infant. METHODS: Four methods of partner assessment were pilot tested: office visit with a family physician, office visit with a registered nurse, telephone survey conducted by the registered nurse, and mailed questionnaire. Written feedback and referrals were provided to all study participants, and verbal feedback and referrals were provided to those who completed in-person or telephone interviews. A chart review was conducted to determine participation bias. RESULTS: Thirty-five pregnant women and 25 partners participated in the study. Self-administered questionnaires and telephone interviews were preferred by study participants. The study group was healthier than the general population. Five partners reported troublesome drinking behavior, and 1 reported smoking two packs of cigarettes per day. CONCLUSIONS: health assessment of partners of pregnant women seems promising for uncovering health problems that would be likely to have an adverse impact on the health of the family. Further development of assessment and intervention strategies is needed.

Umbilical cord blood gas analysis at delivery.

Fetal acid-base status is the end point that all antepartum and intrapartum surveillance tools are designed to assess, either directly or indirectly. Umbilical arterial blood pH is normal in 80% of depressed newborns, thereby proving the absence of birth asphyxia both in the delivery room and in the courtroom. The technique, normal ranges, and risks, benefits and cost analysis of routine versus selected umbilical blood sampling are considered. The American College of Obstetricians and Gynecologists recommends performing umbilical blood sampling for acid-base analysis in selected deliveries. However, in our opinion routine umbilical blood sampling at all deliveries has merit.

Effect of epidural analgesia on fundal dominance during spontaneous active-phase nulliparous labor.

BACKGROUND: The purpose of this investigation was to determine if epidural analgesia, established during active phase labor, results in elimination or reversal of fundal dominance (lower uterine segment pressure equal to or greater than fundal pressure). METHODS: Upper and lower uterine segment intrauterine pressures were prospectively evaluated for 50 min before and 50 min after epidural analgesia using 0.25% bupivacaine in 11 nulliparous women in spontaneous active labor. A total of 958 contractions were evaluated. RESULTS: No significant differences were found in the number of contractions in the interval before epidural analgesia compared to after epidural analgesia. Significantly greater pressure readings were recorded in the upper segment than in the lower segment (consistent with fundal dominance) both before and after epidural analgesia (P<0.01). In addition, fundal dominance increased after epidural analgesia when compared to the preanalgesia period (P<0.01). CONCLUSIONS: Fundal dominance is present both before and after active phase epidural analgesia and is increased during the immediate 50-min postanalgesia period.

Heparin versus normal saline as a peripheral line flush in maintenance of intermittent intravenous lines in obstetric patients.

OBJECTIVE: To compare heparin sodium (100 United States Pharmacopeia U/mL) with 0.9% sodium chloride for use in the maintenance of intermittent intravenous (IV) devices during pregnancy. METHODS: Women at 26-34 weeks' gestation who required serial phlebotomy were assigned randomly to heparin or normal saline flush, administered in a double-blind fashion. Catheter sites were examined and flushed with the study solution at least once every 6 hours. Partial thromboplastin times (PTTs) were measured at catheter insertion and 48 hours later. Statistical analysis was performed with Student t test, Mann-Whitney U test, Fisher exact test, log-rank, and X2 analysis, as appropriate. RESULTS: There was a significant increase in catheter patency rate at 48 and 72 hours in the heparin group (26 of 31 versus 17 of 33, and 21 of 31 versus nine of 33, respectively; P < .01). In addition, there was a significantly lower rate of catheter complications in the heparin group (four of 31 versus 13 of 33; P < .01). There were no differences in PTTs. CONCLUSION: During pregnancy, dilute heparin flush to maintain patency of intermittent IV site devices results in the following: a greater catheter patency rate at 48 and 72 hours after insertion of the catheter, a lower rate of catheter complications requiring therapy, and no alteration in PTT.

Carbohydrate sources for gestational diabetes mellitus screening. A comparison.

One hundred eight patients were prospectively randomized to receive 50 g of a glucose polymer, d-glucose or a candy bar during a one-hour gestational diabetes mellitus (GDM) screening. The polymer had a mean serum glucose similar to that of d-glucose, with significantly fewer side effects, allowing an increased rate of examination completion. The candy bar produced a significantly lower mean serum glucose but had the highest rating for flavor. The polymer was an inexpensive and well-tolerated alternative for GDM screening, while the use of a candy bar needs more study.

Screening for gestational diabetes mellitus with a reflectance photometer: accuracy and precision of the single-operator model.

OBJECTIVE: To investigate the accuracy and precision of a recent-generation reflectance photometer, Accu-Chek III, for gestational diabetes mellitus screening with a single operator. METHODS: Four hundred ten paired capillary and serum glucose samples collected prospectively were evaluated by a reflectance photometer and a glucose oxidase method (Beckman), respectively, during routine gestational diabetes mellitus screening with a single operator. RESULTS: The mean Accu-Chek III result was 12% greater than serum glucose oxidase (115.5 +/- 1.4 and 103.4 +/- 1.3 mg/dL, respectively). A serum glucose level of at least 135 mg/dL by glucose oxidase produced sensitivity and specificity of 0.81 and 0.68, respectively. At 155 mg/dL, the Accu-Chek III sensitivity was 0.81 and specificity 0.74, and the method produced fewer false-positive results (37 of 410 [9.0%] versus 41 of 410 [10%]) than a 135-mg/dL serum cutoff. Adjusting the Accu-Chek III threshold by two times the coefficient of variation resulted in the same number of false positives as the Beckman technique at 135 mg/dL. The receiver operating characteristic curve cutoff for the venous value of 135 mg/dL was an Accu-Chek III value of 141 mg/dL. Linear regression analysis predicted y = 20.6 + 0.919x, r = 0.838. The mean coefficient of variation was 3.9%. CONCLUSIONS: The Accu-Chek III produced accurate and precise gestational diabetes mellitus screening results with a single operator. Because capillary blood is a combination of arterial and venous blood, an Accu-Chek III cutoff of 155 mg/dL may be more appropriate for screening, considering the 10-15% higher capillary glucose level in the fed state. An Accu-Chek III cutoff of 155 mg/dL produced a higher specificity than venous serum at 135 mg/dL, with no decrease in sensitivity.

Epidural analgesia in labor and cesarean delivery for dystocia.

Published studies assessing the effect of epidural analgesia in nulliparous labor on the frequency of cesarean delivery for dystocia are reviewed. There are at least four retrospective studies and two prospective studies that suggest that epidural analgesia may increase the risk of cesarean delivery for dystocia in first labors. The potential for epidural to increase the frequency of cesarean delivery for dystocia is likely influenced by multiple variables including parity, cervical dilatation at epidural placement, technique of epidural placement, management of epidural during labor, and the obstetrical management of labor after placement of epidural analgesia. Two studies suggest that delaying placement of the epidural until 5 cm of cervical dilatation or greater may reduce the risk of cesarean birth. Epidural is safe and may be a superior labor analgesic when compared with narcotics. However, patients should be informed that epidural analgesia may increase the risk of cesarean birth in first labors.

Antepartum vitamin K and phenobarbital for preventing intraventricular hemorrhage in the premature newborn: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To determine whether antepartum phenobarbital and vitamin K reduce the risk of intraventricular hemorrhage in premature newborns. METHODS: Patients at imminent risk for spontaneous or indicated premature delivery between 24-34 weeks' gestation were randomized to receive either placebo or vitamin K and phenobarbital. All patients received betamethasone and antibiotics and were managed uniformly by a single perinatal group in one hospital. All newborns were managed uniformly in the same facility by a single neonatal group. RESULTS: There was a nonsignificant reduction in all grades of intraventricular hemorrhage in the treatment group when compared to the placebo group (48.2 versus 38.3%; P > .05). Frequencies were reduced for severe intraventricular hemorrhage (grades 3 and 4) (6.0 versus 2.5%; P > .05) and mild intraventricular hemorrhage (grades 1 and 2) (42.2 versus 35.8%; P > .05). CONCLUSIONS: Antepartum phenobarbital and vitamin K effected a nonsignificant reduction in both mild and severe intraventricular hemorrhage. The incidence of severe intraventricular hemorrhage in our control group was significantly less than that observed in previous studies.

The risk of pulmonary edema and colloid osmotic pressure changes during magnesium sulfate infusion.

OBJECTIVES: The purposes of this study were to evaluate the effect of magnesium sulfate therapy on colloid osmotic pressure and to determine whether changes in colloid osmotic pressure increased the risk of pulmonary edema. STUDY DESIGN: During a 1-year time period 294 patients received parenteral magnesium sulfate for the treatment of preterm labor or preeclampsia. Both changes in colloid osmotic pressure and magnesium sulfate values and their relationship to clinical outcome parameters were analyzed. RESULTS: Serum magnesium levels were similar for both patients with preeclampsia and patients with preterm labor. Pulmonary edema developed in only four patients, all of whom had preeclampsia and low colloid osmotic pressure values. CONCLUSIONS: This study demonstrated that parenteral magnesium sulfate therapy does not cause significant changes in colloid osmotic pressure values until nearly 48 hours of continuous therapy.

The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial.

OBJECTIVE: Our purpose was to determine the effect of epidural analgesia on nulliparous labor and delivery. STUDY DESIGN: Normal term nulliparous women in early spontaneous labor were randomized to receive either narcotic or epidural analgesia. RESULTS: When compared with the group receiving narcotic analgesia (n = 45), the group receiving epidural analgesia (n = 48) had a significant prolongation in the first and second stages of labor, an increased requirement for oxytocin augmentation, and a significant slowing in the rate of cervical dilatation. Epidural analgesia was associated with a significant increase in malposition (4.4% vs 18.8%, p < 0.05). Cesarean delivery occurred more frequently in the epidural group (2.2% vs 25%, p < 0.05), primarily related to an increase in cesarean section for dystocia (2.2% vs 16.7%, p < 0.05). CONCLUSIONS: In a randomized, controlled, prospective trial epidural analgesia resulted in a significant prolongation in the first and second stages of labor and a significant increase in the frequency of cesarean delivery, primarily related to dystocia.

Iatrogenic omental percutaneous shunt and resolution of obstructive fetal uropathy. A case report.

A double pigtail stent was placed to decompress an obstructed fetal kidney. The stent was dislodged, causing an iatrogenic marsupialization between the renal pelvis omentum and skin. The omentum acted as a drain, decompressing the kidney.

The effect of preterm birth on umbilical cord blood gases.

Apgar scores are used routinely to assess early neonatal status, but are less accurate in the preterm neonate because of developmental immaturity. Attention has been directed to umbilical cord gases as a method of neonatal evaluation. Using a retrospective chart review of all viable preterm births (24-36 weeks' gestation) between January 1986 and December 1989, we tabulated the umbilical cord gas indices of these infants. Fetuses with lethal congenital anomalies and those with abnormal heart rate tracings on admission were excluded from the data base, leaving 1872 infants. Cord arterial blood gas values were available for analysis in 74.4% of cases and cord venous gas values in 81.8%. The mean (+/- standard deviation [SD]) arterial and venous umbilical cord blood gas values for the preterm infants, were, respectively: pH, 7.26 +/- 0.08 and 7.33 +/- 0.07; oxygen pressure, 19.0 +/- 7.9 and 29.2 +/- 9.7 mmHg; carbon dioxide pressure, 53.0 +/- 10.0 and 43.4 +/- 8.3 mmHg; bicarbonate, 24.0 +/- 2.3 and 22.8 +/- 2.1 mEq/L; and base excess, -3.2 +/- 2.9 and -2.6 +/- 2.5 mEq/L. Acidemia was defined statistically as 2 SDs or more below the population mean. The incidence of 5-minute Apgar scores below 7 in the preterm infants was 8.5% and within this group, 17.8% were acidemic (arterial pH 7.10 or lower). More than 82% of neonates with 5-minute Apgar scores less than 7 had normal umbilical cord blood gases. There was no significant difference in umbilical arterial blood gas values between preterm infants and 1924 term deliveries at our institution between 1986-1988.(ABSTRACT TRUNCATED AT 250 WORDS)