Concentration and the second stage of labor: outcomes associated with the interactive metronome.

OBJECTIVE: To analyze the association between concentration, as measured by the Interactive Metronome, and a prolonged second stage of labor in nulliparous patients. STUDY DESIGN: From September 2008 to November 2009, nulliparous women at ≥34 weeks' gestation who were planning to use an epidural were asked to perform a 1-minute Interactive Metronome clapping test. Scores and demographic information were recorded. Data were then abstracted regarding each patient's labor course. The main outcome measure was the frequency of the second stage of labor exceeding 2 hours. Only patients with epidural anesthesia who completed the second stage of labor and did not require operative delivery performed for fetal indications prior to 2 full hours of pushing were included. RESULTS: Of the patients whose Interactive Metronome test scores were in the last quartile, which we associated with poor concentration, 52.9% (18/34) had a second stage of labor exceeding 2 hours compared with only 31.7% (33/104) of patients whose scores placed them in the first three quartiles (p = 0.026). CONCLUSION: Nulliparous patients with poor concentration scores, as measured by the Interactive Metronome, were more likely to push greater than 2 hours in the second stage of labor.

Elective induction compared with expectant management in nulliparous women with an unfavorable cervix.

OBJECTIVES: To compare outcomes of labor between nulliparas with an unfavorable cervix who underwent either elective labor induction or expectant management beyond 39 weeks of gestation. METHODS: We conducted a retrospective cohort study of nulliparous women with a singleton gestation who had an unfavorable cervix (modified Bishop score less than 5) and delivered between 2006 and 2008. One hundred two nulliparous women who underwent elective induction of labor between 39 and 40 5/7 weeks of gestation were compared with 102 nulliparous women who were expectantly managed beyond 39 weeks of gestation. RESULTS: The primary outcome, cesarean delivery, was not statistically different between women who were expectantly managed and those who underwent elective labor induction (34.3% compared with 43.1%, respectively, P=.16). Aside from the more frequent occurrence of meconium in the expectantly managed group (36.3% compared with 7.0%, P<.001), there were no significant differences in other maternal (eg, chorioamnionitis, operative vaginal delivery, third-degree and fourth-degree lacerations, postpartum hemorrhage) or neonatal (arterial cord pH less than 7.0, Apgar score less than 7 at 5 minutes, neonatal intensive care unit admission) outcomes. Women who underwent an elective induction of labor did have longer duration of labor and delivery between admission and delivery (median 16.5 compared with 12.7 hours, P<.001). CONCLUSIONS: For nulliparous women with an unfavorable cervix, elective labor induction increased utilization of labor and delivery resources but did not result in other significant differences in most clinical outcomes.

Expression of glypican 3 in placental site trophoblastic tumor.

BACKGROUND: Glypican-3 (GPC3) is a membrane-bound heparan sulfate proteoglycan that functions in embryonic cell growth and differentiation and is highly expressed in the placenta. GPC3 is mutated in Simpson-Golabi-Behmel syndrome, which is characterized by tissue overgrowth and an increased risk of embryonal malignancies. GPC3 has also been implicated in sporadic cancer, particularly hepatocellular carcinoma, for which it has been shown to be a useful diagnostic marker. Although GPC3 expression has been studied in non-neoplastic placental tissue, its presence in gestational trophoblastic diseases has not been previously explored. The purpose of this study was to investigate the immunohistochemical expression of GPC3 in placental site trophoblastic tumor (PSTT), a very rare gestational trophoblastic neoplasm which may be morphologically confused with non-trophoblastic tumors, and to assess its possible utility as a diagnostic marker. METHODS: Fifteen cases of PSTT, as well as samples from placental site nodule (PSN) (n = 2), leiomyosarcoma (n = 1), leiomyoma (n = 1), invasive cervical squamous cell carcinoma (n = 7) and endometrial adenocarcinoma (n = 11) were examined. Immunoreactivity was semi-quantitatively evaluated as negative (0, < 5% of cells stained), focally positive (1+, 5-10% of cells stained), positive (2+, 11-50% of cells stained) or diffusely positive (3+, > 50% of cells stained). Staining intensity for each subtype was graded from 0 to 3 and a mean intensity was calculated. RESULTS: Eighty percent of PSTT (12/15) were immunoreactive for GPC3 (0, 20; 1+, 20%; 2+, 40%; 3+, 20%) with a mean intensity of 1.3. Stronger, predominately cytoplasmic staining was seen in larger multi- and mononucleated cells with smaller mononucleate cells showing weak muddy cytoplasmic staining. Both PSN cases were positive (1+, 50%; 2+, 50%) and two of nine invasive cervical squamous cell carcinomas showed staining (0, 57%; 1+, 29%; 2+, 14%), predominately in a basal distribution. Other uterine tumors and non-neoplastic tissues were negative. CONCLUSIONS: Identification of GPC3 in PSTT and PSN is consistent with the derivation of these lesions from intermediate trophoblasts, which have been described to express GPC3. GPC3 may be a useful adjunct immunohistochemical marker in differentiating PSTT from non-trophoblastic tumors.

Elective induction compared with expectant management in nulliparous women with a favorable cervix.

OBJECTIVE: To compare outcomes of labor between nulliparous women with a favorable cervix who underwent either elective labor induction or expectant management beyond 39 weeks of gestation. METHODS: A retrospective cohort study was conducted of nulliparous women with a singleton gestation who had a favorable cervix (modified Bishop score of at least 5) and delivered between 2006 and 2008. Two hundred ninety-four nulliparous women who underwent elective induction of labor between 39 and 40 5/7 weeks of gestation were compared with 294 nulliparous women who were expectantly managed beyond 39 weeks of gestation. RESULTS: The primary outcome, cesarean delivery, was similar between the two groups (20.8% compared with 20.1%, respectively, P=.84), a result that did not change in multivariable analysis. There were also no significant differences in other maternal (eg, chorioamnionitis, meconium, operative vaginal delivery, third- and fourth-degree lacerations, postpartum hemorrhage), or neonatal (arterial cord pH less than 7.0, Apgar score less than 4 at 5 minutes, neonatal intensive care unit admission) outcomes. Women who underwent an elective labor induction did have longer duration in labor and delivery between admission and delivery (median 12.7 compared with 9.0 hours, P<.001). CONCLUSION: For nulliparous women with a favorable cervix, elective labor induction has a similar chance of resulting in cesarean delivery as expectant management, although it appears to result in an increase in resource use. LEVEL OF EVIDENCE: II.