Is vaginal delivery preferable to elective cesarean delivery in fetuses with a known ventral wall defect?

OBJECTIVE: We sought to test the hypothesis that vaginal delivery compared with elective cesarean delivery results in improved neonatal outcome in fetuses with a known isolated ventral wall defect. STUDY DESIGN: We performed a retrospective chart review. RESULTS: Between 1989 and 1999, we identified 102 infants with a confirmed antenatal diagnosis of an isolated ventral wall defect with either the diagnosis of an omphalocele or gastroschisis. Sixty-six infants were delivered by cesarean and 36 were delivered vaginally. There were no significant demographic differences between the study groups or between the two sites except that one center (Cincinnati) usually delivered these fetuses by cesarean whereas the other (Louisville) usually delivered such fetuses vaginally. Overall, there were a greater number of infants with gastroschisis than omphalocele (gastroschisis, n = 71; omphalocele, n = 31). After we controlled for primary versus staged closure of ventral wall defect and gestational age at delivery; the medians and interquartile ranges for cesarean and vaginal delivery were 39 (25, 63) days versus 42 (26, 75) days, respectively (P =.32), for neonatal length of stay and 13 (9, 18) days versus 13 (9, 26) days, respectively (P =.16), for days to enteral feeding. After we controlled for the size of the defect and the amount of bowel resected, the odds of primary closure given a vaginal delivery was about half that given a cesarean delivery (odds ratio, 0.56; 95% confidence interval, 0.18-1. 69), but this was not statistically significant. There was no statistically significant difference in the rates of neonatal death (2 [3%] vs 2 [6%]; P =.61) and neonatal sepsis (2 [3%] vs 4 [11%]; P =.18) for cesarean versus vaginal delivery. Maternal length of stay after delivery was found to be 1 day less after vaginal delivery [vaginal, 2 (2, 2) days; cesarean, 3 (2, 3) days; P =.0001]. There were 5 instances of maternal complications, and all 5 pregnancies were delivered by cesarean (P =.16). CONCLUSION: Fetuses with an antenatal diagnosis of an isolated ventral wall defect may safely be delivered vaginally, and cesarean delivery should be performed for obstetric indications only.

Antibiotic prophylaxis at Cesarean delivery.

OBJECTIVE: Our aim was to compare the efficacy of ampicillin, cefotetan, and ampicillin/sulbactam in the prevention of post-Cesarean endomyometritis. METHODS: Consenting patients undergoing Cesarean delivery at the University of Louisville Hospital were enrolled in a prospective, double-blinded randomization to receive either ampicillin/sulbactam (Group 1), cefotetan (Group 2), or ampicillin (Group 3) single dose antibiotic prophylaxis following umbilical cord clamping. The primary outcome variable was the frequency of endomyometritis in the respective groups. RESULTS: Among 301 randomized patients, outcome data was available for 298 patients. Fourteen patients (4.7%), all of whom underwent non-elective Cesarean delivery, developed endomyometritis. The frequency of endomyometritis was not different among groups: Group 1, 4/101 (4%); Group 2, 4/96 (4.2%); and Group 3, 6/101 (5.9%). Wound infections were infrequently observed 4/298 (1.3%) without significant differences among groups. Stepwise discriminative analysis identified only last cervical dilatation as a significant predictor of endomyometritis (P = 0.006). CONCLUSION: Post-Cesarean endomyometritis occurs infrequently following single dose antibiotic prophylaxis after umbilical cord clamping. An advantage of broader spectrum antibiotics over ampicillin was not demonstrated.

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.

A prospective, randomized, clinical study to compare the clinical safety, effectiveness, and cost of oral ofloxacin/clindamycin vs intravenous clindamycin/gentamicin for the treatment of postpartum endomyometritis.

Objective: The primary objective of this prospective, randomized, clinical study was to compare the safety, clinical and microbiologic efficacy, and cost of oral ofloxacin in combination with clindamycin vs intravenous (IV) clindamycin/gentamicin in the early empiric treatment for hospitalized patients with mild to moderate postpartum endomyometritis. The secondary objective is to reduce total hospital and patient treatment cost. Postpartum endomyometritis is a major cause of infectious morbidity in the obstetric patient. It is the most common complication associated with cesarean delivery. Careful timing and amniotomy, limited vaginal examinations, and prophylactic antibiotics for cesarean section delivery may help to reduce the incidence and severity of endomyometritis. Endomyometritis is caused by bacteria that compose the normal cervicovaginal flora. These are anaerobic gram-positive cocci (Peptostreptococcus and Peptococcus), aerobic streptococci (Group B Streptococci and enterococci), Enterobacteriaceae, Bacteroides (B. fragilis, B. bivius, and B. disiens), and clostridium species.Ofloxacin is a synthetic broad-spectrum antibacterial agent for intravenous and oral administration. Following oral administration, the bioavailability in tablet form is 98% with maximum serum concentrations in 1 to 2 hours. Steady state concentrations are achieved after 4 doses. Ofloxacin usually is bactericidal in action. A synthetic broad-spectrum antibacterial agent for intravenous and oral administration. Ofloxacin inhibits DNA topoisomerase (ATP-hydrolyzing), commonly referred to as DNA-gyrase. DNA-gyrase causes double-stranded DNA breakage; it inhibits duplication, transcription, and repair of bacterial DNA.Methods: This is a preliminary study that has enrolled 19 evaluable patients towards the overall enrollment of 60 patients for statistical significance. Patients clinically diagnosed as having postpartum endomyometritis who meet the inclusion/exclusion criteria were entered into the trial. Patients were examined for the presence of fever (102.2 degrees F), pelvic pain, and foul lochia. A medical history, physical examination, and laboratory analysis were obtained prior to the first dose of antibiotic treatment. A signed consent was obtained prior to the study enrollment and randomization. Appropriate endometrial, blood, and urine culture specimens were obtained prior to the initiation of antibiotic therapy.Patients in Group 1 were treated with oral therapy using ofloxacin 400 mg q12h plus clindamycin 900 mg q8h until 24 hrs of afebrility. In Group 2, patients were treated with clindamycin 900 mg IV q8h plus gentamicin IV 5mg/kg/d q 8h until afebrility. Antibiotic therapy was continued for at least 48 hours unless significant clinical deterioration occurred necessitating the withdrawal of the patient from the study.Results:Conclusions: We found in our preliminary study that oral ofloxacin in combination with oral clindamycin was equally as efficacious, well tolerated, and safe as the combination of intravenous therapy with clindamycin and gentamicin for the treatment of postpartum endomyometritis.

Fetal fibronectin as a predictor of preterm birth in patients with symptoms: a multicenter trial.

OBJECTIVE: Our aim was to determine whether the presence of fetal fibronectin in vaginal secretions of patients with symptoms suggestive of preterm labor predicts preterm delivery. STUDY DESIGN: Patients who were examined at the hospital between 24 weeks' and 34 weeks 6 days' gestation with intact membranes, no prior tocolysis, symptoms suggestive of preterm labor, and cervical dilation < 3 cm were recruited at 10 sites. Swabs of the posterior fornix were assayed for the presence of fetal fibronectin by monoclonal antibody assay, with a positive result defined as > or = 50 ng/ml. Results were not available to the managing physicians. Tocolysis was used when clinically indicated after specimen collection. RESULTS: A total of 763 patients had fetal fibronectin results and pregnancy outcome data available for analysis. Fetal fibronectin was detected in specimens from 150 (20%) patients. Compared with patients who had negative results, patients who had positive results for fetal fibronectin were more likely to be delivered within 7 days (relative risk 25.9 [95% confidence interval 7.8 to 86]), within 14 days (relative risk 20.4 [95% confidence interval 8.0 to 53]), and before 37 completed weeks (relative risk 2.9 [95% confidence interval 2.2 to 3.7]). The negative predictive values for delivery within 7 days, within 14 days, and at < 37 weeks were 99.5%, 99.2%, and 84.5%, respectively. When we used multiple logistic regression analysis to control for potential confounding variables among singleton pregnancies, only the presence of fetal fibronectin (odds ratio 48.8, 95% confidence interval 7.4 to 320), prior preterm birth (odds ratio 8.3, 95% confidence interval 1.5 to 46.6), and tocolysis (odds ratio 4.1, 95% confidence interval 1.0 to 16.0) were associated with birth within 7 days; fetal fibronectin (odds ratio 3.6, 95% confidence interval 2.2 to 5.9), prior preterm birth (odds ratio 2.5, 95% confidence interval 1.4 to 4.4), cervical dilatation > 1 cm (odds ratio 2.9, 95% confidence interval 1.6 to 5.2), and tocolysis (odds ratio 4.5, 95% confidence interval 2.8 to 7.2) were all independently associated with delivery before 37 weeks. CONCLUSION: In a population of patients with symptoms, the presence of fetal fibronectin in vaginal secretions best defines a subgroup at increased risk for delivery within 7 days; the high negative predictive value of fetal fibronectin sampling supports less intervention for patients with this result.

Mirror image duplication of the hands and feet: report of a sporadic case with multiple congenital anomalies.

Mirror image duplication of the hands and feet is a rare entity. Based on 3 previous reports, findings include nasal abnormalities, dimelia of ulna and fibula, tibial hypoplasia and mirror image duplication of hands and feet. We report on a sporadic case in which mirror image duplication was associated with multiple congenital anomalies. Although these cases may represent variable expression of the same dominantly transmitted complex polysyndactyly syndrome, it is possible that mirror image duplication of the hands and feet is a manifestation common to a number of distinct clinical entities. During limb bud development, duplication and aberrant positioning of the zone of polarizing activity in relation to the apical ectodermal ridge may account for the anatomic abnormalities of the hands and feet in these patients.

A non-trophoblastic tumor co-existing with a triploid fetus.

Non-trophoblastic neoplasms are the most frequent, benign tumors of the placenta, occurring in approximately 1% of all placentas examined. A case is described of a 24-year-old woman who presented with severe, early-onset pre-eclampsia, high human chorionic gonadotropin (hCG) levels, and a triploid fetus and who was found to have a small choriohemangioma. The woman, gravida 2 para 1, was referred to our hospital for perinatal evaluation. The fetus, gestational age 18 weeks 3 days, had fetal growth restriction with multiple congenital anomalies. The fetal karyotype was 69,XXY. Compared with the normal range for this gestational age, the beta-hCG level was significantly elevated (1,054,000 mIU/ml) as was the maternal serum alpha-feto-protein measurement (539.1 ng/ml). Sonographically, the placenta appeared hydropic, irregularly shaped, and gelatinous. A suction dilatation and evacuation under sonographic guidance was performed. Histological examination of placental tissue revealed hydropic degeneration of the chorionic villi. The specific histological features of a partial molar pregnancy were not present. However, there were changes consistent with a choriohemangioma. Flow cytometric DNA analysis performed on formalin-fixed, paraffin-embedded tissue blocks of placenta showed triploidy. Immunohistochemical staining with human placental alkaline phosphatase was consistent with a hydropic degeneration pattern. We conclude, first, that triploidy does not always imply the presence of a partial mole. Second, the dictum, that pre-eclampsia, if it occurs under 20 weeks' gestation, must be associated with a molar pregnancy, may not hold when placental aneuploidy is present. Although the findings in this pregnancy could have been incidental, there may be an association between a choriohemangioma and polyploidy.

Differential cyclooxygenase-1 and -2 gene expression in human myometria from preterm and term deliveries.

The expression of cyclooxygenase-1 (COX-1) and COX-2 genes in myometria from preterm and term pregnancies was investigated by in situ hybridization, immunoblotting, and immunocytochemistry. In situ hybridization revealed that myometrial smooth muscle contained both COX-1 and COX-2 messenger ribonucleic acid transcripts. Immunoblotting revealed that myometria contained 55- and 67-kilodalton COX-1 proteins as well as 72- and 56-kilodalton COX-2 proteins. Immunocytochemistry showed that COX-1 and COX-2 proteins are present in the myometrial smooth muscle. The expression of COX-1 and COX-2 genes differed in myometria. For example, although COX-1 expression was lower, COX-2 expression was higher at term compared to preterm pregnancy not in labor. In addition, although COX-1 expression was not dependent on labor, COX-2 expression was lower with labor compared to not in labor for both preterm and term pregnancy. The myometrial smooth muscle also immunostained for prostaglandin E2 (PGE2) and PGF2 alpha, suggesting that the cyclooxygenases are catalytically active. The changes in PGE2 and PGF2 alpha paralleled the changes in COX-1 enzyme in terms of being lower at term compared to preterm pregnancy and the changes in COX-2 enzyme in terms of being lower during labor at preterm and term pregnancy. In summary, our results demonstrate that pregnant human myometria express both COX-1 and COX-2 genes. The expression of these genes differed in preterm or term pregnancy myometria from in labor and not in labor.

The current impact of the hypertensive disorders of pregnancy.

The present investigation examines the effect of the various hypertensive disorders of pregnancy on perinatal outcome. Five hundred and five pregnancies associated with hypertension were reviewed, yielding an overall incidence of 8%. Multiparas accounted for 34.7% of all hypertensive patients, 30.7% of these with pre-eclampsia, and 43.3% with chronic hypertension. Transient and chronic hypertension accounted for 32.8% and 24.2% of preterm deliveries respectively. Of those infants necessitating NICU admission, 19(6.6%) and 11(12.0%) were from the transient and chronic hypertensive groups respectively. The total number of days spent in the NICU was 1,160. The perinatal death rate for transient hypertension and chronic hypertension was 4/1,000 and 3/1,000 respectively. Although, proteinuric hypertension in primigravidas results in very high risk pregnancies, a large proportion of the increase in fetal/neonatal risks in women with hypertension are due to other forms of pregnancy associated hypertension.

Obstetric correlates of neonatal retinal hemorrhage.

OBJECTIVE: To determine whether maternal or fetal factors, other than vacuum-assisted delivery, play a role in neonatal retinal hemorrhage, and whether correlates are similar in retinal hemorrhage after spontaneous vaginal delivery. METHODS: A cross-section of assisted deliveries at an urban hospital (n = 156) over 7 months were compared with contemporaneous spontaneous vaginal deliveries (n = 122). A subset of assisted deliveries (n = 87) was prospectively randomized to forceps or vacuum-assisted delivery by sealed envelope. Maternal and neonatal biometric data were collected, and Apgar scores, umbilical artery blood gas analysis, and neonatal ophthalmologic evaluations were performed. RESULTS: Moderate to severe retinal hemorrhage was found in 18% of spontaneous, 13% of forceps, 28% of vacuum-assisted, and 50% of sequential vacuum and forceps-assisted deliveries. Fetal distress (P < .008), vacuum-assisted delivery (P < .02), decreased birth weight for gestation (P < .004), umbilical artery pH less than 7.20 (P < .004), and second stage of labor less than 30 minutes (P < .05) were most closely associated with increased degrees of retinal hemorrhage. Maternal parity, preeclampsia, length of labor, and head circumference were not correlated with retinal hemorrhage. Vacuum-assisted delivery among low birth weight infants (P < .0001), short second stage of labor (P < .006), fetal acidosis (P < .045), and sequential use of vacuum and forceps for assisted delivery (P < .005) formed a logistic model that correctly predicted 81% of moderate to severe retinal hemorrhage cases. Logistic analysis of the randomized assisted deliveries gave similar results. CONCLUSIONS: Maternal and fetal factors other than vacuum-assisted delivery are significant correlates of moderate to severe retinal hemorrhage. Vacuum-assisted delivery among small for gestational age infants is closely correlated with moderate to severe retinal hemorrhage.

Human fetal response to vibroacoustic stimulation as a function of stimulus duration.

The effect of stimulus duration on the initial fetal heart rate (FHR) acceleration response was evaluated by assessing its amplitude and span following a single vibroacoustic stimulation with durations of 0 (sham), 1, 3, or 5 seconds. Statistically significant differences were observed in the mean amplitude and duration of acceleration in groups 3 and 5 when compared with groups 0 and 1 (P less than .05). In addition, groups 3 and 5 demonstrated significantly greater fetal reactivity than group 0 and a decrease in testing time over groups 0 and 1 (P less than .05). Our results suggest that the magnitude of the FHR acceleration response is dependent on the duration of the stimulus. Furthermore, a 3-second sound stimulus appears to be adequate for a shift to the fetal behavioral "awake" state.

Doppler flow velocities in single umbilical arteries.

Fetal compromise has been associated with an umbilical artery waveform pattern of low or absent diastolic velocity relative to systolic velocity. Fetuses with single umbilical arteries have an increased risk of major malformations, mortality, retarded fetal growth, and prematurity. In this study Doppler flow velocities were obtained in 13 fetuses (four twin fetuses and nine singletons) with a single umbilical artery. Five (38%) fetuses, consisting of four singletons and one twin, had anomalies. Six (46%) fetuses were small for gestational age, including two twin fetuses and three singleton fetuses with anomalies. Three (23%) of the 13 systolic-to-diastolic velocity ratios were abnormally high. Whereas this is a higher rate of abnormal ratios than the reported 2% to 3% in control populations, it is interesting to note that 77% of fetuses with single umbilical arteries had normal systolic-to-diastolic ratios.

Cervical cerclage in early pregnancy.

A retrospective review of 33 patients who underwent transvaginal cervical cerclage for the treatment of an incompetent cervix from June 1984 through July 1987 was conducted. A total of 38 transvaginal cerclages were placed. For the purposes of comparison, the patients were divided into three groups according to gestational age at the time of cerclage: group 1 less than or equal to 13 weeks; group 2 greater than 13 weeks, but less than 18 weeks; group 3 greater than or equal to 18 weeks. There was no difference among groups in mean age, gravidity, history of diethylstilbestrol exposure (DES), prior pregnancy loss at or before 20 weeks, or prior dilation and curettage procedure. There were 24 modified McDonald and 14 modified Shrodkar procedures performed. The mean gestational age of cerclage placement in group 1 was earlier than in group 2 and group 3 by 3.5 and 10.5 weeks, respectively. There were no major surgical complications in any of the three groups. The overall incidence of preterm labor and preterm birth were 48.6% and 37.8%, respectively. Analysis of variance demonstrated a trend toward differences in the incidence of preterm labor, preterm birth, and estimated gestational age at delivery, with the earlier group favored. None of these, however, reached the level of statistical significance. Estimated blood loss, obstetric complications, mean birthweight, and mean gestational age at delivery were not statistically different for the three study groups. The above data are discussed and support given for the safety and efficacy of cervical cerclage placement in early pregnancy when compared with the more standard recommendations of placement at from 14 to 17 weeks' gestational age.

Alcohol use in pregnancy.

The epitome of FAS and ARBD has been documented substantially in the medical literature. There appears to be little question that alcohol is a teratogen. The precise nature for the mechanism of causing congenital defects, whether it be direct or indirect, is still unknown. There is no unequivocal information that can be conveyed to patients regarding the quantity of alcohol that can be safely consumed during pregnancy. Because pregnant women generally are receptive to suggestions about controlling their alcohol consumption during pregnancy, the professional is presented with an excellent opportunity to encourage behavior modification. Early recognition of the alcohol-abusing women and appropriate counseling are the cornerstones of treatment for these patients.

Peritoneal closure or non-closure at cesarean.

The value of peritoneal closure at the time of cesarean birth was evaluated prospectively. Two hundred forty-eight women undergoing low transverse cesarean through a Pfannenstiel skin incision were assigned to one of two groups: peritoneum open (N = 127) or peritoneum closed (N = 121). The mean (+/- SEM) surgical time in the open group (48.1 +/- 1.2 minutes) was significantly less than for the closed group (53.2 +/- 1.4 minutes) (P less than .005). There were no postoperative differences between the groups in the incidence of wound infection, dehiscence, endometritis, ileus, and length of hospital stay. Our study suggests that leaving the parietal peritoneum unsutured is an acceptable way to manage patients at cesarean delivery.

Effect of maternal-fetal movement on concentration of cells obtained at genetic amniocentesis.

The number of viable amniotic fluid cells in the aliquot obtained at amniocentesis is an important determinant of the success of subsequent cell culture. However, cell concentration and viability are highly variable, even in samples of equivalent gestational age. We studied the effect of prescribed maternal position change or spontaneous fetal movement on the concentration, viability, and subsequent harvest time of amniotic fluid cells removed at genetic amniocentesis. Samples from 108 patients at 15 to 22 weeks' gestation were evaluated. We did not find a relationship between this type of maternal or fetal movement and the retrieval of amniotic fluid cells.