Effect of maternal cystic fibrosis genotype on diabetes in pregnancy.

OBJECTIVE: To evaluate the association between the cystic fibrosis (CF) genotype and the rate of diabetes complicating pregnancy. METHODS: We conducted a retrospective cohort analysis of all pregnant patients with CF from 1972-2011 at a single institution. Patients who were homozygous for the ΔF508 mutation were compared with patients who were heterozygous for the ΔF508 mutation. Primary outcomes measured were incidence of CF-related diabetes and gestational diabetes mellitus (GDM) stratified by CF genotype. Secondary outcomes measured included pancreatic insufficiency, preterm premature rupture of membranes, preterm delivery, mode of delivery, gestational age at delivery, and maternal mortality. RESULTS: We identified 54 pregnancies among 36 women who met inclusion criteria. Of these pregnancies, 28 (51.9%) were carried by women who were homozygous for the ΔF508 mutation. Homozygous women had a significantly greater incidence of pancreatic insufficiency (89.3% compared with 61.5%, P=.03) and diabetes complicating pregnancy (60.7% compared with 23.1%, P<.01) compared with heterozygous women. In addition, there was some evidence of an increased incidence of GDM specifically among homozygous women (35.7% compared with 15.4%, P=.12). Regarding neonatal outcome, there was a lower mean birthweight (2,881 g compared with 3,203 g, P=.04) among the women who were homozygous for the ΔF508 mutation. There was no statistical difference in preterm deliveries, mode of delivery, gestational age at delivery, rate of preterm premature rupture of membranes, or incidence of maternal mortality between the two groups. CONCLUSION: Women with CF who are homozygous for the ΔF508 mutation have an increased risk of having a pregnancy complicated by diabetes.

Management of mild fetal pyelectasis: a comparative analysis.

OBJECTIVE: The purpose of this study was to compare 2 protocols for the antenatal management of isolated mild fetal pyelectasis and perform a cost analysis. METHODS: A retrospective analysis of unilateral and bilateral mild fetal pyelectasis followed at our institution from 2003 to 2006 was conducted. Fetuses with additional congenital anomalies or aneuploidy were excluded. Chi(2) analysis was used, and P < .05 was considered significant. RESULTS: Two hundred forty-four cases were identified, of which the majority were male (75.4% versus 24.6%). Eighty-eight patients were reevaluated every 4 weeks (protocol 1). The remaining 156 patients were reevaluated once in the third trimester (protocol 2). The mean number of ultrasound examinations in protocol 1 was 3.24, at a cost of $1187, compared with protocol 2, at $798. Resolution occurred in 59%, stabilization in 29%, and progression in 12%. There were no cases of progression to severe pyelectasis or a need for in utero intervention in either group. CONCLUSIONS: Mild fetal pyelectasis can be managed with 1 additional third-trimester ultrasound examination without a compromise in patient care. Average cost savings were $389 per patient for protocol 2, suggesting a benefit from this protocol over protocol 1.

Trial of vaginal breech delivery: current role.

Breech presentation occurs at term in approximately 3% to 4% of singleton gestations. This presentation is associated with a variety of maternal and fetal conditions including preterm labor, abnormal amniotic fluid volume, hydrocephaly, anencephaly, mullerian anomalies, abnormal placentation, and multifetal gestation. Cesarean delivery has been associated with increased risk of subsequent accreta, placenta previa, hemorrhage, and hysterectomy. The Term Breech Trial initially suggested that planned vaginal breech delivery is associated with increased neonatal morbidity and mortality compared with planned cesarean delivery. Long-term follow-up of these vaginally delivered infants contradict the initial findings. Current debate surrounds the dilemma of whether the untoward complications of cesarean delivery are warranted given uncertain minimal increases in neonatal survival and improvement in neurologic outcome with planned cesarean.

Is there a preferred gestational age threshold of viability?: a survey of maternal-fetal medicine providers.

OBJECTIVE: To characterize variation and factors associated with the perceived gestational age for the threshold of viability among maternal-fetal medicine (MFM) providers. METHODS: We performed a web-based online survey of 1375 MFM providers. For this secondary analysis, a subset of survey questions targeted toward perceptions of the limit of viability was analyzed to identify how the respondents viewed the optimal threshold of viability gestational age. Comparative statistics were performed to assess various characteristics that influence the perceived threshold of viability. RESULTS: Five hundred and eight providers (37%), representing all 50 states and 13 countries, responded to the survey. The reported threshold of viability varied among survey respondents: 22 weeks, 2.0%; 23 weeks, 37.2%; 24 weeks, 55.3%; 25 weeks, 3.4%; and 26 weeks, 2.2%. No significant differences were noted in the reported threshold of viability with respect to practitioner age (<50 years old vs. > or =50 years old, p = 0.42), nursery availability (level III vs. other, p = 0.46), and years in practice (<10 years vs. > or =10 years, p = 0.86). Significant differences in the reported threshold of viability were noted with respect to practitioner gender with males tending to have a lower gestational age threshold than females (p = 0.005). Significant differences were also noted among practitioners from academic vs. community/private practice settings (p = 0.008). A logisitic regression model, adusting for both gender and practice setting, revealed that male gender was independently associated with selection of a threshold of viability less than 24 weeks of gestation: male gender OR 1.8 (95% CI 1.3-2.7, p = 0.002); academic practice setting OR 1.1 (95% CI 0.8-1.6, p = 0.50). CONCLUSIONS: Perceived threshold of viability among MFM providers varies with the majority of practitioners identifying 23-24 weeks of gestation. Significant difference, however, exists between practitioner genders.

Beckwith-Wiedemann syndrome presenting with an elevated triple screen in the second trimester of pregnancy.

BACKGROUND: Beckwith-Wiedemann syndrome (BWS) is a distinct clinical syndrome with unique features, generally diagnosed postnatally. CASE: A 26-year-old patient, gravida 4, para 3-0-0-3, was noted to have an abnormal maternal serum screen. Amniocentesis with imaging studies were remarkable only for a two-vessel umbilical cord and prominent maternal ovaries. The patient developed HELLP syndrome at 28 weeks and delivered a viable female infant with distinct clinical features. The diagnosis of BWS was confirmed by hypermethylation of the H19 gene on chromosome 11p15.5. CONCLUSION: This case describes a novel presentation of BWS and underscores the diagnostic potential of routine prenatal screens.

The relationship between practice setting and management of preterm premature rupture of membranes.

OBJECTIVE: To compare preterm premature rupture of membranes (PPROM) management between maternal-fetal medicine (MFM) providers practicing in an academic university (AU) versus other settings (NAU). METHODS: Secondary analysis of a national survey of 1375 MFM providers of whom 504 (37%) responded and answered queries on demographic and practice characteristics and various PPROM management issues. RESULTS: Fifty-three percent of the respondents were in an AU practice setting. Providers in AU and NAU settings reported a similar prevalence of corticosteroid (99% vs. 100%), antibiotic (99% vs. 100%), and tocolytic (74% vs. 76%) use. There was significant variability between NAU and AU providers in issues related to the evaluation and expectant management of PPROM. NAU providers, as compared to AU providers, more commonly reported performing diagnostic amniocentesis in the acute evaluation of PPROM (72% vs. 61%, p = 0.02). There was a higher prevalence of fetal lung maturity assessment among NAU providers (84%) as compared to AU providers (73%, p = 0.005) and significant variability was noted with respect to the fetal lung maturity tests used (p < 0.0001). NAU providers continued expectant management later into gestation than AU providers (p = 0.002). Significant variability was also noted in the use of antepartum surveillance techniques (p = 0.01). CONCLUSION: MFM practitioners from academic universities and non-academic settings utilize similar management strategies for PPROM in regard to corticosteroid, tocolytic, and antibiotic use. However, differences are evident in issues related to the evaluation and expectant management of patients with PPROM.

Use of the Roche LightCycler Strep B assay for detection of group B Streptococcus from vaginal and rectal swabs.

The results for a real-time PCR assay, using the LightCycler Strep B analyte-specific reagents (Roche Diagnostics Corporation, Indianapolis, Ind.), were compared to a direct plate method combined with a broth enrichment culture method for detection of group B streptococcus colonization in pregnant women. Two separate evaluations were conducted using two different automated nucleic extraction instruments, the MagNA Pure LC instrument (Roche Diagnostics Corporation) and the lower-capacity MagNA Pure Compact instrument (Roche Diagnostics Corporation). The sensitivities, specificities, and positive and negative predictive values for the different evaluation methods were as follow: for the LightCycler Strep B assay with MagNA Pure LC, 100, 97, 90, and 100%, respectively; for the LightCycler Strep B assay with MagNA Pure Compact, 92.5, 99, 97, and 97.5%, respectively. The LightCycler Strep B assay combined with either MagNA Pure LC or MagNA Pure Compact extraction is a suitable method for detecting group B streptococcus colonization in pregnant women. An advantage of the LightCycler assay over culture is the considerably reduced turnaround time for results.

Preterm premature rupture of membranes: perspectives surrounding controversies in management.

Preterm premature rupture of the membranes (PPROM) occurs in approximately 3% of all pregnancies, and accounts for one third of all preterm births. Despite its prevalence, optimal management of PPROM remains largely undefined and lacks conformity. In this article, we review the pathophysiology of PPROM, and summarize the available literature describing various management strategies in an effort to define current controversies in the management of PPROM.

Comparative longitudinal study of cervical length and induced shortening changes among singleton, twin, and triplet pregnancies.

OBJECTIVE: To compare cervical length and induced shortening changes during gestation among singleton, twin, and triplet pregnancies. STUDY DESIGN: Thirty-two healthy gravidas (12 singleton, 13 twin, and 7 triplet pregnancies) between 17 and 20 weeks' gestation were prospectively enrolled in this longitudinal investigation of cervical length. Serial transperineal cervical length ultrasound assessments were made weekly until 34 weeks' gestation under 3 conditions: 1) supine, 2) supine with the Valsalva maneuver, and 3) standing. Cervical length, internal os diameter, and presence of cervical funneling were assessed under each condition. Multiple regression models were created using generalized estimating equations to predict these measures and accounting for confounding effects from covariates and adjusting for correlations from repeated measurements on each woman. RESULTS: A total of 1286 cervical sonographic measurements were made. In a multiple linear regression generalized estimating equations model, estimated cervical length was significantly different among singleton, twin, and triplet pregnancies. Overall, changing maternal position from supine to standing resulted in a nonsignificant change (-0.1 +/- 0.4 mm) in cervical length (P = .85). In contrast, measurement of cervical length during the Valsalva maneuver resulted in a significant reduction in cervical length when compared with the cervical length measured in supine (-1.0 +/- 0.3 mm) (P = .0009) and standing positions (-0.9 +/- 0.4) (P = .009). The observed induced shortening changes were similar across gestation, irrespective of singleton, twin, or triplet gestation. CONCLUSION: Longitudinal cervical length changes differ significantly throughout gestation among singleton, twin, and triplet pregnancies. Cervical length measurements made in a standing position are comparable with those measured while supine, whereas cervical lengths measured during the Valsalva maneuver are significantly shorter than those made in either the supine or standing position.

Cardiotocographic abnormalities associated with dinoprostone and misoprostol cervical ripening.

OBJECTIVE: To characterize the frequency and timing of cardiotocographic abnormalities associated with the use of 3 commercially available prostaglandin analogues, misoprostol, dinoprostone gel, and dinoprostone pessary, as labor preinduction agents. METHODS: One-hundred and eleven women undergoing induction of labor with an unfavorable cervix were randomized to receive either misoprostol 50 microg every 6 hours x 2 doses, dinoprostone gel 0.5 mg every 6 hours x 2 doses, or dinoprostone pessary 10 mg x 1 dose for 12 hours intravaginally. Oxytocin induction was initiated per standardized protocol. Cardiotocographic tracings were blindly reviewed, with abnormalities coded using established definitions. RESULTS: Fifty-five percent of women treated with misoprostol demonstrated an abnormal tracing event within the initial 24 hours of induction, compared with 21.1% with dinoprostone pessary and 31.4% with the dinoprostone gel. The mean (+/- standard deviation) number of abnormal events was significantly greater in women treated with misoprostol (5.0 +/- 5.9) versus the dinoprostone pessary (1.6 +/- 2.5) and gel (2.2 +/- 3.1) (P < .05). In addition, these events occurred earlier after initial misoprostol dosing (5.0 +/- 4.0 hours), compared with the dinoprostone pessary (9.4 +/- 5.6 hours) and gel (7.7 +/- 6.6). Thirty-nine percent of the misoprostol-treated women had abnormal patterns within 6 hours of initial dosing, compared with those treated with the dinoprostone pessary (7.9%) and gel (17.1%). CONCLUSION: Cardiotocographic abnormalities are more frequent after misoprostol administration compared with the dinoprostone analogues. The early onset and frequent nature of the tracing abnormalities associated with misoprostol raises concern for the potential use of misoprostol for outpatient cervical ripening.

Contemporary management of preterm premature rupture of membranes (PPROM): a survey of maternal-fetal medicine providers.

OBJECTIVE: This study was undertaken to characterize variations in the management for women with preterm premature rupture of membranes (PPROM) among maternal-fetal medicine (MFM) specialists in the context of current recommendations for clinical practice and evidenced-based practice. STUDY DESIGN: We performed a Web-based survey of 1375 MFM providers. Participants were queried on practice characteristics and management issues including use of tocolytics, antibiotics, steroids, and timing of delivery. RESULTS: A total of 508 providers (37%), representing all 50 states and 13 countries, responded to the survey. Only 30% reported a formal departmental protocol for managing women with PPROM. Consistent use of steroids (99.4%) and antibiotics (99.6%) were reported. Administration of steroids was confined to < or =32 weeks by 37%, and < or =34 weeks by 51% of practitioners. Repeated dosing of steroids was uncommon (16%). The antibiotics use and rationale for use varied among respondents. Tocolytics were used by 73% of respondents with magnesium sulfate the main agent used (98%). Use of tocolytics was generally used for 48 hours or less to attain steroid benefit (88%). Amniocentesis was used by 66% of practitioners in the acute evaluation of PPROM. Fetal lung maturity testing was reported by 78% with variability noted with respect to the test used. Outpatient management of women with PPROM after viability was noted by 43% of respondents. Gestational age at which expectant management is abandoned in women with PPROM varied significantly between respondents: > or =34 weeks by 56%, > pr =35 weeks by 26%, > or =36 weeks by 12%, and > or =37 weeks by 4.0%. CONCLUSION: Although many management practices for women with PPROM are consistent with currently available evidence and practice recommendations, substantial variations still exist among MFM providers.

A prospective trial of elective preterm delivery for fetal gastroschisis.

To test the hypothesis that preterm delivery of fetal gastroschisis prevents serious gastrointestinal compromise, facilitates primary surgical closure, and improves surgical outcome, we enrolled 16 women in a management plan. This included high-resolution ultrasound, weekly re-evaluation of the fetal gut (> or = 26 weeks), corticosteroids, and delivery if evidence of bowel compromise was present > 30 weeks. These fetuses were compared with 16 consecutive patients treated prior to establishment of this plan. Comparison of prospective trial patients with controls revealed significant differences in age at delivery (34.2 versus 37.7 weeks), serious bowel compromise (0 versus 70%), use of a surgically constructed silo (0 versus 77%), wound complications (0 versus 23%), duration of total parenteral nutrition (18.7 versus 34.7 days), time to full enteral feeding (19.1 versus 35.1 days), and hospital discharge (22.7 versus 37.7 days). Elective preterm delivery using specific ultrasound criteria resulted in improved surgical outcome without significant morbidity secondary to prematurity.

Homeostatic control of T-cell generation in neonates.

T cells are produced through 2 mechanisms, thymopoiesis and proliferative expansion of postthymic T cells. Thymic output generates diversity of the pool, and proliferation achieves optimal clonal size of each individual T cell. To determine the contribution of these 2 mechanisms to the formation of the initial T-cell repertoire, we examined neonates of 30 to 40 weeks' gestation. Peripheral T cells were in a state of high proliferative turnover. In premature infants, 10% of T cells were dividing; the proliferation rates then declined but were still elevated in mature newborns. Throughout the third trimester, concentrations of T-cell-receptor excision circles (TRECs) were 10 per 100 T cells. Stability of TREC frequencies throughout the period of repertoire generation suggested strict regulation of clonal size to approximately 10 to 20 cells. Neonatal naive CD4+ and CD8+ T cells were explicitly responsive to IL-7; growth-promoting properties of IL-15 were selective for newborn CD8+ T cells. Neonatal T cells expressed telomerase and, in spite of the high turnover, built up a telomeric reserve. Thus, proliferative expansion, facilitated by increased cytokine responsiveness, and thymopoiesis complement each other as mechanisms of T-cell production in neonates. Maintaining optimal clonal size instead of filling the space in a lymphopenic host appears to regulate homeostatic T-cell proliferation during fetal development.

Maternal and transplacental pharmacokinetics of azithromycin.

OBJECTIVE: The purpose of this study was to characterize the pharmacokinetics of orally administered azithromycin in the term gravid woman. STUDY DESIGN: Twenty women who were scheduled for elective cesarean delivery were enrolled prospectively and received 1 g of oral azithromycin at either 6, 12, 24, 72, or 168 hours before the operation. All women received spinal anesthesia, at which time a sample of cerebrospinal fluid was obtained for analysis. Maternal serum and urine were obtained immediately before the operation. Intraoperatively, samples of myometrium, maternal adipose tissue, placenta, amniotic fluid, and umbilical arterial and venous cord blood were obtained. Azithromycin levels were determined quantitatively with high-pressure liquid chromatography with electrochemical detection. RESULTS: All participants tolerated the preoperative azithromycin without significant adverse reactions. Peak maternal serum azithromycin levels occurred within 6 hours of drug administration. Although high serum levels of azithromycin were reached early, a rapid decline in drug concentration was noted over the initial 24 hours after the drug administration (6-hour: 311 ng/mL; 24-hour: 63 ng/mL). In contrast, azithromycin levels in myometrial, adipose, and placental tissue were higher (>500 ng/mL) and sustained for up to 72 hours after administration. High urine levels of azithromycin (>5000 ng/mL) were noted similarly during the initial 72 hours after drug administration. Umbilical arterial and venous serum azithromycin levels were low (19-38 ng/mL) during the first 72 hours. Amniotic fluid levels were highest at 6 hours (151 ng/mL) and declined rapidly. Maternal cerebrospinal azithromycin concentrations were undetectable for all time points. CONCLUSION: Azithromycin has a rapid serum half-life in the term gravid woman with a prolonged half-life and high-sustained antibiotic levels noted within myometrium, adipose, and placental tissue. Given the broad antimicrobial spectrum and placental penetration, azithromycin may have potential use for the treatment of perinatal infections.

Comparative efficacy and cost of the prostaglandin analogs dinoprostone and misoprostol as labor preinduction agents.

OBJECTIVE: The purpose of this study was to compare the relative efficacy and cost of three commercially available prostaglandin analogs, misoprostol (Cytotec), dinoprostone gel (Prepidil), and dinoprostone insert (Cervidil), as labor preinduction agents. STUDY DESIGN: One-hundred eleven women with an unfavorable cervix who underwent labor induction were assigned randomly to receive either misoprostol 50 microg every 6 hours for two doses, dinoprostone gel 0.5 mg every 6 hours for two doses, or dinoprostone insert 10 mg for one dose intravaginally. Twelve hours later, oxytocin induction was initiated per standardized protocol. Efficacy and cost of the labor preinduction/induction with the study treatments were compared. RESULTS: Mean Bishop score change (+/-SD) over the initial 12-hour interval was significantly greater in the misoprostol group (5.2 +/- 3.1) compared with the dinoprostone insert (3.2 +/- 2.3) or the dinoprostone gel groups (2.2 +/- 1.3, P <.0001). The proportion of women who reached complete dilation (68.4%, 50.0%, 51.4%, respectively; P =.14) and who were delivered (60.5%, 47.4%, 40.0%, respectively; P =.10) within 24 hours of the initiation of induction were not significantly different between the misoprostol, dinoprostone insert, and dinoprostone gel groups. Induction-to-delivery intervals, however, were significantly shorter among women who treated with misoprostol (24.0 +/- 10.8 hours) compared with either the dinoprostone gel (31.6 +/- 13.4 hours) or the dinoprostone insert (32.2 +/- 14.7 hours, P <.05). Overall mean cost per patient that was incurred by labor induction was significantly less for the misoprostol group ($1036.13) compared with the dinoprostone insert group ($1565.72) or the dinoprostone gel group ($1572.92, P <.0001). No significant differences were noted with respect to the mode of delivery or to the adverse maternal/neonatal outcome. CONCLUSION: Misoprostol is more cost-effective than the comparable commercial dinoprostone prostaglandin preparations as an adjuvant to labor induction in women with an unfavorable cervix.

Characterization of the relationship between joint laxity and maternal hormones in pregnancy.

OBJECTIVE: To evaluate peripheral joint laxity during pregnancy and to correlate changes with serum cortisol, estradiol, progesterone, and relaxin. METHODS: Forty-six women with first-trimester singleton gestations consented to participate in this longitudinal observational study. Bilateral wrist laxity measurements (flexion-extension and medial-lateral deviation) were made using a clinical goniometer, and serum levels of cortisol, estradiol, progesterone, and relaxin were determined during each trimester of pregnancy and postpartum. Patients were also screened for subjective joint complaints. Statistical analysis included Student t test, analysis of variance, and linear regression analysis. RESULTS: Eleven women (24%) were excluded from the study after spontaneous first-trimester pregnancy loss. Fifty-four percent (19 of 35) demonstrated increased laxity (10% or higher) in either wrist from the first to the third trimester. Although serum levels of cortisol, estradiol, progesterone, and relaxin were significantly elevated during pregnancy, no significant differences in these levels were noted between those who became lax during gestation and those who did not. Linear regression analysis of wrist joint laxity and level of serum estradiol, progesterone, and relaxin demonstrated no significant correlation. Wrist flexion-extension laxity, however, did significantly correlate with level of maternal cortisol (r = 0.18, P =.03). Fifty-seven percent of women developed subjective joint pain during pregnancy, which was not associated with increased joint laxity, but was associated with significantly increased levels of estradiol and progesterone. CONCLUSION: Peripheral joint laxity increases during pregnancy; however, these changes do not correlate well with maternal estradiol, progesterone, or relaxin levels.

Effect of vaginal pH on efficacy of the dinoprostone gel for cervical ripening/labor induction.

OBJECTIVE: The purpose of this study was to evaluate whether vaginal pH has an effect on the efficacy of the dinoprostone gel for cervical ripening/labor induction. STUDY DESIGN: Thirty-two women with an unfavorable cervix who were undergoing labor induction were enrolled in this prospective, double-blinded investigation. Initial vaginal pH and Bishop score assessment were made by an independent examiner. All women received cervical ripening with the dinoprostone gel 5 mg intracervically, with repeated dosing one time 6 hours later. Twelve hours later, oxytocin induction was initiated per standardized protocol, and outcome data were collected. RESULTS: Mean (+/-SD) initial vaginal pH was 4.7 +/- 0.6 (range, 4.0-6.0) for the study cohort. No significant differences were noted between women with a high vaginal pH (>4.5, n = 16 women) and women with a low vaginal pH (< or =4.5, n = 16 women) with respect to maternal age, parity, gestational age, or initial Bishop score. Although Bishop score change over the initial 12 hours of cervical ripening did not significantly differ between the high vaginal pH (2.3 +/- 2.3) and the low vaginal pH group (2.3 +/- 2.5, P = not significant), time to active labor (19 +/- 10 hours vs 33 +/- 17 hours, P =.001), complete dilation (24 +/- 10 hours vs 37 +/- 19 hours, P =.03), and delivery (26 +/- 10 hours vs 38 +/- 18 hours, P =.02) were significantly shorter in women with a high vaginal pH compared with women with a low vaginal pH, respectively. A significant association was noted between vaginal pH and time to active labor (r = -0.52, P =.003), complete dilation (r = -0.50, P =.006), and delivery (r = -0.44, P =.01); however, pH was not significantly associated with Bishop score change during the initial 12 hours of cervical ripening. CONCLUSION: Vaginal pH is an important factor that affects the efficacy of the dinoprostone gel as an adjuvant for labor induction.

Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery.

OBJECTIVE: This study was undertaken to determine the incidence of clinically overt postpartum urinary retention after vaginal delivery and to examine what maternal, fetal, and obstetric factors are associated with this problem. STUDY DESIGN: This was a retrospective case-controlled study of women who had overt postpartum urinary retention after vaginal delivery from August 1992 through April 2000. RESULTS: Fifty-one of 11,332 (0.45%) vaginal deliveries were complicated by clinically overt postpartum urinary retention. In most cases (80.4%), the problem had resolved before hospital dismissal. Persons with urinary retention were more likely than control subjects to be primiparous (66.7% vs 40.0%; P <.001), to have had an instrument-assisted delivery (47.1% vs 12.4%; P <.001), to have received regional analgesia (98.0% vs 68.8%; P <.001), and to have had a mediolateral episiotomy (39.2% vs 12.5%; P <.001). On multivariate logistic regression analysis, of these 4 variables, only instrument-assisted delivery and regional analgesia were significant independent risk factors. CONCLUSION: Clinically overt postpartum urinary retention complicates approximately 1 in 200 vaginal deliveries, with most resolving before hospital dismissal. Factors that are independently associated with its occurrence include instrument-assisted delivery and regional analgesia.

Chiari I malformation in parturients.

STUDY OBJECTIVE: To assess complications of regional as well as general anesthesia in parturients with Chiari I malformation. DESIGN: Retrospective chart review. SETTING: Academic medical center. PATIENTS: All parturients in our institution who had the diagnosis of Chiari I malformation and delivered in our hospitals over a 50-year period. MAIN RESULTS: 12 parturients delivered 30 babies. Three deliveries were facilitated with general anesthesia. Nine deliveries were facilitated with central axis anesthesia, six with epidural anesthesia, two with a single injection of a spinal anesthetic, and one with a continuous spinal catheter. The patient who received a continuous spinal catheter developed a postdural puncture headache that resolved with an epidural blood patch. None of the patients who received general, spinal, or epidural anesthesia for their deliveries developed symptoms or had exacerbation of preexisting symptoms of Chiari I malformation. CONCLUSIONS: General anesthesia, as well as spinal and epidural anesthesia, appeared to be safe and effective in our series of vaginal or cesarean delivery patients. The small number of patients in our series does not negate the cautious recommendations of others, but suggests that general anesthesia, as well as spinal or epidural anesthesia, can be used safely and effectively in these patients.

Pneumoamnion and pregnancy loss after second-trimester laparoscopic surgery.

BACKGROUND: Midtrimester laparoscopic surgery is considered safe; however, both maternal and fetal complications can occur. We report a case of midtrimester pregnancy loss with pneumoamnion after laparoscopic appendectomy. CASE: A young woman presented at 21 weeks' gestation with a 3-day history of nausea and severe abdominal pain. Diagnostic laparoscopy was performed with normal appendix and pelvic anatomy noted. Worsening pain prompted a repeat laparoscopic evaluation. A small defect in the uterine serosa was noted, which presumably resulted from inadvertent Veress needle injury. Abdominal computerized tomography was performed, which demonstrated a pneumoamnion. Spontaneous rupture of membranes and labor ensued, resulting in the delivery of a stillborn fetus. CONCLUSION: Inadvertent introduction of the Veress needle into the gravid uterus with subsequent pneumoamnion represents a catastrophic complication of midtrimester laparoscopic surgery.