The association of prepregnancy body mass index with pregnancy outcomes in triplet gestations.

The impact of obesity on triplet gestations is poorly understood. In this study, we investigate the association of obesity with birth outcomes in triplets. Triplet births in the state of Missouri from 1989 through 1997 were analyzed. Obesity was defined as maternal prepregnancy body mass index (BMI) >or=30 kg/m(2). We assessed the association between obesity and the following outcomes: stillbirth, preeclampsia, very preterm, small for gestational age (SGA), and a composite adverse birth outcome. We employed logistic regression with further correction for intracluster correlation to obtain adjusted estimates. A total of 667 triplet gestations were analyzed. As compared with normal-weight mothers, the likelihood of stillbirth and preeclampsia was higher among obese mothers (odds ratio[OR] = 3.70; 95% confidence interval [CI] = 1.37 to 9.97 and OR = 3.02; 95% CI = 1.69 to 5.40 respectively). Obese mothers were also about twice as likely to experience at least one of the adverse birth outcomes considered. Obese women with triplet gestations have about four- and threefold elevated risks for stillbirth and preeclampsia as compared with their counterparts with normal weight. This observation may be of utility in the preconceptional counseling of women considering the use of assisted reproductive technology.

Prenatal diagnosis of a 4q33-4qter deletion in a fetus with hydrops.

OBJECTIVE: The 4q- syndrome comprises all microscopically visible deletions of the long arm of chromosome 4. Cases with 4q deletions represent a diverse group that share several phenotypic characteristics. We report the prenatal diagnosis of an isolated terminal 4q33 deletion in a fetus with hydrops. METHOD: A comprehensive workup, including an amniocentesis, was performed on a 32-week fetus presenting with massive hydrops and polyhydramnios. RESULTS: The karyotype obtained from the amniotic fluid showed an unusual banding pattern on chromosome 4q. Fluorescent in situ hybridization revealed a 4q33-qter deletion. The proband shared several of the phenotypic characteristics of the 4q- syndrome. Multidisciplinary evaluation of the newborn confirmed the genotype and failed to identify another cause for the hydrops. CONCLUSION: We suggest that the broad spectrum of phenotypes expressed by patients with terminal 4q33 deletions includes hydrops fetalis.

What is the definition of pulsatile umbilical venous flow in twin-twin transfusion syndrome?

OBJECTIVE: The aim of the study was to derive an objective definition of pulsatile umbilical venous flow (PUVF). STUDY DESIGN: Pulsed Doppler waveform analysis of the umbilical vein was performed in stages III and IV twin-twin transfusion syndrome (TTTS) patients. In patients with PUVF, the umbilical vein maximum (Vmax) and the umbilical vein minimum velocity (Vmin) and the resistance index for the umbilical vein (UVRI) = (100 x [Vmax - Vmin]/Vmax) were assessed. RESULTS: PUVF was noted in 130 of 226 stages III and IV TTTS patients. Digital images were available for analysis in 65 of 130 patients (50%). The minimum UVRI associated with PUVF was 16% for stages III and IV TTTS. There was a trend for increasing UVRI with stage (P = .052). Stage IV patients were more likely to have an UVRI greater than 30% (P = .02). CONCLUSION: PUVF can be defined as an UVRI greater than 15%. A scale definition of PUVF may further facilitate assessment of the degree of fetal hemodynamic compromise.

Intrauterine growth restriction in monochorionic twins.

Intrauterine growth restriction (IUGR) occurs in approximately 3-10% of singleton pregnancies, in 9.1% of all twins, and in 9.9% of monochorionic twins. Spontaneous demise of the IUGR twin may occur and may result in concomitant demise or severe neurological handicap of the other twin. Currently, monochorionic twins with selective IUGR (SIUGR) are managed expectantly. Alternatively, all adverse consequences resulting from the potential demise of the SIUGR twin could be averted by unlinking the circulations between the two fetuses. The latter can be achieved by laser photocoagulation of communicating vessels or by umbilical-cord occlusion. The purpose of this chapter is to review this important entity in obstetrics.

Buccal misoprostol to prevent hemorrhage at cesarean delivery: a randomized study.

OBJECTIVE: The purpose of this study was to assess the efficacy of buccal misoprostol to decrease uterine atony, hemorrhage, and the need for additional uterotonic agents during cesarean delivery. STUDY DESIGN: Patients who underwent cesarean delivery were assigned randomly to either 200-microg misoprostol or placebo placed in the buccal space. A dilute intravenous oxytocin infusion was given to all patients at delivery of the placenta. The primary outcome variable was the need for additional uterotonic agents. RESULTS: A total of 352 women received random assignments. Demographic and intrapartum characteristics were similar between the groups. More women in the placebo group required 1 additional uterotonic agent (43% vs 26%; P < .01; relative risk, 1.3; 95% CI, 1.10, 1.50). There was not a difference between the groups in the incidence of postpartum hemorrhage or a difference in preoperative and postoperative hemoglobin level. CONCLUSION: Buccal misoprostol reduces the need for additional uterotonic agents during cesarean delivery.

Thrombosis in a pregnant hemophilia A carrier after intrapartum recombinant factor VIII.

BACKGROUND: Symptomatic hemophilia A is a rare disorder in females. Pregnancy and delivery in such women can be life threatening. Obstetric management is challenging and requires a multidisciplinary approach to ensure a good outcome. CASE: A woman with hemophilia A delivered by cesarean developed a deep vein thrombosis 10 days postpartum after recombinant factor VIII administration. CONCLUSION: Hemophilia A due to skewed X-inactivation is a rare cause of peripartum bleeding. Recombinant factor VIII administration can prevent hemorrhage during and after cesarean delivery but may be associated with development of deep vein thrombosis.