Effect of mode of birth on purine and malondialdehyde in umbilical arterial plasma in normal term newborns.

OBJECTIVE: To examine the effect of mode of birth on plasma purine and malondialdehyde levels in normal term infants. STUDY DESIGN: Umbilical arterial cord blood was obtained immediately after birth from a convenience sample of 119 normal term newborns born by vaginal delivery, with or without oxytocin augmentation or by elective cesarean delivery. Plasma was analyzed for purine and/or malondialdehyde levels. Numeric data were analyzed utilizing independent samples t-test and ordinal data were analyzed using Mann-Whitney test. Correlation coefficients were obtained using Spearman's rho. RESULT: Uric acid levels were significantly elevated (P<0.001) in neonates undergoing vaginal birth, compared to neonates born by elective cesarean delivery. When the effect of oxytocin and length of labor was analyzed, neonates born to mothers on oxytocin had lower hypoxanthine, significantly lower xanthine (P=0.05) and higher uric acid levels. In addition, malondialdehyde levels were significantly higher (P<0.006) in neonates born to mothers who received oxytocin compared to neonates born to mothers without oxytocin augmentation. We also found significant correlations between malondialdehyde (MDA) and hypoxanthine (r=-0.465, P<0.039) and between MDA and xanthine (r=-0.753, P=0.003) in neonates born via oxytocin-augmented birth. Mode of birth had no statistically significant effect on clinical outcomes, although infants born by elective cesarean had higher incidence of acute respiratory distress and transient tachypnea of the newborn compared to those born vaginally. CONCLUSION: Neonates born by elective cesarean had the lowest purine levels in cord blood compared to neonates born vaginally. Oxytocin augmentation is associated with some degree of uterine hyperstimulation which may enhance the ATP degradation pathway resulting in the rapid conversion of hypoxanthine to xanthine and xanthine to uric acid. Significantly higher MDA levels in neonates whose mothers received oxytocin as well as significant correlation between MDA and the purines hypoxanthine and xanthine, suggest free-radical production, most likely due to xanthine oxidase activation. However, despite differences in plasma purine and malondialdehyde levels, no significant differences were seen in neonatal outcome. Further studies are required to fully characterize the effect of mode of birth on purine metabolism and free-radical production.

Soluble human leukocyte antigens, interleukin-6, and interferon-gamma during pregnancy.

PROBLEM: Soluble human leukocyte antigens (sHLA), interferon-gamma (IFN-gamma), and interleukin-6 (IL-6) were studied during human pregnancy to test the hypothesis that sHLA concentrations are regulated by these specific cytokines. METHOD OF STUDY: Enzyme-linked immunoadsorbent assays (ELISA) were used to measure sHLA I and II in maternal circulation, cord blood, and placenta effluents of pregnant and nonpregnant women; maternal serum cytokines were also determined. RESULTS: sHLA in maternal and cord blood were equivalent to that in the placenta. By the third trimester, sHLA I concentrations in maternal plasma were significantly reduced compared to the first or second trimesters. sHLA II was increased during the second trimester relative to that postpartum. Maternal IL-6 and IFN-gamma concentrations were not statistically different throughout gestation or postpartum. CONCLUSIONS: These data do not suggest a role for maternal plasma IL-6 or IFN-gamma in regulation of systemic sHLA class I during pregnancy, but they do not address whether such events take place in local tissues of the maternal-fetal unit.

Prediction of cervical cerclage outcome by endovaginal ultrasonography.

OBJECTIVE: We hypothesized that shortened upper cervical segment length, measured by endovaginal ultrasonography, identifies patients with cervical cerclage at greater risk of preterm delivery. STUDY DESIGN: A total of 121 endovaginal ultrasonographic examinations were performed on 32 patients after cervical cerclage. Ultrasonographic measurements included length of the closed cervical canal segments above and below the cerclage and dilatation of the internal cervical os (funneling) with and without fundal pressure. The risk of preterm delivery was tested by Fisher's exact test (two-tailed). RESULTS: Development of funneling of the internal os and shortening of the upper cervical segment length were the most predictive of outcome in patients with cervical cerclage. Twelve patients had shortening of the upper cervical segment (< or = 10 mm) before 30 weeks' gestation (mean 22.6 +/- 2.7 weeks), whereas 20 patients continued to have upper cervical segment measurements > 10 mm. A short upper cervical segment before 30 weeks' gestation was associated with a significantly higher risk of preterm delivery before 36 weeks (58% vs 10%, p = 0.006) and before 34 weeks (50% vs 5%, p = 0.006). CONCLUSION: Endovaginal ultrasonographic assessment of the cervix in patients with cervical cerclage is a useful adjunct for predicting outcome and for counseling the patient.

Sonographic characteristics of antenatally diagnosed extralobar pulmonary sequestration and congenital cystic adenomatoid malformation.

Fetal chest masses are uncommonly noted on obstetrical ultrasound examinations. Some masses will undergo in utero regression with no neonatal morbidity whereas others are almost universally fatal. An accurate prenatal diagnosis is essential in enhancing parental decision-making. This paper reviews the published literature of two specific kinds of prenatally diagnosed fetal chest masses (congenital cystic adenomatoid malformations and pulmonary sequestrations) with emphasis on ultrasound characteristics and pregnancy outcome.

Spontaneous, in utero regression of antenatally diagnosed solid fetal chest masses. A report of two cases.

Mediastinal, displacing solid fetal chest masses have been regarded as lethal and thus considered cause for pregnancy termination at diagnosis. This report describes two cases in which solid fetal chest masses regressed spontaneously in utero.

Prolonged parenteral meperidine analgesia during pregnancy for pain from an abdominal wall mesh graft.

BACKGROUND: Although successful pregnancy has been reported in women with prosthetic mesh abdominal wall grafts, the complication of severe pain in pregnancy from shearing of the graft has not been described. We report an unusual case of severe pain in pregnancy caused by abdominal wall stretching by the enlarging uterus. Pain was controlled with long-term intravenous meperidine analgesia. CASE: A 21-year-old multigravida with a previously placed mesh graft for multiple abdominal wall hernias presented at 30 weeks' gestation with severe abdominal pain. Meperidine patient-controlled analgesia at a mean dose of 14.2 mg/kg/day controlled the symptoms, allowing pregnancy prolongation for 28 days before induction of labor at 34 weeks when fetal lung maturity was confirmed. CONCLUSION: This is the first reported case of the use of high-dose patient-controlled parenteral narcotic analgesia in a woman whose abdominal wall mesh graft partially sheared from its attachments. The patient went on to have a successful vaginal delivery.

Elective cesarean section improves outcomes of neonates with gastroschisis.

OBJECTIVE: Our objective was to compare neonatal postoperative morbidity for the neonate with prenatally diagnosed gastroschisis delivered vaginally with that for the perinate undergoing elective cesarean at or before the onset of labor. STUDY DESIGN: Retrospective maternal and neonatal data were obtained by chart review on 22 neonates prenatally diagnosed with gastroschisis who underwent operative closure of the ventral wall defect between 1987 and 1991 at Loma Linda University Medical Center. Perioperative data and postoperative courses were compared between 12 infants who underwent labor with vaginal delivery and 10 infants who were delivered by elective cesarean section at or before the onset of labor. RESULTS: Neonatal transports and significant bowel edema were more likely (p < 0.05) in the vaginal delivery group. The elective cesarean section infants had less sepsis (p < 0.05), fewer hospital days (p < 0.01) and parenteral nutrition days (p < 0.01), and shorter time to enteral feedings (p < 0.01). CONCLUSIONS: Elective cesarean section at or before the onset of labor may benefit the fetus with gastroschisis, compared with undergoing labor and vaginal delivery.

Fundal uterine leiomyoma obscuring first-trimester transabdominal sonographic diagnosis of fetal holoprosencephaly. A case report.

With new techniques in transvaginal ultrasound, higher resolution allows the earlier diagnosis of fetal developmental anomalies. We describe a case of first-trimester antenatal diagnosis of alobar holoprosencephaly using transvaginal and perineal ultrasound that was obscured from transabdominal sonography by a large uterine leiomyoma.

Ehlers-Danlos syndrome type III and pregnancy. A case report.

Ehlers-Danlos syndrome (EDS) is a heterogeneous connective tissue disorder rarely complicating pregnancy. Some types are associated with high maternal mortality, while others appear more benign. Two term, vaginally delivered pregnancies with good outcomes from one patient were managed with EDS type III. The patient experienced no significant morbidity attributable to the EDS. The only other previously reported case of EDS type III involved serious problems with joint laxity and pain morbidity, requiring preterm cesarean delivery.

Management of antenatally diagnosed fetal ovarian cysts.

1. Fetal ovarian cysts are usually unilateral, diagnosed in the third trimester and are uncommon. 2. Average ovarian cyst size is 5 x 5 cm at diagnosis and size does not change throughout the pregnancy. 3. Most cysts are functional in origin and histologically benign, simple cysts. 4. Polyhydramnios is a common finding but associated anomalies are rare. 5. Although large cysts can compress other viscera and torsion or rupture can occur, in utero aspiration has limited value in prenatal management. 6. Vaginal delivery with confirmed fetal pulmonary maturity or at term is appropriate. 7. Soft tissue dystocia is rare. Cesarean delivery should be reserved for obstetrical indications only. 8. The best predictor of neonatal cyst torsion risk is length of the cyst pedicle rather than cyst size. 9. When surgery is indicated a cystectomy, with preservation of maximal ovarian tissue is to be preferred over oophorectomy. 10. Ultrasound-guided aspiration of neonatal ovarian cysts may be an alternative to surgical management.

Epidural analgesia. Effect on the likelihood of a successful trial of labor after cesarean section.

From October 1984 to April 1986, 237 women who had had an earlier cesarean section underwent a trial of labor (TOL). The delivery outcomes for 87 who received epidural analgesia were compared retrospectively with those for the 150 who did not. There were no overt uterine ruptures. The rates were similar for successful TOL, uterine scar dehiscence, blood transfusions, endometritis and one- and five-minute Apgar scores. The rate of operative vaginal delivery was higher in the epidural group. When epidural subjects were divided into vaginal and cesarean delivery groups, the failed-TOL group differed from the successful-TOL group in greater maternal weight gain, heavier and longer infants, higher rate of oxytocin administration, less cervical dilation and higher station at epidural activation. When the oxytocin-treated subjects were excluded, however, the epidural and no-epidural patients had the same successful TOL rates (94% and 92%, respectively) and spontaneous vaginal delivery rates (70% and 76%, respectively). Epidural analgesia, when controlled for oxytocin use, appears to have no effect on the failed-TOL or operative vaginal delivery rate.

Routine postcesarean urine culture. A cost-effectiveness analysis.

Paired urinalysis and urine culture reports on 302 postcesarean patients were studied to determine whether screening postcesarean urinalyses could be useful in predicting positive urine cultures. A positive culture was predicted with a specificity of 97.5% and a sensitivity of 90.4%. The screening urinalysis had a positive predictive value of 73.1% and a negative predictive value of 99.3%. Routine postcesarean urine cultures were not found to be cost effective.

Optimal route of delivery for meningomyelocele.

No agreement exists in the literature regarding the optimal route of delivery for meningomyelocele (MMC) fetuses. Thirty-five MMC cases were retrospective divided into two study groups: vaginal delivery (n = 20); and cesarean delivery (n = 15). The groups were comparable demographically as well as for size and location of the MMC lesion. There were no differences in: 1 and 5 minute Apgar scores; incidence of MMC sac disruption; infants requiring ventriculoperitoneal shunts; infants exhibiting neurogenic bladders, fecal incontinence, orthopedic deformities, seizure disorders or neonatal meningitis. These data suggest neonatal outcome of MMC fetuses is unrelated to route of delivery.

Oxytocin use after previous cesarean: why a higher rate of failed labor trial?

When used for patients undergoing trial of labor after previous cesarean, oxytocin is associated with an increased failure rate. Previous reports have not studied why this occurs. From October 1984 to April 1986, 237 patients with previous cesareans underwent a trial of labor. The delivery outcomes of 73 women who received oxytocin were compared with those of the 164 who did not. Rates were similar for uterine scar dehiscence, uterine rupture, operative vaginal delivery, blood transfusions, endometritis, and low Apgar scores. Successful trial of labor occurred in 68% in the oxytocin group, compared with 89% in the no-oxytocin group. Failed trial of labor was significantly more frequent in patients who received oxytocin for induction of labor than in those who did not. When subjects who received oxytocin were divided into induction (N = 47) and augmentation (N = 26) groups, successful trial of labor occurred in 58% of the former group versus 88% of the latter group. Other characteristics of the augmentation group were spontaneous labor, greater cervical dilation and effacement at initiation of oxytocin, shorter duration of infusion, and lower oxytocin infusion rates. For patients who have had previous cesareans and who desire trial of labor, oxytocin by controlled infusion is safe. Successful trial of labor may be enhanced by awaiting spontaneous labor or inducing with a favorable cervix.

Routine predelivery coagulation screening in previous cesarean patients: impact on patient management.

Coagulation profiles (platelet count, prothrombin time, partial thromboplastin time) obtained as part of predelivery screening were examined in patients who presented for delivery with a history of previous cesarean section. Coagulation test results (N = 1439) were reviewed from charts of 482 patients. No change in patient management occurred and no cesarean sections or vaginal deliveries were deferred as a result of the laboratory tests. There were no hemorrhagic complications. No blood products were transfused as a result of the tests. Routine coagulation evaluation is not justified for subsequent delivery of patients who had a previous cesarean section.

Antenatal diagnosis of cephalothoracopagus twins in a triplet pregnancy. A case report.

The occurrence of conjoined twins in a triplet pregnancy is rare. Cephalothoracopagus twins were diagnosed on ultrasonography at 17 weeks' gestation. This is the first case of conjoined twins in a triplet pregnancy diagnosed early enough antenatally to allow vaginal pregnancy termination.

Management of stab wounds to the pregnant uterus: a case report and a review of the literature.

Only 18 cases of stab wounds to the pregnant uterus have been reported to date. This paper presents an additional case--a patient at 26 weeks' gestation with multiple voluntary stab wounds to the abdomen and lower chest resulting in fetal death. The literature is reviewed and management of abdominal stab wounds in pregnancy is discussed.