Expectant management of preterm premature rupture of membranes and nonvertex presentation: what are the risks?

OBJECTIVE: Preterm premature rupture of membranes (PPROM) continues to be a major cause of preterm births. The objective of this study was to compare the morbidity of patients with PPROM nonvertex presentations with patients with PPROM with vertex presentations. STUDY DESIGN: A retrospective analysis of data from 74 patients with PPROM with nonvertex presentations (study group) and 74 patients with PPROM with vertex presentations (control group) comprised the 2 study groups. All patients that met the study admission criteria were treated in a similar manner at 1 of 3 level-III hospitals. The gestational ages at delivery of all patients were between 23-34 weeks, and the gestational ages between case and control patients were matched for gestational age. RESULTS: A statistically significant (P = .03) higher incidence of a prolapsed umbilical cord was found in the study group (n = 8; 10.8%) relative to the control group (n = 1; 1.4%). More infants in the study group had low 5-minute Apgar scores (<5) and/or low cord pH (<7.20; n = 25 [33.8%]) than in the control group (n = 12 [16.2%]; P = .02). Five infants with breech presentations underwent a precipitous unplanned vaginal delivery. Significant morbidity was not detected in these 5 infants. CONCLUSION: After transfer to an antenatal ward, patients with PPROM with nonvertex presentations appear to have a significantly higher risk for prolapsed umbilical cords, lower Apgar scores, and/or lower umbilical cord blood pH values, when compared with their vertex counterparts. Additionally, there appears to be substantial risk of an unintended, vaginal breech delivery.

Urolithiasis in pregnancy. Diagnosis, management and pregnancy outcome.

OBJECTIVE: To review our experiences with ureterolithiasis and nephrolithiasis in pregnancy and compare their outcomes with those in the rest of the obstetric population. STUDY DESIGN: A database of obstetric deliveries was used to identify patients with (cases) and without (controls) urolithiasis and to compare demographics and pregnancy complications between the groups. Furthermore, retrospective chart review of the cases group was utilized to obtain additional pertinent information. RESULTS: Over a 3-year period, there were 21,010 deliveries, 86 of which had symptomatic urolithiasis, for an incidence of 1 in 244 pregnancies. Renal calculi occurred more commonly in Caucasians than African Americans. Patients were more likely to become symptomatic in the second or third trimester, and most stones passed spontaneously. Pregnancy complications were similar between the groups; however, there was a higher percentage of preterm premature rupture of membranes in the nephrolithiasis cases (7.0% vs. 2.9%, P < .05). CONCLUSION: Nephrolithiasis and ureterolithiasis occurred more commonly in Caucasians during pregnancy. The majority of patients became symptomatic in the last two-thirds of pregnancy and usually passed the calculus spontaneously. A higher incidence of preterm premature rupture of membranes was noted in pregnancies complicated by urolithiasis.

Perinatal outcomes in preeclampsia that is complicated by massive proteinuria.

OBJECTIVE: Current treatment of preeclampsia no longer mandates delivery for proteinuria of >5 g per 24 hours. We sought to determine whether delayed delivery of preeclampsia with massive proteinuria (>10 g/24 h) increased maternal or neonatal morbidity. STUDY DESIGN: Records of all women with preeclampsia who were delivered at <37 weeks of gestation between January 1, 1997, and June 30, 2001, were reviewed. Patients with underlying renal disease or multiple gestation were excluded. Patients were characterized as having mild (<5 g/24 h), severe (5-9.9 g/24 h), or massive (>10 g/24 h) proteinuria. Outcomes were compared using the chi(2) test, one-way analysis of variance, or Fisher exact test. RESULTS: Two hundred nine patients met the inclusion criteria: 125 patients had mild proteinuria, 43 patients had severe proteinuria, and 41 patients had massive proteinuria. No significant differences in maternal morbidity were seen. Massive proteinuria was associated with earlier onset of preeclampsia, earlier gestational age at delivery, and higher rates of prematurity complications. After correction for prematurity, massive proteinuria has no significant effect on neonatal outcomes. CONCLUSION: Women with preeclampsia and massive proteinuria did not have increased maternal morbidity compared with women with severe or mild proteinuria. Massive proteinuria appears to be a marker for early-onset disease and progression to severe preeclampsia. Neonatal morbidity appears to be a function of prematurity rather than of massive proteinuria itself.

Respiratory morbidity in well-dated twins approaching term. What are the risks of elective delivery?

OBJECTIVE: To evaluate morbidity, particularly respiratory, in well-dated, near-term twins delivered electively and to compare them to those delivered either spontaneously or for obstetric indications. STUDY DESIGN: Charts from twin deliveries were reviewed for inclusion in this study. Inclusion criteria were well-dated twins (American College of Obstetricians and Gynecologists criteria for dating) and absence of (1) corticosteroids, (2) intravenous tocolysis, (3) lung maturity studies, (4) fetal malformations, (5) diabetes, and (6) medical indications for delivery in the elective delivery group. Those meeting the criteria were divided into elective and nonelective (both spontaneous and indicated) delivery groups. Outcome variables included incidence of transient tachypnea and respiratory distress syndrome in each group. RESULTS: During the study period, 168 sets of twins met the admission criteria. Controlling for gestational age, no difference was noted in the incidence of respiratory distress syndrome, transient tachypnea and admission to the special care nursery. Infants born during the 36th week of gestation were more likely to be admitted to the special care nursery (37.8% vs. 10.6%, P < .05) and had a greater incidence of respiratory complications (23.2% vs. 6.7%, P < .01) than those born after 37 weeks. No difference was identified between the 37th and 38th weeks. CONCLUSION: In this large series of well-dated twin pregnancies, there was no evidence of increased respiratory morbidity or special care nursery admissions with elective delivery at or beyond 37 weeks. Twins delivered during the 36th week of gestation had increased respiratory morbidity and special care nursery admissions.