Adverse perinatal events and subsequent cesarean rate.

OBJECTIVE: To determine whether severe intrapartum complications resulting in poor neonatal outcome increased obstetricians' cesarean delivery rates. METHODS: From July 1996 through June 1998 we prospectively studied 3008 deliveries by 12 obstetricians. We chose adverse neonatal outcomes that would be viewed by obstetricians as anxiety-provoking experiences that are rare in obstetric practice. Index events included head entrapment of breech infants, Apgar score less than 3 at 10 minutes, shoulder dystocia resulting in persistent brachial plexus injury, and intrapartum fetal death. After an index event was identified, the obstetrician's cesarean delivery rate for the 50 deliveries before the index event was compared with the 50 deliveries after the index event. Obstetricians who had no intrapartum complication during the observational period were matched as controls. RESULTS: Six index events were identified, three cases of shoulder dystocia and three intrapartum fetal deaths. In three of these six cases, the Apgar score at 10 minutes was less than 3. Obstetricians who attended a delivery with severe intrapartum complications had an average increase in their cesarean delivery rate of 37% in the 50 deliveries after the index event (21.0% to 28.7%, P < .05). This rate was greater (P < .05) than that of matched control obstetricians observed during the same observation period (19.0% to 18.7%). CONCLUSION: Intrapartum complications such as persistent neonatal brachial plexus injury or fetal death increased the cesarean delivery rate of the obstetrician experiencing these events. Obstetricians should be aware of the effect of these adverse events on their practice of obstetrics.

Spontaneous rectus sheath hematoma during pregnancy mimicking abruptio placenta.

Sudden disruption of a deep epigastric vessel may result in an abdominal wall hematoma, which, depending upon its location and size, can produce symptoms and clinical findings compatible with a variety of acute intra-abdominal conditions. The literature has noted a predominance of pregnant patients among those affected with this malady. Such hematomas are infrequently encountered and early accurate diagnosis could prevent surgical intervention. Unfortunately, the clinical manifestations of rectus muscle hematoma are sometimes so dramatic that laparotomy is performed under the belief that intra-abdominal pathology is present. We present a case of a suspected abruptio placenta misdiagnosed by clinical and ultrasound examination that was subsequently discovered to be a rectus sheath hematoma at the time of surgery.

Modern analysis of pathologic uterine rings.

A computerized medical record search of 61,406 live births from January 1, 1990, through December 31, 1994, identified 14 cases of pathologic uterine rings. This yielded an incidence of pathologic uterine rings of 0.02% of all live births. In a retrospective, matched study design, three control subjects having vaginal delivery and three having cesarean delivery were matched with each case of pathologic uterine ring for age, race, parity, estimated gestational age, single or multiple gestation, primary or repeat cesarean section, and indication for the cesarean delivery. Comparison with controls who had cesarean section showed no significant differences in duration of labor, rupture of membranes, use of oxytocin, or fetal head position. Pathologic uterine rings continue to occur in modern obstetrics, but their reported incidence has decreased. These data suggest that the characteristics of parturition have no clear association with the formation of a pathologic uterine ring.

A retrospective analysis of the effect of antenatal steroid administration on the incidence of respiratory distress syndrome in preterm twin pregnancies.

Respiratory distress syndrome (RDS) is the major cause of morbidity and mortality in preterm twin deliveries. Therapy with corticosteroids has been shown to reduce the incidence of RDS in preterm singleton gestations but similar reductions in twin pregnancies have not been demonstrated. Maternal and neonatal medical records were reviewed from twins delivered between 24 to 34 weeks gestation over the period of January 1, 1990 to December 31, 1994. Twenty-one pairs of twins received optimal steroid treatment defined as the use of two 12 mg doses of betamethasone, with birth occurring between 24 hours and 7 days after the first dose. Sixty-three pairs received no treatment. The mean gestational age at delivery was 29.9 +/- 2.6 weeks. No decrease was seen in the incidence of RDS (optimal steroid 70.7% versus no treatment 68.0%, unadjusted odds ratio [OR] 1.14, 95% confidence interval [CI] 0.49 to 2.65). Multivariate logistic regression showed no statistical difference in the incidence of RDS in the optimal steroid compared to the no treatment group (adjusted OR 0.63, 95% CI 0.2 to 1.95). No statistical differences were noted in the incidence of mechanical ventilation (58.6% versus 55.4%, p = 0.83), median duration of intubation (5.0 versus 5.0 days, p = 0.47), the median maximum inspiratory pressure requirements (20.0 versus 22.0 mm Hg; p = 0.15) in the optimal treatment versus no treatment group, respectively. The current regimen of antenatal corticosteroids utilized in twin pregnancies does not reduce the incidence of RDS.

Myocardial infarction and coronary artery dissection during pregnancy associated with type IV Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) is a rare, genetically transmitted connective tissue disorder which occurs with an incidence of 1 in 5000. Nine subtypes of EDS have been identified, with type IV being associated with sudden death due to rupture of the bowel, uterus, or major blood vessels. We describe a case of a patient with type IV EDS who presented at 30 weeks' gestation with preterm labor which was treated with subcutaneous terbutaline followed by oral maintenance therapy. Approximately 72 hours later she suffered a myocardial infarction, which led to coronary artery dissection and death. This is the first case of type IV EDS in pregnancy that resulted in maternal death due to coronary artery dissection. We suggest that betamimetic tocolytics should be avoided in patients with EDS and preterm labor.

Effect of changing gloves before placental extraction on incidence of postcesarean endometritis.

OBJECTIVE: We sought to determine if changing the surgeon's gloves after delivery of the infant and prior to manual placental removal decreases the incidence of postcesarean endometritis. METHODS: Laboring women undergoing cesarean delivery between September 1, 1994, and August 31, 1995, were prospectively randomized into either a change or no-change glove group. In the change-glove group, the surgeon's gloves were changed after delivery of the infant and before manual removal of the placenta. All patients enrolled received a single prophylactic dose of an IV antibiotic after clamping of the umbilical cord. Endometritis was diagnosed by an oral temperature of > or =38 on 2 occasions at least 6 h apart and >24 h after delivery, uterine tenderness, peripheral blood leukocytosis (> or =15,000 cells/ml), and the exclusion of other foci of infection. In order to detect a reduction in endometritis from 14% to 2%, at P < 0.05 with 80% power, we needed 95 patients in each group. RESULTS: Two hundred twenty-eight women were randomized to 2 groups: 113 were in the change group and 115 in the no-change group. No significant differences were noted between the groups with respect to demographics, duration of labor, length of ruptured membranes, number of vaginal examinations, duration of internal monitoring, length of surgery, blood loss, or infant weight. There was no decrease in the incidence of endometritis between the change group (17.7%) and the no-change group (15.7%) (relative risk 1.1, 95% confidence interval 0.75-1.47). CONCLUSIONS: In this study, the incidence of postcesarean endometritis was not decreased by changing the surgeon's gloves after delivery of the infant but before placental extraction.

Amoxicillin or erythromycin for the treatment of antenatal chlamydial infection: a meta-analysis.

OBJECTIVE: To compare the effectiveness of amoxicillin and erythromycin for the treatment of antenatal Chlamydia trachomatis infection by meta-analysis of available trials involving random assignment of subjects. DATA SOURCES: A computer search of English-language abstracts using MEDLINE and the Cochrane Pregnancy and Childbirth Database (medical subject heading terms: pregnancy, chlamydia, erythromycin, amoxicillin, antenatal antibiotics) was supplemented with a review of the bibliographies of the relevant articles generated by the computer search. METHODS OF STUDY SELECTION: Five trials were identified, four of which met our inclusion criteria for the meta-analysis. DATA EXTRACTION AND SYNTHESIS: Trials to be included in this meta-analysis underwent trial quality evaluation and data abstraction. An estimate of the relative risk (RR) was calculated for the dichotomous outcomes using a fixed-effects model. The pooled RR for the effectiveness of amoxicillin compared with erythromycin was 1.11 (95% confidence interval [CI] 1.05-1.18), and the pooled RR for gastrointestinal side effects of amoxicillin compared with erythromycin was 0.29 (95% CI 0.20-0.42). The pooled RR for gastrointestinal side effects that resulted in discontinuation of therapy of amoxicillin compared with erythromycin was 0.14 (95% CI 0.06-0.36). CONCLUSION: The available data suggest that amoxicillin is more effective than erythromycin for the treatment of antenatal C trachomatis infection and has fewer gastrointestinal side effects, leading to better compliance.

Gastrointestinal hemorrhage during pregnancy in a patient with a history of vertical-banded gastroplasty.

Pregnancy after gastric bypass for morbid obesity is well reported; however, the only maternal complications described have involved nutritional deficiencies. We report a case of gastrointestinal hemorrhage during pregnancy resulting from erosion of a synthetic graft from a vertical-banded gastroplasty performed 4 years previously.

Use of thrombolytics for the treatment of thromboembolic disease during pregnancy.

The incidence of thromboembolic disease is increased during pregnancy. Prevention and treatment of thromboembolic disease can have a significant impact on the morbidity and mortality of pregnant women. Anticoagulation with heparin is the treatment of choice; however, in some instances this is inadequate or contraindicated. In the nonpregnant patient, alternative therapies have included surgical intervention or fibrinolytic agents. Traditionally, thrombolytic therapy has been considered a relative contraindication during pregnancy due to the maternal and fetal risk of hemorrhagic complications. Hence, no controlled trials of agents such as streptokinase, urokinase, or tissue plasminogen activator for the treatment of thromboembolic events during pregnancy, have been performed, or are currently feasible. Since 1961, 36 reports have been published describing the use of thrombolytic agents during pregnancy. In a review of the world's literature, 172 pregnant women affected with thromboembolic conditions were treated with thrombolytic medications. A maternal mortality rate of 1.2 percent was observed. Approximately 10 pregnancy losses were noted (5.8 percent). Hemorrhagic complications were reported in 8.1 percent of patients. We summarize the published literature on the use of thrombolytic agents during pregnancy and discuss the treatment success and reported complications.

Randomized prospective study comparing erythromycin, amoxicillin, and clindamycin for the treatment of chlamydia trachomatis in pregnancy.

OBJECTIVE: The purpose of this study was to compare the efficacy and side effects of erythromycin, amoxicillin, and clindamycin in eradicating Chlamydia trachomatis from the lower genital tract of pregnant women. METHODS: A total of 174 women at <36 weeks gestation with positive cervical cultures for C. trachomatis were enrolled. Patients were assigned in a randomized prospective fashion to either erythromycin (500 mg q.i.d, for 7 days), amoxicillin (500 mg t.i.d, for 7 days), or clindamycin (600 mg t.i.d, for 10 days). Six women elected not to participate and 8 patients were lost to follow-up, leaving 53 patients in the erythromycin group, 55 patients in the amoxicillin group, and 52 patients in the clindamycin group. All sexual partners of the enrolled women were offered doxycycline (100 mg b.i.d. for 7 days) and patients were instructed to use barrier contraception until treatment was complete. RESULTS: All 3 medications were effective agents for the treatment of antenatal C. trachomatis infection with treatment efficacies of 96%, 94%, and 98% for the erythromycin, amoxicillin, and clindamycin groups, respectively. When the antibiotic groups were compared, no statistically significant differences were noted in intolerance. However, the differences in the incidence of gastrointestinal symptoms between erythromycin and amoxicillin and/or clindamycin were significant (P < 0.05). CONCLUSIONS: These findings suggest that 1) all 3 antibiotic regimens are efficacious, 2) erythromycin has a higher incidence of side effects, and 3) amoxicillin or clindamycin are reasonable alternatives for the treatment of C. trachomatis in pregnant patients unable to tolerate erythromycin.

Right atrial thrombus as a complication of total parenteral nutrition in pregnancy.

BACKGROUND: Right atrial thrombus, a rare but potentially fatal complication of central venous catheter use in total parenteral nutrition, has not been reported during pregnancy. CASE: A pregnant woman with persistent hyperemesis gravidarum developed a right atrial thrombus related to central venous catheter use for total parenteral nutrition. CONCLUSION: Right atrial thrombus can be treated successfully with heparin, leading to its resolution and a normal pregnancy outcome.

Recurrent Bandl's ring as an etiology for failed vaginal birth after cesarean section.

A pathologic retraction ring (Bandl's ring) of the uterus is a constriction located at the junction of the thinned lower uterine segment and the thick retracted upper uterine segment that is associated with obstructed labor. The following is the first reported case of recurrent pathologic retraction ring and an attempted vaginal birth after cesarean section following such an abnormality.

von Willebrand factor in lysates of washed canine platelets.

Canine and human platelets (washed 4 times in a solution containing EDTA, prostaglandin E1, and theophylline to prevent release of alpha-granule constituents) were lysed by being frozen and thawed in the presence of detergent. Radioelectroimmunoassay for von Willebrand factor (vWf) in 5 human platelet lysates produced precipitin rockets, shaped like those produced from vWf in plasma from healthy human beings, and indicated that the mean von Willebrand factor antigen (vWf:Ag) content in platelets from healthy human being was 526 +/- 87 human U/10(12) platelets. Radioelectroimmunoassay for vWf in platelet lysates from 17 healthy dogs with normal plasma. vWf:Ag concentration produced precipitin rockets that looked different from those produced from canine plasma and indicated vWf:Ag content of 59 +/- 35 canine U/10(12) platelets. Inclusion of protease inhibitors in the lysing solution did not normalize the appearance of the precipitin rockets or substantially alter the measured platelet content of vWf:Ag. The array of vWf multimers revealed by sodium dodecyl sulfate-agarose gel electrophoresis of canine platelet lysates had a distinct appearance that differed from that of vWf in canine or human plasma and platelets; the intensity of the canine platelet vWf multimer bands was skewed, with relatively greater density in the lower molecular weight region and faint or undetectable multimer bands in the higher molecular weight region. Electrophoretograms with visible multimers in the high molecular weight region had vWf components that had higher molecular weight than did any vWf components in canine plasma. Radioelectroimmunoassay for fibronectin in these same canine platelet lysates indicated that the fibronectin content in platelets was 2.89 +/- 1.10 mg/10(12) platelets.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of desmopressin acetate on bleeding times and plasma von Willebrand factor in Doberman pinscher dogs with von Willebrand's disease.

Effects of desmopressin acetate (1-desamino-8-D-arginine vasopressin [DDAVP]) on plasma von Willebrand factor (vWf) were studied in 12 purebred Doberman pinschers confirmed to have von Willebrand's disease (vWd) (plasma vWf antigen [vWf:Ag] concentrations, less than 30 U/dl). Twelve dogs had subnormal plasma botrocetin cofactor (BCf) activity and 11 dogs had prolonged buccal mucosa bleeding times. Tranquilization of three dogs with lenperone and three dogs with xylazine did not induce significant changes in mean plasma vWf:Ag concentrations or mean BCf activities. Thirty and 120 minutes after administration of DDAVP (1 micrograms/kg subcutaneously), there was significant shortening of the mean buccal mucosa bleeding time. Ten dogs responded to DDAVP with increases in BCf activity which exceeded 10 U/dl at 30 or 120 minutes, or both, after the drug was administered. At the same time, increases in plasma vWf:Ag concentrations were smaller than the increases in BCf activity. It was shown by multimeric analysis that primarily the higher molecular weight forms of vWf increased in plasma in response to DDAVP.

Canine von Willebrand's disease. A heterogeneous group of bleeding disorders.

The term "von Willebrand's disease," refers to a group of inherited bleeding disorders, all of which are caused by a deficiency of the multimeric plasma glycoprotein, von Willebrand factor. The various forms of canine von Willebrand's disease can be categorized into one of three major types: in type I canine von Willebrand's disease, all sizes of von Willebrand factor multimers can be detected in the plasma; in type II canine von Willebrand's disease, only the smaller von Willebrand factor multimers are found in the plasma (larger multimers are absent); and in type III canine von Willebrand's disease, von Willebrand factor is completely absent from the plasma or present in only trace amounts. Von Willebrand's disease is common in dogs, but some forms of the disease are so mild that they are of questionable clinical significance.