A randomized controlled trial comparing oxytocin administration before and after placental delivery in the prevention of postpartum hemorrhage.

OBJECTIVE: To determine if the timing of the administration of prophylactic oxytocin influences the incidence of postpartum hemorrhage caused by uterine atony, retained placenta, and third-stage duration. STUDY DESIGN: Parturients who presented for vaginal delivery were randomized in a double-blinded fashion to receive oxytocin, 20 units in a 500-mL crystalloid intravenous bolus, beginning upon delivery of either the fetal anterior shoulder or placenta. For all patients, the third stage of labor was managed with controlled cord traction until placental expulsion, followed by at least 15 seconds of fundal massage. Patients were excluded if they had a previous cesarean section, multiple gestation, antepartum hemorrhage, or bleeding disorder. RESULTS: A total of 1486 patients were enrolled: 745 in the before-placenta group and 741 in the after-placenta group. The groups were similar with respect to gestational age, fetal weight, labor duration, maternal age, parity, and ethnicity. The incidence of postpartum hemorrhage did not differ significantly between the two groups (5.4% vs 5.8%; crude OR, 0.92; 95% CI, 0.59 to 1.43). There were no significant differences between the two groups with respect to incidence of retained placenta (2.4% vs 1.6%; OR, 1.49; 95% CI, 0.72 to 3.08), or third-stage duration (7.7 minutes vs 8.1 minutes; P =.23). CONCLUSIONS: The administration of prophylactic oxytocin before placental delivery does not reduce the incidence of postpartum hemorrhage or third-stage duration, when compared with giving oxytocin after placental delivery. Early administration, however, does not increase the incidence of retained placenta.

Secretory component in human amniotic fluid and gestational tissues: a potential endogenous phospholipase A2 inhibitor.

OBJECTIVES: Prostaglandins (PGs) are essential mediators of labor during human pregnancy. Phospholipase A2 (PLA2) provides the essential substrate for PG synthesis through the liberation of arachidonic acid from membrane phospholipid stores. Nonlaboring amniotic fluid (NL-AF) contains secretory component (SC)-like protein(s) that suppress in vitro PLA2 activity. This study characterizes the biologic activity, identity, and tissue distribution of these protein(s) in NL-AF and gestational tissues. METHODS: Third-trimester NL-AF was collected by amniocentesis, fractionated by ammonium sulfate precipitation, and submitted to an in vitro PLA2 assay. Identity of the PLA2 inhibitor in NL-AF was confirmed by Western blot and antibody neutralization studies. Secretory component-immunoreactive proteins were purified by immunoaffinity chromatography and visualized by sodium dodecyl sulfate-gel electrophoresis. Tissue distribution of SC in gestational tissues was determined by immunohistochemistry. RESULTS: The 100% pellet and supernatant fractions of NL-AF suppressed PLA2 activity, and this activity was neutralized by a polyclonal antibody to SC. Western blot studies revealed an SC-reactive protein in the 70-80-kD range in the 100% pellet fraction of NL-AF. Two SC-reactive proteins were detected in the 60-80-kD range in the eluate from the SC immunoaffinity column, along with minor proteins of 30 and greater than 100 kD. Immunohistochemical studies revealed SC in placental trophoblast, amniotic membranes, and decidual epithelium. CONCLUSIONS: These results demonstrate that proteins homologous to SC are present in human gestational tissues and possess anti-PLA2 activity. These proteins may contribute to the maintenance of pregnancy by suppressing local PG production.

Premature rupture of membranes at 34 to 37 weeks' gestation: aggressive versus conservative management.

OBJECTIVE: Our purpose was to compare induction of labor with preterm rupture of membranes between 34 and 37 weeks' gestation with expectant management. STUDY DESIGN: In this prospective investigation 120 gravid women at > or = 34 weeks 0 days and < 36 weeks 6 days of gestation were randomized to receive oxytocin induction (n = 57) or observation (n = 63). RESULTS: Estimated gestational age at rupture of membranes (34.3 +/- 1.4 weeks vs 34.5 +/- 1.4 weeks) and ultrasonographically estimated fetal weight (2230 +/- 321 gm vs 2297 +/- 365 gm) were equivalent between groups (not significant). Chorioamnionitis occurred more often (16% vs 2%, p = 0.007), and maternal hospital stay (5.2 +/- 6.8 days vs 2.6 +/- 1.6 days, p = 0.006) was significantly longer in the control group. Neonatal sepsis was also more common in the observation group (n = 3) than among induction patients (n = 0), but the difference was not statistically significant. CONCLUSION: Aggressive management of preterm premature rupture of the membranes at > or = 34 weeks 0 days of gestation by induction of labor is safe for the infant in our population and avoids maternal-neonatal infectious complications.

Premature rupture of membranes at term with an unfavorable cervix: comparison of expectant management, vaginal prostaglandin, and oxytocin induction.

BACKGROUND: Our objective was to determine the best treatment for parturients at term with an unfavorable cervix and premature rupture of membranes (PROM). METHODS: In this prospective study, 96 women with PROM and an unfavorable cervix were randomized into one of three treatment groups: oxytocin induction, vaginal prostaglandin E2 gel followed by oxytocin, or expectant management. RESULTS: Length of labor, cesarean section rate, and maternal/neonatal morbidity were not significantly different. In contrast, the interval from PROM until delivery and length of hospital stay were significantly longer in the expectantly managed group than in the other groups. Four of the patients who received expectant management required delivery because of nonreassuring fetal assessments. CONCLUSIONS: Expectant management of PROM at term significantly prolongs hospital stay without decreasing the incidence of abdominal delivery or infectious morbidity. There appears to be potential for cord compression in patients managed expectantly without continuous electronic fetal surveillance.

Amniotic fluid interleukin-6 and interleukin-8 levels predict the success of tocolysis in patients with preterm labor.

OBJECTIVE: To determine whether the levels of the cytokines interleukin-6 (IL-6) and IL-8 in amniotic fluid identify patients with preterm labor who are resistant to tocolysis. METHODS: Amniocenteses were performed in 23 women with documented preterm labor at 20-32 weeks' gestational age who were treated subsequently with tocolytics. The concentrations of IL-6 and IL-8 in amniotic fluid were determined by double-antibody radioimmunoassay methods using recombinant human IL standards. RESULTS: Of the 23 patients, five failed to respond to tocolysis (four delivered within 48 hours), and of the remaining 18, all delivered more than 9 days after tocolysis was initiated (mean 31 +/- 10 days; range 9-61). In women who had failed tocolysis, discriminatory concentrations of IL-6 and IL-8 were 20 and 15 ng/mL, respectively. Of the patients who had amniotic fluid concentrations higher than these thresholds, all failed tocolysis (100% positive predictive value) and delivered within 6 days. The patients with levels below these discriminatory concentrations had successful tocolysis, and 17 of 18 delivered more than 2 weeks after treatment (95% negative predictive value). CONCLUSION: The success of tocolysis and thus delivery remote from an episode of preterm labor is associated with discriminatory amniotic fluid IL-6 and IL-8 levels of less than 20 and less than 15 ng/mL, respectively. If the immunologic response that causes the release of IL-6 and IL-8 has not occurred, the likelihood of successful tocolysis is extremely high. However, if both IL-6 and IL-8 are elevated, tocolysis is likely to fail and delivery may occur within 48 hours.

Tocolysis for recurrent preterm labor using a continuous subcutaneous infusion pump.

This study attempted to determine the best method of treatment for patients with recurrent preterm labor: administration of terbutaline via an automated, programmable, subcutaneous infusion pump or oral terbutaline. In this retrospective, controlled study, 32 patients diagnosed with recurrent preterm labor, as determined by persistent uterine contractions with cervical change, were treated with a programmable infusion pump adjusted to control uterine contraction frequency to < or = 4 contractions per hour. Patients in this group were matched for age, race, parity, gestational age and cervical dilation at diagnosis of recurrent preterm labor in subjects taking oral terbutaline. The patients receiving oral terbutaline were given an average of 6.5 mg every four to six hours to maintain uterine quiescence, while those in the pump group were given basal rates of terbutaline and in addition received four to six boluses per day (< 3 mg/d total dose) to achieve this outcome. Patients using the pump were more likely to reach term and less likely to fail tocolytic therapy than were those taking oral terbutaline. The terbutaline pump appeared to be more successful in prolonging pregnancies to term after the diagnosis of recurrent preterm labor than did oral terbutaline.

Blood loss at time of cesarean section by method of placental removal and exteriorization versus in situ repair of the uterine incision.

The current study was undertaken to determine if blood loss at the time of cesarean section is affected by method of placental removal (spontaneous versus extracted) or uterine position for repair (in situ versus exteriorized). This prospective randomized study involved 100 women who were undergoing a cesarean section. The patients were placed into one of four groups--1, spontaneous placenta detachment, in situ uterine repair; 2, spontaneous placental detachment, exteriorized uterine repair; 3, manual placental removal, in situ uterine repair, and 4, manual placental removal, exteriorized uterine repair. Patients with spontaneous placental separation (groups 1 and 2) compared with manual removal (groups 3 and 4) revealed a significant decrease in blood loss (p < 0.001). Uterine position did not significantly affect blood loss in the spontaneous group (1 and 2; p = 0.971) or the manual placental removal groups (3 and 4; p = 0.061). The hematocrit values for all groups were similar preoperatively, but postoperatively, were significantly lower in the manual removal groups when compared with the spontaneous placental separation groups (p < 0.001). The method of placental removal and not the position of the uterus at the time of its repair has a significant role in blood loss during cesarean birth.

Neonatal morbidity between 34 and 37 weeks' gestation.

The objective of this study was to determine the risk of significant neonatal morbidity in women with preterm labor who deliver between 34 and 37 weeks' gestation. A total of 101 women between 34 and 37 weeks' gestation with documented preterm labor met inclusion and exclusion criteria; 90 gave informed consent and were randomly assigned to receive either intravenous magnesium tocolysis (treatment group) or conservative management with hydration, sedation, and observation (control group). Of the 90 women entering the study (45 in the treatment group and 45 in the control group), 2 discontinued tocolytic therapy because of gastrointestinal side effects. The gestational age on admission, cervical dilatation at diagnosis of preterm labor, interval to delivery, and birth weight were not significantly different between the treatment and control groups. There were no serious neonatal complications. In each group, three women had transient tachypnea and one had respiratory distress syndrome. We conclude that neonatal morbidity after delivery between 34 and 37 weeks' gestation is unchanged whether or not attempts to arrest labor are unsuccessful. The extra expense and maternal risk of tocolysis are not justified by beneficial results in the infant.

Pregnancy in a woman with an automatic implantable cardioverter-defibrillator. A case report.

Two years after insertion of an automatic implantable cardioverter-defibrillator, a 33-year-old woman had an uneventful cesarean delivery.

Oncofetal fibronectin in patients with false labor as a predictor of preterm delivery.

OBJECTIVE: Our objective was to determine whether fetal fibronectin is a discriminator for preterm labor and early delivery in women who have intact membranes and uterine activity. STUDY DESIGN: In our prospective study 28 women between 24 and 34 weeks' gestation with regular, persistent uterine contractions (> 10/hr) and intact membranes were assessed for presence of fetal fibronectin. A Dacron swab was applied to the external os for 10 seconds. The cervix was < or = 1 cm, and all patients were diagnosed as having false labor. The assay was performed by using monoclonal antibody FDC-6 to bind fetal fibronectin. RESULTS: Of the 28 patients with false labor, 14 had a positive fetal fibronectin, and all had preterm labor (specificity and positive predictive value 100%). Of these, nine delivered preterm, yielding a specificity and positive predictive value of 72% and 64%, respectively. Among the 14 women with a negative fetal fibronectin, only four developed preterm labor (sensitivity 78%, negative predictive value 71%). One patient delivered preterm at 34 weeks (sensitivity 90% and negative predictive value 93%). CONCLUSIONS: A positive fetal fibronectin in women who have false labor indicates a significant risk for preterm labor and early delivery. A negative fetal fibronectin is a reassuring sign.

Neurologic diseases in pregnancy.

Although most neurologic problems require conservative management, such as headaches and nerve compression syndromes, other demand aggressive treatment, such as plasmapheresis in Guillain-Barré syndrome and prompt surgery in those patients with hemorrhagic strokes secondary to a ruptured aneurysm or arteriovenous malformation. Myasthenia gravis, discussed in the autoimmune disease section, and epilepsy are associated with congenital anomalies, whereas the progeny of patients with multiple sclerosis are at a much greater risk than the general population of contracting this disease. Therefore, knowledge of these risks is essential in providing quality preconceptional counseling. Pregnancy provides many physiologic changes that alter the course of preexisting neurologic conditions as well as increasing the risks and morbidity of other diseases. It is for this reason that a cooperative team effort, including the obstetrician, neurologist, and, if needed, the neurosurgeon, is essential for an optimal outcome.

Interval to delivery in high-risk patients: do tocolytic agents really work?

Some question whether tocolytic drugs reduce uterine activity and prolong gestation. The interval from discontinuance of tocolytics until spontaneous labor and delivery in patients (n = 69) with documented preterm labor (PTL) versus subjects receiving prophylactic tocolytic therapy (n = 41) was studied. Women with documented PTL delivered sooner after cessation of tocolytics (6.1 +/- 6.9 days) than control (C) patients (14.7 +/- 10.8 days, P less than 0.001). Also, 28 of the 69 (41%) patients in the PTL group delivered within 24 h of discontinuation of tocolysis compared to 4 (10%) in the C group (P less than 0.0004). We conclude that tocolytic therapy for documented preterm labor suppresses uterine activity and when these agents are discontinued, contractions return and labor ensues.

Subcutaneous tocolytic infusion therapy for patients at very high risk for preterm birth.

Patients with multiple gestations or recalcitrant preterm labor are at very high risk for preterm birth in spite of adequate tocolysis. Subcutaneous infusion of tocolytic medications on an ambulatory basis has been used in several small series and has effectively prolonged gestation. This retrospective analysis presents data from 992 patients at very high risk for preterm delivery who were prescribed this therapy. The amount of tocolytic medication was individualized by utilizing the patient's volume of distribution and clearance. Pharmacists adjusted the dosage based on uterine activity strips received by nursing personnel. The average basal rate was .073 +/- .020 mg/h. Patients received an average of seven scheduled boluses per day and 1.54 +/- .93 unscheduled boluses per week (.25 +/- .03 mg each). The therapy extended the gestation a mean of 38 +/- 23 days and average gestational age at delivery was 36.3 +/- 2.6 weeks with a mean birthweight of 2759 +/- 681 g. This study, utilizing a large number of patients, confirms earlier reports that for women at very high risk for preterm delivery subcutaneous tocolytic infusion therapy is beneficial. Prospective studies evaluating such treatment on a randomized basis are indicated.

Effect of pregnancy on the accuracy of light-reflection rheography.

Light-reflection rheography is a noninvasive method to detect venous obstruction by indirectly measuring venous emptying time. In nonpregnant women it has greater than 90% sensitivity when compared with venography but has not been tested during gestation. To determine if the nonthrombotic occlusion of venous outflow by the pregnant uterus might alter the performance of light-reflection rheography, we examined 17 normal patients with a vascular Accuscan (Hemodynamics, Inc., Boca Raton, Fla.) in the third trimester of pregnancy and 11 patients during the early second trimester. These results were compared with the defined normal (nonpregnant) rate of venous emptying (slope 0.54 +/- 0.06). The mean (+/- SD) for the entire sample was 0.58 +/- 0.23 mm/sec in the right leg and 0.52 +/- 0.19 mm/sec in the left leg measured in the standard sitting position (p = 0.21). The results did not vary with gestational age. A subset of patients in late pregnancy were used to compare the effect of various positions (supine, lateral decubitus, and sitting) on test performance. Positions other than sitting provided results that were inconsistent. It appears that the large pregnant uterus does not significantly obstruct venous outflow from the lower extremities in the standard sitting position; thus the results of light-reflection rheography are not affected. Comparison of light-reflection rheography versus venography in pregnant patients with suspected venous thrombosis is being investigated.

Cordocentesis (funipuncture) by maternal-fetal fellows: the learning curve.

One hundred cordocenteses were attempted at the University of Mississippi Medical Center between July 1, 1989, and June 1, 1991. There were 1.3 attempts for each successful umbilical blood sampling. The overall success rate was 94%. The first-year fellows-in-training attempted 61 procedures with a 90.2% success rate within two attempts and an overall success rate of 95.1%. Second-year fellows attempted 32 procedures with a 93.8% success rate within two attempts and an overall success rate of 93.8%. Procedure-related complications included five episodes of fetal bradycardia (one resulting in a stillbirth at 20 weeks) and a single case of chorioamnionitis. Of the three perinatal deaths, two were associated with severe congenital anomalies resulting in a corrected procedure-related mortality rate of 1%. The morbidity and mortality associated with cordocentesis appears to be relatively low and fellows-in-training can perform such procedures with no apparent increase in complications if appropriately supervised.

A comparison study of pain associated with endocervical sampling techniques.

Endocervical curettage (ECC) is an important tool in the diagnosis and treatment of cervical neoplasia. Its use has been limited, however, because of the pain it can cause. We show that the use of a soft plastic curette cause statistically less pain without compromising the quantity or quality of the sample.