Risks and complications of tocolysis.

In this article, the author has reviewed available information on maternal, fetal, and neonatal risks and complications of tocolytic therapy. Because no ideal tocolytic agent exists, clinicians must be aware of the potential problems that can be encountered from initiating tocolysis. A variety of tocolytic agents may be effective in delaying preterm delivery. However, whether these agents reduce perinatal morbidity and mortality is debatable. This review emphasizes that serious complications occur from the use of these drugs including maternal, fetal, and neonatal death. Clinicians who use tocolysis, even oral terbutaline, must be aware of the significant side effects associated with these agents. Caution should be exercised not only in their initiation but also in their continuation. Additional research is needed and ongoing to limit the use of tocolytic agents and develop drugs with more efficacy, less risk, fewer complications, and more tolerable means of administration.

Perinatal bacteremia due to group F streptococci.

Perinatal septicemia due to Lancefield groups A, B, C, and G, but not the group F, streptococci have been documented. A case of perinatal bacteremia and septicemia due to group F streptococci is described.

Home uterine activity monitoring.

Despite tremendous improvements in maternal and neonatal care, preterm delivery remains the leading cause of infant mortality. Widespread use of tocolytics and aggressive preterm labor management have had little effect on reducing the overall neonatal mortality. To improve the success of tocolysis and preterm labor management, it is critical that preterm labor be diagnosed prior to significant cervical change. At present, a combination of several components is indicated for successful preterm birth prevention programs. These should include periodic risk assessment, patient education, cervical assessment, daily contact by highly skilled perinatal nurses, daily home uterine activity monitoring, and aggressive patient management. Studies support that this approach results in early detection of preterm labor, subsequently more effective tocolytic therapy and prevention of preterm birth.

Perinatal outcomes of twin pregnancies at term.

A review of a two-year experience in our community disclosed that 57% of twin pregnancies (118/207) deliver at term. Little attention has been focused on perinatal outcomes of twin pregnancies remaining undelivered after 36 completed weeks. Therefore, we reviewed our experience to determine whether our practice should change to maximize perinatal care. Nearly all the study pregnancies (115/117, or 97.5%) delivered by the estimated date of confinement. Fetal malpresentation, failure to progress and the patient's lack of desire for a vaginal birth after cesarean delivery were common reasons for the high cesarean rate (62/117, or 52%). The neonatal outcomes were favorable regardless of the route or interval between deliveries. Discordant fetal growth was found in only eight cases (6.8%). No perinatal deaths occurred, and five-minute Apgar scores less than 7 (2/234, or 0.9%) and rates of anomalies (5/234, or 2.1%) were not different from those in singleton pregnancies delivering during the same period. Using the principles of obstetric practice used in our community, we would expect the perinatal outcomes in term twin gestations to be favorable.

Preventing preterm birth in twin gestation: home uterine activity monitoring and perinatal nursing support.

In this investigation, 45 women with twin gestations in four centers were randomly assigned to either daily home uterine activity monitoring and perinatal nursing support (19) or an education group (26). Patients in the home uterine activity monitoring and perinatal nursing support group monitored uterine activity twice daily, transmitted the data each day, and had 24 hour-a-day access to nursing support. Education patients were counseled regarding the common signs and symptoms of preterm labor. Both groups had scheduled prenatal visits at least every 2 weeks. Sixteen (62%) of the education group and 14 (74%) of the home uterine activity monitoring and perinatal nursing support group developed preterm labor, values that were not significantly different. Of the monitored group who experienced preterm labor, all 14 were dilated 3 cm or less at diagnosis of the first preterm labor, compared with ten of 16 in the education group (P = .01; one-tailed Fisher test). The mean cervical dilatation at the first preterm labor episode in the group receiving daily monitoring and contact (1.6 cm) was significantly less (P = .01) than that in the education group (2.9 cm). Thus, fewer preterm births were recorded in the home uterine activity monitoring and perinatal nursing support group and significantly fewer patients delivered because of failed tocolysis (P = .03).

Home uterine activity monitoring is associated with a reduction in preterm birth.

The value of home uterine activity monitoring plus perinatal nursing support in the prevention of preterm birth among high-risk patients has been demonstrated by several studies. Other reports with less stringent guidelines and less intensive nursing contact have questioned the contribution of home uterine activity monitoring and perinatal nursing support to a preterm birth prevention program. In this large, prospective, randomized multicenter study, patients were assigned to receive either daily monitoring and nursing contact or a preterm birth prevention program including intensive education and more frequent prenatal visits. Among the monitored patients, there was a significant increase in early detection of preterm labor (2 cm or less), successful tocolysis, and prolongation of pregnancy to term. Thirty-one percent of these diagnoses of preterm labor resulted from evaluation of increased uterine activity without associated patient-perceived symptoms. We conclude that a program of daily uterine activity monitoring and perinatal nursing support results in earlier diagnosis of preterm labor and subsequently more effective tocolysis.

Management of preterm labor patients at home: does daily uterine activity monitoring and nursing support make a difference?

Daily home uterine activity monitoring and perinatal nursing support were compared with standard care in managing patients with recurrent preterm labor during the current pregnancy in an effort to reduce preterm birth. Sixty-seven successfully treated preterm labor patients were randomly assigned in this multicenter study to daily home uterine activity monitoring and perinatal nursing support or to a standard-care group. Recurrent preterm labor occurred in 15 (45%) of monitored patients and 19 (56%) of standard-care patients. The risk of preterm birth (before 37 weeks) for patients with recurrent preterm labor was significantly reduced (P = .025) in the monitored group (seven, or 47%) compared with the standard-care group (16, or 84%). The relative risk of delivering because of failed tocolysis was 2.8 for the standard-care group versus the monitored group. There were no patients in the monitored group who delivered at the first recurrence of preterm labor for failed tocolysis. The data suggest that home uterine activity monitoring and perinatal nursing support are helpful in achieving term birth through earlier detection and treatment of recurrent preterm labor.

Home uterine activity monitoring in a rural setting.

Home uterine activity monitoring and daily perinatal nursing contact were used in patients at risk for preterm labor in a rural area using provider consultation with a perinatologist in a tertiary center. In the management of 25 subjects at high risk for preterm delivery, it was noted that the patients had decreased anxiety. They felt that the service was beneficial to them and allowed them to stay in their local area. The providers felt confident that this daily contact allowed them to manage the patients without transfer to the tertiary center. Likewise, concerning women who developed preterm labor, the physicians were confident that the diagnosis would be early enough that transport, if necessary, could be carried out safely. Finally, the physicians felt that verbal reassurance from the perinatologist and weekly written contact with the monitoring service facilitated local management of such patients, particularly as it concerned administration of tocolytic agents.

Uterine activity compared with symptomatology in the detection of preterm labor.

The relative contribution of uterine activity obtained by home monitoring with a guard ring tocodynamometer compared with seven specific signs and symptoms reported during patient/nurse contact as an aid in detecting preterm labor has not been studied. In this prospective, multicenter study, patients at risk for developing early labor who were randomized to receive home uterine activity monitoring and perinatal nursing support were assessed. The initiator of provider contact (uterine activity detected on routine transmission, patient-perceived signs and symptoms of preterm labor during perinatal nurse contact, or both) resulting in a diagnosis of preterm labor was recorded. Contraction data were then analyzed for an association with preterm labor. There was a strong association of increased uterine activity (four or more contractions per hour) on a repeat monitoring strip with preterm labor (P less than .001). Among patients diagnosed with preterm labor, 31% had increased uterine activity detected on a routine transmission without patient-reported signs and symptoms, compared with 24% who were diagnosed as the result of patient-reported symptoms without increased uterine activity. Daily objective uterine activity data alone have greater incremental value over and above other signs and symptoms as an aid to the physician in diagnosing preterm labor.

The contribution of symptomatology and/or uterine activity to the incidence of unscheduled visits.

Home uterine activity monitoring and perinatal nursing support have been shown to be associated with a decrease in preterm births with no increase in the number of unscheduled patient visits. This prospective, randomized multicenter study compared the frequency of unscheduled visits in patients receiving home uterine activity monitoring and perinatal nursing support with that of patients receiving education regarding the detection and reporting of preterm labor symptomatology. The contribution of patient-reported signs and symptoms versus objective uterine activity data to unscheduled visits is assessed. The overall frequency of unscheduled visits was similar in both groups. In the home uterine activity monitoring and perinatal nursing support group, the contributions of uterine activity versus signs and symptoms to the diagnosis of preterm labor were equal, with 36% of patients diagnosed with preterm labor sent to the physician for increased uterine activity and 36% for signs and symptoms. The sensitivity for the group receiving monitoring and nursing support in detecting preterm labor was 93%. The majority of false-positive visits were associated with patient symptoms. These data show that this combination service does not lead to a clinically significant increase in unscheduled visits. Further, the visits resulting from the combination service provide a sensitive predictive method to aid physicians in detecting early labor.

Relationship of uterine contractility to preterm labor.

An increased uterine contraction rate is associated with preterm labor. The contraction rate in individual patients, however, has not been evaluated critically as to its predictive value in forecasting early labor. In this randomized multicenter study, 105 patients at high risk for preterm delivery monitored their contraction rate at home on a daily basis. An analysis was conducted to determine the association of at least four contractions per hour on a routine strip followed by at least four contractions per hour on a repeat tracing with subsequent preterm labor. Using this threshold, 70% of the patients were correctly classified. This contraction rate resulted in a sensitivity of 57%, a specificity of 80%, a positive predictive value of 72%, and a negative predictive value of 68%. A threshold rate of at least four contractions per hour on a remonitor strip identifies a patient at increased risk for preterm labor (P = .003).

Let's get rid of the term "Braxton Hicks contractions".

The early detection of preterm labor and the prevention of preterm birth require special attention to early subtle signs and symptoms of preterm labor. The concept of "Braxton Hicks contractions" may negate these early signs and symptoms by falsely reassuring patients, thus encouraging them not to seek medical care promptly.

Insulin-like growth factors in fetal macrosomia with and without maternal diabetes.

Insulin-like growth factors (IGFs/somatomedins) have been implicated as regulators of fetal growth. This study investigates whether IGFs are related to macrosomia in infants of normal or insulin-dependent diabetic mothers. Cord concentrations of IGF-I (radioimmunoassay), total IGF (radioreceptor assay) and IGF binding protein (radiobinding assay) were measured in 15 term infants of diabetic mothers (IDM) and 29 term infants of nondiabetic mothers. In infants of control mothers cord IGF and total IGF levels were significantly higher in large-for-gestational-age than appropriate-for-gestational-age infants; but this relationship was lost in IDM, in whom IGF-I concentrations were similar to control infants. IGF binding protein levels were not significantly different in any of these groups. The absence of elevated IGF levels in macrosomic IDM indicates that the pathologic process does not involve a simple increase in these growth factors.