A scoring system for the prediction of successful delivery in low-risk birthing units.

OBJECTIVE: To establish and test the effectiveness of a low-risk scoring system to predict obstetric outcome for the selection of women suitable for confinement in low-intervention units. METHODS: Retrospective analyses were performed on data from 2900 women enrolled in the Western Australian Pregnancy Cohort Study and 1353 women managed at a midwifery-based birth center. A combination of the principal predictors of obstetric outcome, incorporating a previously published scoring system and various clinical features, was used to exclude high-risk cases at 18 weeks' and 36 weeks' gestation. Stepwise multivariate logistic regression analyses of the remaining pregnancies then produced a low-risk scoring system. RESULTS: This system predicted a 55% chance of an uncomplicated delivery in a midwifery-based setting after allocating 54% of women to the low-risk category. It predicted an 82% chance of an uncomplicated delivery in a primary medical care setting with the allocation of 84% of women as low risk. CONCLUSION: The results of this study suggest that adding induction and augmentation of labor, together with low pelvic instrumental delivery, to the treatment options in a low-intervention unit would raise the rate of successful confinement within the unit from 55% to 82%. Our scoring system now requires prospective evaluation to further assess its clinical value.

A hepatic ectopic pregnancy treated with direct methotrexate injection.

PIP: A 32-year-old mother presented at King Edward Memorial Hospital for Women in Subiaco, Western Australia, with a 30-day history of strong, perpetual epigastric pain with nausea and a 14-day history of light vaginal bleeding. Even though she had a positive pregnancy test (human chorionic gonadotropin [hCG] level = 18,000 IU/l), ultrasound found no intrauterine pregnancy and suggested a left adnexal mass. She had a normal sized uterus, closed cervical os, and no cervical excitation. Laparoscopy revealed normal Fallopian tubes, a corpus luteal cyst on the left ovary, about 20 ml of old blood in the pouch of Douglas, and no apparent ectopic pregnancy. She was discharged 2 days after the nausea had subsided. She returned the day after discharge with right iliac fossa pain and syncope. Her hemoglobin value was down to 10.5 g/l from 11.8 g/l. Ultrasound revealed a small mass (2.2 x 2.3 cm) in the caudate lobe of the liver near the neck of the gallbladder. A laparotomy was performed. The surgeon explored and divided the fibrinous adhesions posterior to the neck of the gallbladder. An unruptured ectopic pregnancy (1.5 cm in diameter with an embryo within the sac) was implanted on the inferior surface of the liver and the structures of the porta hepatis. Since surgical removal of the ectopic pregnancy would be dangerous, the surgeon infiltrated the ectopic bed with POR-8 diluted with normal saline and injected 20 mg of methotrexate directly into the sac. The woman was discharged 10 days postoperatively. By day 26 postoperatively, hCG levels had fallen to 20. Hepatic ectopic pregnancy is very rare and is difficult to diagnose. This case was managed differently from hepatic ectopic pregnancy cases in the literature, which necessitated omental grafts, oversewing of the liver, and ligature of the right hepatic artery. Direct injection of methotrexate has the advantage of a reduced dosage and reduced risk of toxicity.^ieng