Preterm Premature Rupture of Membranes in Twins: Comparison of Rupture in the Presenting Versus Non-presenting Sac.

OBJECTIVE: This study sought to compare the latency from membrane rupture to delivery and subsequent neonatal outcomes in twin gestations complicated by preterm premature rupture of membranes (PPROM) of the presenting versus non-presenting sac. METHODS: This was a retrospective study of twin pregnancies over a 7-year period diagnosed with PPROM between 12 and 37 weeks gestation with a latency period to delivery of >24 hours. The ruptured sac was identified by ultrasound scan. The study compared the latency period from PPROM to delivery and subsequent neonatal morbidity and mortality resulting from rupture of the presenting versus non-presenting sac. Obstetric and neonatal outcomes were evaluated using a matched-cohort subset analysis (Canadian Task Force Classification II-2). RESULTS: During the study period, 77 twin pregnancies diagnosed with PPROM satisfied the inclusion criteria. The mean latency periods from PPROM to delivery were 10.1 days (n = 7) when the presenting sac ruptured and 41.3 days (n = 10) when the non-presenting sac ruptured (P < 0.05). Neonatal death was higher with PPROM of the presenting than the non-presenting sac (21.4% vs. 0%, respectively; P = 0.05). Neonates were more likely to be affected by retinopathy of prematurity (57% vs. 19%; P < 0.05) but less likely to have persistent pulmonary hypertension of the newborn (0% vs. 25%; P < 0.05) when the rupture occurred in the presenting sac. The rates of other neonatal adverse outcomes were similar between the two groups. CONCLUSIONS: In twin gestations there is a longer latency from PPROM to delivery and fewer neonatal complications when rupture occurs in the non-presenting rather than the presenting sac.

Kick-starting action: Canadian women's understanding of fetal movement guidelines.

OBJECTIVE: To determine whether obstetrical patients in a large tertiary-care centre receive counselling, are aware of the proper actions in relation to fetal movement (on the basis of discussion with caregivers, educational pamphlet, or access to any information), have an understanding similar to that prescribed in the SOGC guidelines, and seek timely assessment in the event of decreased fetal movement. METHODS: We surveyed a convenience sample of pregnant women (N = 206) at term between July and October 2011. After collecting demographic and provider information, we assessed patient familiarity with fetal movement counting, including sources, timeliness, counting protocols, and response to decreased fetal movement. We calculated incidence rates, measures of association, and statistical significance by chi-square testing. RESULTS: The majority of patients (147/206 = 71.4%) relied on their care provider for information, and 44.1% of patients were very familiar with fetal movement counting. A majority, 57.8% (119), received timely information, although 8.1% (27) received information late in pregnancy or not at all. Quite consistently amongst subgroups (low vs. high-risk pregnancy, nullipara vs. multipara, patients of varied providers), one third (34.7%, 70/202) of patients had no knowledge or incorrect knowledge of the SOGC guidelines, 35.1% (71/202) had knowledge of fetal movement counting and what to do, while 30.2% (61/202) who knew how to monitor fetal movements did not know how to respond to decreased movement. CONCLUSION: Timely intervention for decreased fetal movement results in a substantial reduction in the rate of stillbirth. Only one third of our patients were both informed and would have sought further investigation for decreased movement. Reinforcing the significance of fetal movement counting in scholarly publications can remind care providers about the importance of informing all patients about this simple, inexpensive, and successful monitoring protocol.

Women's views on elective primary caesarean section.

OBJECTIVE: Elective primary Caesarean section (EPCS), Caesarean section performed at a woman's request in the absence of a recognized obstetrical indication, is becoming increasingly common. Recent articles and opinions in both the medical and lay press have polarized this issue. The purpose of this study was to determine the opinions and choices of nulliparous and multiparous women with respect to mode of delivery. METHODS: All women attending antenatal clinics at Kingston General Hospital from May to August 2005 were invited to participate in a confidential survey. Basic demographic data including maternal age, level of education, parity, and previous mode of delivery were collected. Respondents who had had a previous Caesarean section were excluded from data analysis. The questionnaire provided a written statement of potential benefits and risks of an EPCS compared with vaginal delivery; no other counselling was provided. Respondents were asked if EPCS should be offered to all women and whether they would choose EPCS if given the choice. Respondents were also asked to indicate the most and least influential factors in their decision. RESULTS: Responses were received from 107 nulliparous women and 103 multiparous women. Thirteen percent of nulliparas (14/107) stated that they would choose EPCS if given the option, compared with 5% of multiparas (5/103). Fifty-one percent of nulliparas (55/107) and 28% of multiparas (29/103) believed that EPCS should be offered to all women receiving antenatal care. The most and least important reasons, chosen from a list, for requesting or declining EPCS varied between nulliparas and multiparas. The convenience of scheduling permitted by Caesarean section was not important for either multiparas or nulliparas. The perceived risks of vaginal delivery were commonly cited by both nulliparas and multiparas as reasons for requesting EPCS, whereas the risks of Caesarean section for the baby or for future pregnancies were the most commonly cited reasons to decline EPCS in both groups. Regardless of the decision to request or decline EPCS, cost to the health care system was not an important factor for either nulliparas or multiparas. CONCLUSION: The majority of pregnant women surveyed would not request an EPCS. However, a significant number of pregnant women, both nulliparous and multiparous, felt that women should be given the option of undergoing EPCS.