Neonatal outcomes and operative vaginal delivery versus cesarean delivery

We compared outcomes for neonates with forceps-assisted, vacuum-assisted, or cesarean delivery in the second stage of labor. This is a secondary analysis of a randomized trial in laboring, low-risk, nulliparous women at >or=36 weeks' gestation. Neonatal outcomes after use of forceps, vacuum, and cesarean were compared among women in the second stage of labor at station +1 or below (thirds scale) for failure of descent or nonreassuring fetal status. Nine hundred ninety women were included in this analysis: 549 (55%) with an indication for delivery of failure of descent and 441 (45%) for a nonreassuring fetal status. Umbilical cord gases were available for 87% of neonates. We found no differences in the base excess (P = 0.35 and 0.78 for failure of descent and nonreassuring fetal status) or frequencies of pH below 7.0 (P = 0.73 and 0.34 for failure of descent and nonreassuring fetal status) among the three delivery methods. Birth outcomes and umbilical cord blood gas values were similar for those neonates with a forceps-assisted, vacuum-assisted, or cesarean delivery in the second stage of labor. The occurrence of significant fetal acidemia was not different among the three delivery methods regardless of the indication.

Second trimester cervical length and risk of preterm birth in women with twin gestations treated with 17-α hydroxyprogesterone caproate

OBJECTIVE

To compare rates of preterm birth before 35 weeks based on cervical length measurement at 16-20 weeks in women with twin gestations who received 17-α hydroxyprogesterone caproate (17OHPC) or placebo.

METHODS

This is a secondary analysis of a randomised, double-blind, placebo-controlled trial of twin gestations exposed to 17OHPC or placebo. Baseline transvaginal ultrasound evaluation of cervical length was performed prior to treatment assignment at 16-20 weeks. Cervical length measurements were categorised according to the 10th, 25th, 50th and 75th percentiles in the women studied. The effect of 17OHPC administration in women with a short (25th percentile) and long (75th percentile) cervix was evaluated.

RESULTS

Of 661 twin gestations studied, 221 (33.4%) women enrolled at 11 centers underwent cervical length measurement. The 10th, 25th, 50th, 75th percentiles for cervical length at 16-20 weeks were 32, 36, 40 and 44 mm, respectively. The risk of preterm birth <35 weeks was increased in women with a cervical length <25th percentile (55.8 vs. 36.9%, p=0.02). However, a cervical length >75th percentile at this gestational age interval was not protective for preterm birth (36.5 vs. 42.9%, p=0.42). Administration of 17OHPC did not reduce preterm birth before 35 weeks among those with either a short or a long cervix (64.3 vs. 45.8%, p=0.18 and 38.1 vs. 35.5%, p=0.85, respectively).

CONCLUSION

Women with twin gestations and a cervical length below the 25th percentile at 16-20 weeks had higher rates of preterm birth. In this subgroup of women, 17 OHPC did not prevent preterm birth before 35 weeks gestation. A cervical length above the 75th percentile at 16-20 weeks did not significantly reduce the risk of preterm birth in this high risk population.

Vitamins C and E to prevent complications of pregnancy-associated hypertension

BACKGROUND

Oxidative stress has been proposed as a mechanism linking the poor placental perfusion characteristic of preeclampsia with the clinical manifestations of the disorder. We assessed the effects of antioxidant supplementation with vitamins C and E, initiated early in pregnancy, on the risk of serious adverse maternal, fetal, and neonatal outcomes related to pregnancy-associated hypertension.

METHODS

We conducted a multicenter, randomized, double-blind trial involving nulliparous women who were at low risk for preeclampsia. Women were randomly assigned to begin daily supplementation with 1000 mg of vitamin C and 400 IU of vitamin E or matching placebo between the 9th and 16th weeks of pregnancy. The primary outcome was severe pregnancy-associated hypertension alone or severe or mild hypertension with elevated liver-enzyme levels, thrombocytopenia, elevated serum creatinine levels, eclamptic seizure, medically indicated preterm birth, fetal-growth restriction, or perinatal death.

RESULTS

A total of 10,154 women underwent randomization. The two groups were similar with respect to baseline characteristics and adherence to the study drug. Outcome data were available for 9969 women. There was no significant difference between the vitamin and placebo groups in the rates of the primary outcome (6.1% and 5.7%, respectively; relative risk in the vitamin group, 1.07; 95% confidence interval [CI], 0.91 to 1.25) or in the rates of preeclampsia (7.2% and 6.7%, respectively; relative risk, 1.07; 95% CI, 0.93 to 1.24). Rates of adverse perinatal outcomes did not differ significantly between the groups.

CONCLUSIONS

Vitamin C and E supplementation initiated in the 9th to 16th week of pregnancy in an unselected cohort of low-risk, nulliparous women did not reduce the rate of adverse maternal or perinatal outcomes related to pregnancy-associated hypertension (ClinicalTrials.gov number, NCT00135707).

A multicenter, randomized trial of treatment for mild gestational diabetes

BACKGROUND

It is uncertain whether treatment of mild gestational diabetes mellitus improves pregnancy outcomes.

METHODS

Women who were in the 24th to 31st week of gestation and who met the criteria for mild gestational diabetes mellitus (i.e., an abnormal result on an oral glucose-tolerance test but a fasting glucose level below 95 mg per deciliter [5.3 mmol per liter]) were randomly assigned to usual prenatal care (control group) or dietary intervention, self-monitoring of blood glucose, and insulin therapy, if necessary (treatment group). The primary outcome was a composite of stillbirth or perinatal death and neonatal complications, including hyperbilirubinemia, hypoglycemia, hyperinsulinemia, and birth trauma.

RESULTS

A total of 958 women were randomly assigned to a study group--485 to the treatment group and 473 to the control group. We observed no significant difference between groups in the frequency of the composite outcome (32.4% and 37.0% in the treatment and control groups, respectively; P=0.14). There were no perinatal deaths. However, there were significant reductions with treatment as compared with usual care in several prespecified secondary outcomes, including mean birth weight (3302 vs. 3408 g), neonatal fat mass (427 vs. 464 g), the frequency of large-for-gestational-age infants (7.1% vs. 14.5%), birth weight greater than 4000 g (5.9% vs. 14.3%), shoulder dystocia (1.5% vs. 4.0%), and cesarean delivery (26.9% vs. 33.8%). Treatment of gestational diabetes mellitus, as compared with usual care, was also associated with reduced rates of preeclampsia and gestational hypertension (combined rates for the two conditions, 8.6% vs. 13.6%; P=0.01).

CONCLUSIONS

Although treatment of mild gestational diabetes mellitus did not significantly reduce the frequency of a composite outcome that included stillbirth or perinatal death and several neonatal complications, it did reduce the risks of fetal overgrowth, shoulder dystocia, cesarean delivery, and hypertensive disorders. (ClinicalTrials.gov number, NCT00069576.)

The effect of 17-alpha hydroxyprogesterone caproate on the risk of gestational diabetes in singleton or twin pregnancies

OBJECTIVE

To compare the rates of gestational diabetes among women who received serial doses of 17-alpha hydroxyprogesterone caproate vs placebo.

STUDY DESIGN

Secondary analysis of 2 double-blind randomized placebo-controlled trials of 17-alpha hydroxyprogesterone caproate given to women at risk for preterm delivery. The incidence of gestational diabetes was compared between women who received 17-alpha hydroxyprogesterone caproate or placebo.

RESULTS

We included 1094 women; 441 had singleton and 653 had twin gestations. Combining the 2 studies, 616 received 17-alpha hydroxyprogesterone caproate and 478 received placebo. Among singleton and twin pregnancies, rates of gestational diabetes were similar in women receiving 17-alpha hydroxyprogesterone caproate vs placebo (5.8% vs 4.7%; P = .64 and 7.4% vs 7.6%; P = .94, respectively). In the multivariable model, progesterone was not associated with gestational diabetes (adjusted odds ratio, 1.04; 95% confidence interval, 0.62-1.73).

CONCLUSION

Weekly administration of 17-alpha hydroxyprogesterone caproate is not associated with higher rates of gestational diabetes in either singleton or twin pregnancies.

Prevention of preterm birth in triplets using 17 alpha-hydroxyprogesterone caproate: a randomized controlled trial

OBJECTIVE

To assess whether 17 alpha-hydroxyprogesterone caproate reduces the rate of preterm birth in women carrying triplets.

METHODS

We performed this randomized, double-blinded, placebo-controlled trial in 14 centers. Healthy women with triplets were randomly assigned to weekly intramuscular injections of either 250 mg of 17 alpha-hydroxyprogesterone caproate or matching placebo, starting at 16-20 weeks and ending at delivery or 35 weeks of gestation. The primary study outcome was delivery or fetal loss before 35 weeks.

RESULTS

One hundred thirty-four women were assigned, 71 to 17 alpha-hydroxyprogesterone caproate and 63 to placebo; none were lost to follow-up. Baseline demographic data were similar in the two groups. The proportion of women experiencing the primary outcome (a composite of delivery or fetal loss before 35 0/7 weeks) was similar in the two treatment groups: 83% of pregnancies in the 17 alpha-hydroxyprogesterone caproate group and 84% in the placebo group, relative risk 1.0, 95% confidence interval 0.9-1.1. The lack of benefit of 17 alpha-hydroxyprogesterone caproate was evident regardless of the conception method or whether a gestational age cutoff for delivery was set at 32 or 28 weeks.

CONCLUSION

Treatment with 17 alpha-hydroxyprogesterone caproate did not reduce the rate of preterm birth in women with triplet gestations.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00099164

LEVEL OF EVIDENCE

I.

A trial of 17 alpha-hydroxyprogesterone caproate to prevent prematurity in twins

BACKGROUND

In singleton gestations, 17 alpha-hydroxyprogesterone caproate (17P) has been shown to reduce the rate of recurrent preterm birth. This study was undertaken to evaluate whether 17P would reduce the rate of preterm birth in twin gestations.

METHODS

We performed a randomized, double-blind, placebo-controlled trial in 14 centers. Healthy women with twin gestations were assigned to weekly intramuscular injections of 250 mg of 17P or matching placebo, starting at 16 to 20 weeks of gestation and ending at 35 weeks. The primary study outcome was delivery or fetal death before 35 weeks of gestation.

RESULTS

Six hundred sixty-one women were randomly assigned to treatment. Baseline demographic data were similar in the two study groups. Six women were lost to follow-up; data from 655 were analyzed (325 in the 17P group and 330 in the placebo group). Delivery or fetal death before 35 weeks occurred in 41.5% of pregnancies in the 17P group and 37.3% of those in the placebo group (relative risk, 1.1; 95% confidence interval [CI], 0.9 to 1.3). The rate of the prespecified composite outcome of serious adverse fetal or neonatal events was 20.2% in the 17P group and 18.0% in the placebo group (relative risk, 1.1; 95% CI, 0.9 to 1.5). Side effects of the injections were frequent in both groups, occurring in 65.9% and 64.4% of subjects, respectively (P=0.69), but were generally mild and limited to the injection site.

CONCLUSIONS

Treatment with 17 alpha-hydroxyprogesterone caproate did not reduce the rate of preterm birth in women with twin gestations. (ClinicalTrials.gov number, NCT00099164 [ClinicalTrials.gov].).

Fetal pulse oximetry and cesarean delivery

BACKGROUND

Knowledge of fetal oxygen saturation, as an adjunct to electronic fetal monitoring, may be associated with a significant change in the rate of cesarean deliveries or the infant's condition at birth.

METHODS

We randomly assigned 5341 nulliparous women who were at term and in early labor to either "open" or "masked" fetal pulse oximetry. In the open group, fetal oxygen saturation values were displayed to the clinician. In the masked group, the fetal oxygen sensor was inserted and the values were recorded by computer, but the data were hidden. Labor complicated by a nonreassuring fetal heart rate before randomization was documented for subsequent analysis.

RESULTS

There was no significant difference in the overall rates of cesarean delivery between the open and masked groups (26.3% and 27.5%, respectively; P=0.31). The rates of cesarean delivery associated with the separate indications of a nonreassuring fetal heart rate (7.1% and 7.9%, respectively; P=0.30) and dystocia (18.6% and 19.2%, respectively; P=0.59) were similar between the two groups. Similar findings were observed in the subgroup of 2168 women in whom a nonreassuring fetal heart rate was detected before randomization. The condition of the infants at birth did not differ significantly between the two groups.

CONCLUSIONS

Knowledge of the fetal oxygen saturation is not associated with a reduction in the rate of cesarean delivery or with improvement in the condition of the newborn. (ClinicalTrials.gov number, NCT00098709 [ClinicalTrials.gov].).

Mechanical Methods of Cervical Ripening and Labor Induction

This article reviews the safety and efficacy of mechanical agents for cervical ripening. Hygroscopic dilators, balloon catheters, and devices designed for cervical ripening have all been shown to be safe and effective for cervical ripening. Mechanical agents are as efficacious as other agents for cervical ripening. However, there is no method that has been conclusively shown to improve mode of delivery or perinatal outcome. The advantages of preinduction cervical ripening with mechanical devices include low cost, low incidence of systemic side effects, and low risk of uterine hyperstimulation.

The maternal-fetal medicine fellowship match system: effectiveness at identifying successful clinician-investigators at 1 institution

OBJECTIVE

To determine if rank position on the match list of a maternal-fetal medicine (MFM) fellowship program predicted applicant academic success.

STUDY DESIGN

The Thomas Jefferson University MFM fellowship program rank order lists and the results of the match were reviewed for 1991-2002. Evaluation of candidates includes an application, 3 letters of recommendation, curriculum vitae and interview upon invitation. Career success of graduated fellows was defined as MFM board certification, number of peer-reviewed publications and of Society for MFM (SMFM) abstract publications.

RESULTS

Applicants ranked higher tended to have more peer-reviewed publications per applicant (9.2 vs. 4.7 vs. 4.4, p = 0.5) and more abstracts presented at SMFM (7.6 vs. 8.0 vs. 3.8 p = 0.5) as compared to lower-ranked applicants. Ranked applicants had a higher probability of being MFM board certified (74 vs. 22%, p = 0.005), having more peer-reviewed publications (6.8 vs. 1.4, p = 0.005), and more abstracts (7.1 vs. 2.1, p < 0.0001) as compared to nonranked applicants.

CONCLUSION

MFM fellowship applicants who were ranked higher were more likely to publish as compared to lower-ranked applicants. Ranked applicants were more likely to publish and be MFM board certified as compared to nonranked applicants.

Maternal complications with vaginal birth after cesarean delivery: a multicenter study

OBJECTIVE

This study was undertaken to determine incidence and risk factors for uterine rupture in women attempting vaginal birth after cesarean delivery (VBAC) in a wide range of hospital settings.

STUDY DESIGN

We performed a case-control study nested within a cohort of women who have had a prior cesarean to determine the incidence and risk factors for uterine rupture in women attempting VBAC.

RESULTS

The incidence rate of uterine rupture in those who attempt VBAC was 9.8 per 1000. A prior vaginal delivery was associated with a lower risk of uterine rupture (adjusted odds ratio [OR] = 0.40, 95% CI 0.20-0.81). Although prostaglandins alone were not associated with uterine rupture, sequential use of prostaglandin and pitocin was associated with uterine rupture (adjusted OR = 3.07, 95% CI 0.98-9.88).

CONCLUSION

Women with a prior cesarean should be offered VBAC, and women with a prior cesarean and prior vaginal delivery should be encouraged to VBAC. Although other studies have suggested that prostaglandins should be avoided, we suggest that inductions requiring sequential agents be avoided.

Fetal Fibronectin as a Predictor of Vaginal Birth in Nulliparas Undergoing Preinduction Cervical Ripening

OBJECTIVE

We sought to evaluate whether the presence of a positive fetal fibronectin (> or = 50 ng/mL) in nulliparous women undergoing preinduction cervical ripening with the intracervical Foley catheter predicted vaginal birth.

METHODS

This was a prospective blinded observational trial of nulliparous women undergoing preinduction cervical ripening. We excluded women who had a contraindication to vaginal birth. Cervical and vaginal fetal fibronectin specimens were obtained before preinduction cervical ripening with an intracervical Foley catheter. The managing obstetrician was blinded to these results.

RESULTS

A total of 241 women met the inclusion criteria, of which 54.4% delivered vaginally. There was no difference in the rate of vaginal delivery among women with either a positive cervical fetal fibronectin (positive fetal fibronectin 55.8% compared with negative fetal fibronectin 53.3%, P = .70) or positive vaginal fetal fibronectin (positive fetal fibronectin 57.6% compared with negative fetal fibronectin 53.3%, P = .56). Women with a positive cervical fetal fibronectin did have a shorter duration of cervical ripening (fetal fibronectin-positive 229 +/- 220 minutes compared with fetal fibronectin-negative 379 +/- 193 minutes, P < .05), duration of oxytocin (fetal fibronectin-positive 655 +/- 555 minutes compared with fetal fibronectin-negative 731.5 +/- 342 minutes, P < .025) and required lower maximal doses of oxytocin (fetal fibronectin-positive 18.4 mIU/min compared with fetal fibronectin-negative 21.8 mIU/min, P = .005). Women with a positive vaginal fetal fibronectin demonstrated only a shorter duration of cervical ripening compared with their fetal fibronectin negative counterparts (fetal fibronectin-positive 300 +/- 216 minutes compared with fetal fibronectin-negative 345 +/- 201 minutes, P < .05).

CONCLUSION

Fetal fibronectin does not predict vaginal delivery in nulliparous women requiring preinduction cervical ripening.

LEVEL OF EVIDENCE

II-2.

A randomized trial of amnioreduction versus septostomy in the treatment of twin-twin transfusion syndrome

OBJECTIVE

Left untreated, severe twin-to-twin transfusion syndrome (TTTS) presenting in the early second trimester of pregnancy is often associated with significant maternal morbidity and almost universal perinatal loss. Removal of excessive amounts of amniotic fluid through serial amniocenteses (amnioreduction) has been the mainstay of therapy. We sought to compare amnioreduction to intentional perforation of the intervening twin membrane (septostomy).

STUDY DESIGN

Pregnant women with TTTS before 24 weeks' gestation were randomly assigned to serial amnioreduction or septostomy. A single puncture technique under ultrasound guidance was used for the septostomy. The primary outcome measure was survival to neonatal discharge, and was assessed based on the number of pregnancies or the number of fetuses as appropriate.

RESULTS

The study was terminated at the planned interim analysis stage after 73 women were enrolled. This was because the rate of survival of at least 1 infant was similar in the amnioreduction group compared to the septostomy group (78% vs 80% of pregnancies, respectively; RR=0.94, 95%CI 0.55-1.61; P=.82). Patient undergoing septostomy were more likely to require a single procedure for treatment (64% vs 46%; P=.04).

CONCLUSION

Although overall perinatal survival is not enhanced, septostomy offers the advantage of often requiring a single procedure compared to serial amnioreduction in the treatment of severe twin-to-twin transfusion syndrome.

Uterine rupture in patients with a prior cesarean delivery: the impact of cervical ripening

The purpose of this study was to examine factors that were associated with uterine rupture in patients attempting vaginal birth after cesarean delivery. We analyzed the results of all patients attempting vaginal birth after cesarean delivery between September 1996 to December 1999 at a single institution using a contemporaneously maintained registry. Maternal factors, fetal factors, and management of labor were all assessed to determine the risk factors associated with symptomatic uterine rupture at the time of attempted vaginal birth after cesarean delivery. Twenty-eight symptomatic ruptures were identified in 972 attempts of vaginal birth after cesarean delivery at a gestational age greater than 24 weeks (2.88%). The use of preinduction cervical ripening was significantly associated with an increased risk of symptomatic uterine rupture (odds ratio, 3.92; 95% confidence interval, 1.78 to 8.62). Patients who underwent preinduction cervical ripening were significantly less likely to delivery vaginally than women who had not (46.71 versus 76.87%; p < 0.001). No other differences were noted between the two groups. Preinduction cervical ripening is associated with an increased risk of uterine rupture in women attempting vaginal birth after cesarean delivery.

The timing of elective delivery in preterm premature rupture of the membranes: a survey of members of the Society of Maternal-Fetal Medicine

OBJECTIVE

We sought to assess the gestational age at which elective delivery is considered in an otherwise uncomplicated patient with preterm premature rupture of the membranes (PROM) by members of the Society of Maternal Fetal-Medicine (SMFM).

STUDY DESIGN

A 3-page survey was mailed to members of the SMFM for this observational study. Information solicited included demographic data and practice patterns for the timing of delivery in patients with preterm PROM.

RESULTS

Seven hundred seventeen questionnaires (40%) were completed. The majority (81%) did not believe there is a consensus regarding the gestational age for elective delivery in patients with preterm PROM. With confirmed fetal lung maturity, the greatest number of respondents selected 32 and 34 weeks as the earliest gestational age for elective delivery. In the absence of fetal pulmonary maturity testing, the majority of respondents chose 34 weeks.

CONCLUSION

Most SMFM respondents electively deliver uncomplicated patients with preterm PROM by 34 weeks' gestation.

Preinduction cervical ripening with the Foley catheter and the risk of subsequent preterm birth

OBJECTIVE

The Foley catheter is a safe and effective form of preinduction cervical ripening and is quickly growing in popularity. Its major effect appears to be through mechanical dilation, which has raised the concern that the use of the Foley catheter for cervical ripening may damage the cervix and result in a higher rate of subsequent preterm birth.

STUDY DESIGN

We conducted a review of all induction of labor at our institution from July 1998 to July 2001 that required preinduction cervical ripening and had a subsequent birth. The primary outcome variable was preterm birth at <35 weeks of gestation. Demographic and potential confounding variables were analyzed. A probability value of <.05 was considered significant.

RESULTS

The cases of 126 women (63 women in the Foley group and 63 women in the prostaglandin group) were studied. Women in the prostaglandin group had a prostaglandin agent used. There was no difference in maternal age, gravidity, parity, Bishop score, total time of induction, gestational age, oxytocin use, maximum oxytocin level, tobacco or drug use, or type of delivery in the index pregnancy between the groups. In the subsequent pregnancies, there were no differences in maternal age, gravidity, parity, spontaneous abortions, terminations, cone or Loop Electrosurgical Excision Procedure (LEEP) procedures, history of cervical manipulation, tobacco or drug use, stillbirth, need for induction, mode of delivery, episiotomy, gestational age at delivery, Apgar scores, labor duration, use of oxytocin, or birth weight. There were no differences in preterm birth at 37, 35, or 32 weeks of gestation between the groups.

CONCLUSION

The use of the Foley catheter for preinduction cervical ripening does not appear to increase the risk of preterm birth in a subsequent pregnancy.

The Effect of Board-Imposed Changes on Maternal-Fetal Medicine Fellowships

OBJECTIVE

A 1996 survey of Maternal-Fetal Medicine fellows revealed that there was cause for serious concern over fellow experience. In 1997, Maternal-Fetal Medicine fellowships underwent significant changes, including a lengthening of the program and more stringent requirements for protected research performance. We investigated whether the changes imposed in Maternal-Fetal Medicine fellowships in 1997 have improved fellow experience.

METHODS

Fellows were identified through the Society of Maternal-Fetal Medicine. An identical survey to a 1996 survey using the Likert scale, ordinal- and categorical-scale questions were used. The results of the 1996 survey were compared with the results of the 2000 survey. chi2, Mann-Whitney U test, Fisher exact test, and analysis of variance were used where appropriate.

RESULTS

Sixty-five of 100 fellows returned the survey (return rate, 65%). Overall, there has been improvement in many areas of fellow experience. Significant changes include an increase in research time (7 months versus 18 months; P <.001), number of research projects (2.9 versus 4.3 projects/fellow; P <.001), fellows rating research time as adequate (66.4% versus 85.6%; P=.003), fellows receiving grant training (20.2% versus 37.1%; P=.012), 2 or more research presentations (36.2% versus 47.1%; P=.028), pursuit of a postgraduate degree (5.7% versus 32.9%; P <.001), presence of a mentor (68.1% versus 80.8%; P=.049), and the rating of mentorship as strong (59.4% versus 77.9%; P=.039). Of concern, 24.3% of current fellows did not believe they would receive their full-protected research time.

CONCLUSION

The changes imposed in Maternal-Fetal Medicine fellowships in 1997 appear to have had a positive impact on fellows' experience, especially the ability to perform and present research.

Caesarean delivery and outcome in very low birthweight infants

OBJECTIVE

To determine the relationship between mode of delivery, intraventricular haemorrhage (IVH), and mortality in very low birthweight (VLBW) infants.

STUDY DESIGN

A historical cohort study of infants admitted to a single level III neonatal intensive care unit during a five-year period. Infants < 1500 g born by caesarean delivery (n = 400) were compared to those born by vaginal delivery (n = 305).

RESULTS

After controlling for potential confounding variables including: gestational age, fetal presentation, and multiple birth, caesarean delivery was not associated with a decreased odds of IVH (odds ratio 1.2, 95% CI 0.7-2.0), severe IVH (1.9, 0.9-4.0), or mortality (1.2, 0.6-2.4).

CONCLUSIONS

In our population of very low birthweight infants, caesarean delivery is not associated with a decreased risk for mortality or intraventricular haemorrhage.

Early transvaginal ultrasonography versus early cerclage in women with an unclear history of incompetent cervix

OBJECTIVE

Our aim was to compare outcomes in women with a questionable history of incompetent cervix, followed up with early transvaginal ultrasonography, with outcomes in women who had early cerclage.

STUDY DESIGN

Charts were reviewed and patients identified for incompetent cervix from our obstetric database from 1995 through 1997. We included women who had an unclear history of incompetent cervix as follows: second-trimester loss or termination, > or =3 first-trimester terminations, cone biopsy or loop electrosurgical excision, or exposure to diethylstilbestrol. The primary outcome variable was gestational age at delivery.

RESULTS

A total of 106 women were included, 45 in the early cerclage group and 61 in the early transvaginal ultrasonography group. The mean gestational age at delivery was 35.1 weeks for the early cerclage group versus 36.1 weeks for the early transvaginal ultrasonography group.

CONCLUSION

In women with an unclear history of incompetent cervix, early cerclage does not appear to offer significant benefit over early transvaginal ultrasonography.

Preeclampsia does not increase the risk for culture proven sepsis in very low birth weight infants

The risk of sepsis associated with neutropenia in infants born to mothers with preeclampsia remains controversial. The objective of this study is to investigate the incidence of culture-proven sepsis along with changes in the complete blood count in very-low-birth-weight infants born to mothers with preeclampsia. We conducted a retrospective cohort study of infants cared for at a single tertiary care neonatal intensive care unit during a 4-year period. Infants born to mothers with preeclampsia (n = 88) were compared to infants born to mothers without preeclampsia (n = 416) by univariate and multivariate analysis. Although infants born to mothers with preeclampsia had lower absolute neutrophil and platelet counts throughout the first week of life, they were no more likely to have a platelet count <100,000 /mm3, and only more likely to be neutropenic at 24 and 72 hr of life compared to infants born to mothers without preeclampsia. After controlling for potential confounding variables, there was no increase in the odds of culture proven sepsis in infants born to mothers with preeclampsia (odds ratio 1.6, 95% confidence intervals 0.7-3.6, p = 0.3) compared to those infants born to mothers without preeclampsia. We conclude that very-low-birth-weight infants born to mothers with preeclampsia are not at increased risk of culture proven sepsis despite a reduction in absolute neutrophils.

Lysosomal enzymuria in preeclampsia

We hypothesize that the preeclamptic patient has proximal tubule epithelial injury, which leads to the release of lysosomal enzymes, and that the excretion of these enzymes might serve as a diagnostic or predictive marker in preeclamptic women. The study group consisted of 14 women with preeclampsia (10 severe and 4 mild, as defined by The American College of Obstetricians and Gynecologists criteria) and 28 normotensive controls with singleton pregnancies at 27 to 41 weeks. There were no significant differences between the two groups for gestational age, maternal age, or race. Maternal serum and urine specimens were prospectively obtained and analyzed for beta-glucuronidase, beta-hexosaminidase, alpha-galactosidase, beta-galactosidase, and alpha-mannosidase using fluorometric assays. Median serum and urine activities and fractional excretions of each of the five hydrolases were compared between the two study groups using the Mann-Whitney two-sample rank test. The serum enzyme activities of beta-hexosaminidase (P = 0.002), alpha-galactosidase (P = 0.0001), and alpha-mannosidase (P = 0.02) were significantly lower in preeclamptic patients than in controls. The urine enzyme activities of beta-glucuronidase (P = 0.001), alpha-galactosidase (P = 0.002), beta-galactosidase (P 0.0003), and alpha-mannosidase (P = 0.003) were significantly higher in the preeclamptic patients. The fractional enzyme excretions of all five lysosomal hydrolases were higher in preeclamptic patients than in controls with P < or = 0.0003 for each enzyme. Preeclampsia is associated with a significant decrease in serum activities of three of the five hydrolases studied, a significant increase in urine enzyme activities in four of the five hydrolases studied, and a significant increase in the fractional excretion of all five lysosomal hydrolases.