Onset and persistence of postpartum depression in an inner-city maternal health clinic system

OBJECTIVE

Postpartum depressive disorders lead to maternal disability and disturbed mother-infant relationships, but information regarding the rates of major depressive disorder in minority women is noticeably lacking. The goal of this study was to determine whether the risk factors for and rate of postpartum major depressive disorder in a predominantly African American and Hispanic clinic population would be similar to those reported for Caucasian women.

METHOD

Investigators systematically screened all women scheduled for their first postpartum visit on selected days at four publicly funded inner-city community maternal health clinics in Dallas County (N=802). A multistage screening process included the Edinburgh Postnatal Depression Scale, the Inventory of Depressive Symptomatology, and the Structured Clinical Interview for DSM-IV for a maximum of three assessments during the initial 3-5-week postpartum period.

RESULTS

The estimated rate of major depressive disorder during the postpartum period among women in this setting was between 6.5% and 8.5%. Only 50% of the depressed women reported onset following birth. Bottle-feeding and not living with one's spouse or significant other were associated with depression at the first evaluation; persistent depressive symptoms were linked with the presence of other young children at home. Greater severity of depressive symptoms at first contact predicted major depressive disorder several weeks later.

CONCLUSIONS

Rates of postpartum depression among Latina and African American postpartum women are similar to epidemiologic rates for Caucasian postpartum and nonpostpartum women. As previously shown for Caucasian women, major depressive disorder in many Latina and African American postpartum women begins before delivery, revealing the need to screen pregnant women for depression.

A randomized trial of labor analgesia in women with pregnancy-induced hypertension

OBJECTIVE

The purpose of this study was to compare the peripartum and perinatal effects of epidural with intravenous labor analgesia in women with pregnancy-induced hypertension.

STUDY DESIGN

Women with pregnancy-induced hypertension who had consented to participate were randomized to receive either epidural or intravenous analgesia for labor pain. Both methods were given according to standardized protocols. All women received magnesium sulfate seizure prophylaxis. Obstetric and neonatal outcomes were compared according to intent-to-treat allocation.

RESULTS

Seven hundred thirty-eight women were randomized: 372 women were given epidural analgesia, and 366 women were given intravenous analgesia. Maternal characteristics were similar, including the severity of hypertension. Epidural analgesia was associated with a significantly prolonged second-stage labor, an increase in forceps deliveries, and an increase in chorioamnionitis. Cesarean delivery rates and neonatal outcomes were similar. Pain relief was superior with the epidural method. Hypotension required treatment in 11% of women in the epidural group.

CONCLUSION

Epidural labor analgesia provides superior pain relief but no additional therapeutic benefit to women with pregnancy-induced hypertension.

Urinary tract infections during pregnancy

Urinary tract infections are relatively common in pregnancy and may result in significant morbidity for the pregnant woman and fetus. The authors recommend that all pregnant women be screened for the presence of bacteriuria at their first prenatal visit. Failure to treat bacteriuria during pregnancy may result in as many as 25% of women experiencing acute pyelonephritis. Women with acute pyelonephritis may sustain significant complications, such as preterm labor, transient renal failure, ARDS, sepsis and shock, and hematologic abnormalities. Pregnant women with urinary tract infections should be followed up closely after treatment because as many as one third will experience a recurrence.

Cardiac disease in pregnancy

Cardiovascular adaptations of pregnancy are generally well tolerated in the healthy gravida; however, these changes can place undue stress on women with underlying cardiovascular disease and can result in increased risk for morbidity and mortality. In this article, we will review issues related to preconceptional counseling, cardiovascular adaptations of pregnancy, and the prognosis and management of the gravida with cardiac disease in pregnancy.

Labor induction

Labor induction has become commonplace in modern obstetrics. The increasing rate of labor induction has probably played a role in the increased rate of cesarean delivery observed in the United States during the past few decades. Clearly, the favorability of the cervix has a substantial impact on the potential success of any labor induction. Induction in the setting of an unfavorable cervix can result in prolonged induction, prolonged hospitalization, failed induction, and an increased cesarean delivery rate. In this modern era of healthcare reform and cost containment, the identification of therapeutic strategies to enhance the success and cost-effectiveness of labor induction are of great interest. Ongoing research is needed to advance our knowledge of the mechanisms of parturition and cervical ripening in order to direct interventions for labor induction more effectively.

An appraisal of treatment guidelines for antepartum community-acquired pneumonia

OBJECTIVE

The optimal strategy for the initial evaluation and management, including criteria for hospitalization, of pregnant women with pneumonia has not been defined. Our purpose was to evaluate a treatment protocol for antepartum pneumonia and to identify criteria for selection of women for potential outpatient treatment.

STUDY DESIGN

A protocol based on British and American Thoracic Society guidelines was introduced and included prompt hospitalization and empiric initiation of erythromycin therapy. Maternal and neonatal outcomes were analyzed to assess the efficacy of the protocol. A second analysis involved the retrospective application of published guidelines to ascertain for which women outpatient management might have been appropriate.

RESULTS

There were no maternal deaths among the 133 women studied, and in 14 (10%) women there was a misdiagnosis at admission. Erythromycin monotherapy was judged adequate in all but one of the 99 women so treated. Using a modified version of the American Thoracic Society guidelines, we project that only 25% of the women hospitalized with pneumonia could have been managed safely as outpatients.

CONCLUSION

Most pregnant women with pneumonia respond well to monotherapy with erythromycin. Outpatient management may be a reasonable option for selected women.

Infection and cerebral palsy

Recent data suggest a possible association of infection and cerebral palsy. The objective of this article is to examine the relationship between intrauterine infection, fetal infection, and long-term neurological dysfunction. In some children maternal infection is associated with brain white matter damage, periventricular leukomalacia, and cerebral palsy.

Other factors/conditions associated with cerebral palsy

The cause for most cases of cerebral palsy is unknown. There are however, risk factors that have been associated with this chronic neuromuscular disease. The objective of this article is to review the maternal and fetal conditions (other than asphyxia and infection) strongly associated with increased rate of cerebral palsy. What remains to be elucidated is whether or not these associations are causative.

Fallopian tube prolapse after hysterectomy

BACKGROUND

Fallopian tube prolapse is reported to most commonly occur after vaginal hysterectomy. Both diagnosis and management have varied, resulting in differing efficacies of treatment.

METHODS

We reviewed the presentation, diagnosis, management, and outcomes of 18 cases of tubal prolapse in 17 women.

RESULTS

Most cases (65%) occurred after abdominal hysterectomy. The post-hysterectomy course was complicated by cuff cellulitis in three women, an infected cuff hematoma in one, and post-extubation pulmonary edema in one; four were observed for elevated temperature only. At presentation, 44% complained of dyspareunia, 39% vaginal bleeding, 33% vaginal discharge, 28% abdominal pain, and 28% were asymptomatic. Seven women had vaginal excision (one requiring an additional abdominal procedure), three had laparotomy with salpingectomy, and seven (41%) had spontaneous disappearance of prolapsed fallopian tube without treatment.

CONCLUSIONS

In our series, tubal prolapse most commonly occurred after abdominal hysterectomy. Moreover, women with tubal prolapse may be asymptomatic, and observation alone may lead to resolution.

Peripartum cocaine use and adverse pregnancy outcome

The objective of the study was to analyze possible adverse effects of peripartum cocaine use on maternal and fetal outcomes. Informed consent was given by 720 (97%) of 740 women who delivered consecutively at a large urban public hospital to test an umbilical cord blood sample for the presence of non-medically administered drugs of abuse and alcohol and to be interviewed for the study. Samples were tested for the presence of a cocaine metabolite (benzoylecgonine-BZE) by radioimmunoassay. The presence of other substances of abuse (alcohol, methamphetamine, opiates) resulted in exclusion from the sample of 143 subjects. Thus, in this cohort analysis, drug-free controls (N = 469) were compared to those positive for cocaine only (N = 108). Peripartum exposure to cocaine only, and no other substances of abuse, was associated with an increased frequency of abruptio placentae (1.9% vs 0% for control, P < 0.004), thick meconium stained amniotic fluid (3.9% vs 0.7% for controls, P < 0.006), premature rupture of membranes (P < 0.02), genitourinary anomalies (OR = 3.6, P < 0.05), abdominal wall defects (OR = 4.4, P < 0.01) and increased frequency of low birth weight (OR = 2.0, P < 0.02). These are important findings because previous studies have been complicated by the confounding effects of other substances of abuse. Am. J. Hum. Biol. 11:598-602, 1999. Copyright 1999 Wiley-Liss, Inc.

Maternal cardiac troponin I levels during normal labor and delivery

OBJECTIVE

Diagnosis of myocardial infarction in pregnant women on the basis of changes in biochemical markers is complicated by the release of some of these markers from noncardiac tissue sources. We compared troponin I levels with those of other markers in normal pregnant women.

STUDY DESIGN

In 51 healthy women at term in labor, cardiac troponin I, myoglobin, creatine kinase, and creatine kinase MB levels were determined at admission, during the second stage of labor, and within 30 minutes, 12 hours, and 24 hours after delivery.

RESULTS

Mean admission levels for all markers were below the upper limit of normal. Mean concentrations of myoglobin, creatine kinase, and creatine kinase MB mass were increased nearly twofold within 30 minutes after delivery. The highest level of troponin I (0.134 ng/mL) at all time points was below the cutoff value (0.15 ng/mL) for discriminating myocardial infarction.

CONCLUSIONS

Because only troponin I levels remained undetectable during and after delivery, it is potentially the most useful biochemical marker for monitoring pregnant women for myocardial injury.

A randomized study of combined spinal-epidural analgesia versus intravenous meperidine during labor: impact on cesarean delivery rate

BACKGROUND

Combined spinal-epidural (CSE) analgesia produces rapid-onset pain relief and allows ambulation in early labor. Epidural local anesthetics may contribute to an increase in operative deliveries by decreasing perineal sensation and causing motor weakness. Operative delivery rates might be reduced with CSE, by avoiding or delaying administration of local anesthetics. This study compares the operative delivery rates associated with a CSE technique and those associated with intravenous meperidine for labor analgesia.

METHODS

Healthy parturients at full term were assigned randomly to receive CSE or intravenous meperidine analgesia. The CSE group received 10 microg intrathecal sufentanil, followed by epidural bupivacaine and fentanyl at their next request for analgesia. Parturients receiving intravenous meperidine had 50 mg on demand (maximum, 200 mg in 4 h). Labor and delivery outcomes in both groups were recorded and compared.

RESULTS

An intent-to-treat analysis of 1,223 women indicated that CSE does not increase the rate of cesarean delivery for dystocia in nulliparous and parous women (CSE, 3.5% vs. intravenous meperidine, 4; P=not significant) or in nulliparous women alone (CSE, 7% vs. intravenous meperidine, 8%; P=not significant). Profound fetal bradycardia that necessitated emergency cesarean delivery within 1 h of the time the mother received sufentanil occurred in 8 of 400 parturients (compared with 0 of 352 who received meperidine; P < 0.01). However, the method of fetal monitoring differed between the two groups. Despite this, neonatal outcomes were similar overall.

CONCLUSIONS

Combined spinal-epidural analgesia during labor does not increase the cesarean delivery rate for dystocia in healthy parturient patients at full term, regardless of parity. However, an unexpected increase in the number of cesarean deliveries for profound fetal bradycardia after intrathecal sufentanil was observed. Further investigation is warranted.

The long-term consequences of thrombotic microangiopathy (thrombotic thrombocytopenic purpura and hemolytic uremic syndrome) in pregnancy

OBJECTIVE

To characterize perinatal outcomes and long-term maternal complications from thrombotic microangiopathy manifested during pregnancy, and to review the clinical course and long-term follow-up of pregnant women with this condition at our institution over the past 25 years.

METHODS

We identified prospectively pregnant women who met clinical and laboratory criteria for thrombotic thrombocytopenic purpura or hemolytic uremic syndrome. Their clinical and laboratory findings, response to treatment, perinatal outcomes, and long-term sequelae were then analyzed.

RESULTS

Between 1972 and 1997, 11 women had 13 pregnancies complicated by thrombotic microangiopathy, representing an incidence of one per 25,000 births. In three pregnancies (23%), severe and refractory disease developed before midpregnancy. In ten other pregnancies, disease developed either peripartum (62%) or several weeks postpartum (15%). In only two pregnancies with peripartum or postpartum onset of disease was there a clinical picture of severe preeclampsia. In general, the response to treatment was prompt. One woman died of her initial disease in early pregnancy, and mean follow-up of nine survivors was 8.7 years. Disease recurred at least once in 50% of these, two during a subsequent pregnancy. There was at least one serious long-term sequela in all but two survivors; these included recurrence of thrombotic microangiopathy, renal failure, severe hypertension, chronic blood-borne infections, and death.

CONCLUSION

Thrombotic microangiopathy complicating pregnancy is rare, and with careful evaluation, it should not be confused with atypical preeclampsia. With prompt and aggressive treatment including plasma exchange, the likelihood of immediate survival is high; however, long-term morbidity and mortality are common.

The course of labor with and without epidural analgesia

OBJECTIVE

Our purpose was to measure effects of epidural analgesia on labor compared with boluses of meperidine in a cohort of women with similar clinical circumstances.

STUDY DESIGN

One hundred ninety-nine nulliparous women who were delivered spontaneously at term and who received oxytocin for labor augmentation before the initiation of analgesia were identified for analysis. All these women were managed in a low-risk labor unit according to a standardized protocol. This management protocol encouraged early amniotomy and the use of oxytocin when ineffective labor was diagnosed.

RESULTS

The demographic characteristics of the two study groups were similar with respect to age, height, weight, and maternal age. The two groups had the same cervical dilatation on admission (3.3 cm) and at the time of analgesia administration (4.1 vs 4.2 cm), indicating similar progress of labor before oxytocin administration. The length of the active phase of labor was longer in the epidural group (7.9 vs 6.3 hours, p = 0.005), as was the second stage (60 vs 48 minutes, p = 0.03). The mean and maximal rates of oxytocin infusion were similar between the two study groups; however, the amount of oxytocin required for each centimeter of cervical change was more in the epidural group (22 vs 16 mU per cm of cervical change, p = 0.009). Neonatal outcomes were unaffected by the type of labor analgesia.

CONCLUSION

Epidural analgesia decreases uterine performance during oxytocin-stimulated labor, resulting in an increase in the length of the first and second stages of labor.

A study of the cellular mechanism by which lead affects catecholamine secretion

Our purpose was to determine the role of protein kinases in the mediation of the stimulatory effects of lead on catecholamine secretion. Pheochromocytoma cells were incubated for 90 minutes with W-7 (calmodulin antagonist), calphostin C (protein kinase C inhibitor), Sp-cAMPS (cAMP agonist), Rp-cAMPS (cAMP antagonist), forskolin (activator of adenylyl cyclase), or lead nitrate. Catecholamines were measured by liquid chromatography. Lead had a stimulatory effect on catecholamine secretion, whereas W-7 was inhibitory. In the presence of both lead and W-7, the response was markedly decreased compared to that seen with lead alone. Calphostin C suppressed the secretion of catecholamines; however, in the presence of lead and calphostin C, the secretion was similar to that seen with lead alone. Compared to control, Sp-cAMPS was stimulatory. Co-incubation of Sp-cAMPS and lead had a slight synergistic effect. Rp-cAMPS decreased catecholamine secretion, but co-incubation of Rp-cAMPS and lead resulted in a slight reduction compared to lead alone. Forskolin markedly increased the secretion of catecholamines, and co-incubation of lead and forskolin resulted in a synergistic increase. In the absence of calcium, lead had no effect. We conclude that lead stimulates catecholamine secretion by acting through the calcium/calmodulin-dependent protein kinase II system and not through the protein kinase C or protein kinase A system, and requires the presence of calcium for its action.

The relationship of infection to method of delivery in twin pregnancy

OBJECTIVE

Our purpose was to determine whether manipulation of the second twin increases the risk of postpartum infection.

STUDY DESIGN

Medical records of all twin deliveries between January 1991 and December 1994 were reviewed. The route of delivery (vaginal vs cesarean section) was examined. The vaginal group was further divided into those delivered in the vertex/vertex position (i.e., no uterine manipulation) versus those delivered vertex/breech extraction (i.e., manipulation). The chi 2 and Student t test were used where appropriate.

RESULTS

A total of 718 twins were identified, and maternal age, parity, gestational age at delivery (36 weeks), and birth weight (2278 gm) were similar among groups. The metritis rate was higher in the cesarean group (74/447 or 18%) than in the vaginal group (17/299 or 5.7%, p < 0.001). In comparing the vaginal group delivered without uterine manipulation with the vaginal group delivered with manipulation (i.e., breech extraction), there was no difference in the incidence of metritis (10/147 or 6.8% vs 7/152 or 4.6%, not significant). The length of time between delivery of twin A and twin B did not affect the metritis rate. Neonatal outcomes including sepsis, neonatal death, and length of hospitalization were similar among groups (not significant).

CONCLUSION

Uterine manipulation of the second twin does not increase the risk of postpartum metritis or neonatal sepsis. In addition, the time interval between delivery of twins A and B has no effect on the rate of metritis. Although the rate of endometritis has been reported to be higher with twins delivered by cesarean section compared to singletons, the 18% rate of endometritis in twins delivered by cesarean section in this study is slightly lower than in our general population of cesarean deliveries (22%).

Cesarean delivery: a randomized trial of epidural versus patient-controlled meperidine analgesia during labor

BACKGROUND

Reports indicate that the administration of epidural analgesia for pain relief during labor interferes with labor and increases cesarean deliveries. However, only a few controlled trials have assessed the effect of epidural analgesia on the incidence of cesarean delivery. The authors' primary purpose in this randomized study was to evaluate the effects of epidural analgesia on the rate of cesarean deliveries by providing a suitable alternative: patient-controlled intravenous analgesia.

METHODS

Seven hundred fifteen women of mixed parity in spontaneous labor at full term were randomly assigned to receive either epidural analgesia or patient-controlled intravenous meperidine analgesia. Epidural analgesia was maintained with a continuous epidural infusion of 0.125% bupivacaine with 2 microg/ml fentanyl. Patient-controlled analgesia was maintained with 10-15 mg meperidine given every 10 min as needed using a patient-controlled pump. Procedures recorded in a manual that prescribed the intrapartum management were followed for each woman randomized in the study.

RESULTS

A total of 358 women were randomized to receive epidural analgesia, and 243 (68%) of these women complied with the epidural analgesia protocol. Similarly, 357 women were randomized to receive patient-controlled intravenous meperidine analgesia, and 259 (73%) of these women complied with the patient-controlled intravenous analgesia protocol. Only five women who were randomized and received patient-controlled intravenous meperidine analgesia according to the protocol crossed over to epidural analgesia due to inadequate pain relief. There was no difference in the rate of cesarean deliveries between the two analgesia groups using intention-to-treat analysis based on the original randomization (epidural analgesia, 4% [95% CI: 1.9-6.2%] compared with patient-controlled intravenous analgesia, 5% [95% CI: 2.6-7.2%]). Similar results were observed for the analysis of the protocol-compliant groups (epidural analgesia, 5% [95% CI: 2.6-8.5%] compared with patient-controlled intravenous analgesia, 6% [95% CI: 3-8.9%]). Women who received epidural analgesia reported lower pain scores during labor and delivery compared with women who received patient-controlled intravenous analgesia.

CONCLUSIONS

Epidural analgesia was not associated with increased numbers of cesarean delivery when compared with a suitable alternative method of analgesia.

Anticoagulants and thrombolytics during pregnancy

Although venous thromboembolism is a rare complication of pregnancy, it is one of the leading causes of maternal mortality. As many as 40% of asymptomatic women with deep venous thrombosis may indeed have a pulmonary embolism. Therefore, pregnant women with thromboembolic disease, a history of thromboembolic disease, or those who are at increased risk of thromboembolism (mechanical cardiac valve prostheses, antithrombin II, or protein C or S deficient) should receive anticoagulant therapy. The choice of anticoagulant therapy in a pregnant woman as well as the dose and duration will depend on the specific condition being treated. Although anticoagulant therapy is beneficial, it is not without risks to both mother and fetus. This article discusses the use of anticoagulants and thrombolytics in pregnant women.

Antepartum diagnosis of pelvic arteriovenous malformation

BACKGROUND

An arteriovenous fistula in the female pelvis is a rare finding. We report a pelvic arteriovenous fistula diagnosed antepartum.

CASE

At 38 weeks' gestation, a 32-year-old woman, gravida 3, para 1, was found on bimanual examination to have a pulsating mass on the left vaginal sidewall. Magnetic resonance imaging revealed a tangle of arteries feeding into an aneurysmal dilation of a branch vein of the left internal iliac, extending to the left lateral wall of the cervix and vagina, and ending in a large varix in the lateral wall of the vagina. The patient was asymptomatic and underwent primary cesarean delivery of a healthy female infant. Twice during her postpartum course, she underwent angiography and embolization of extensive left- and right-sided feeding vessels. Five to 6 weeks after each embolization, the vaginal mass recurred.

CONCLUSION

A pelvic arteriovenous malformation diagnosed antepartum presents a dilemma in regards to risk of hemorrhage, congestive heart failure, and successful ablation.

Asthma treatment in pregnancy: a randomized controlled study

OBJECTIVE

Our purpose was to study the effect of inhaled corticosteroids on asthma exacerbations in pregnancy.

STUDY DESIGN

We prospectively studied 84 pregnant women with 105 asthma exacerbations. Women were hospitalized if the forced expiratory volume in 1 second was < 70% after sequential bronchodilator therapy. They were randomly assigned to receive either intravenous aminophylline and inhaled beta 2-adrenergic receptor agonist or intravenous methylprednisolone and a beta 2-adrenergic receptor agonist. At discharge women were randomly assigned to receive either inhaled beclomethasone, beta 2-adrenergic receptor agonist, and an oral corticosteroid taper or a beta 2-adrenergic receptor agonist and a corticosteroid taper.

RESULTS

Sixty-five (62%) of 105 women with exacerbation required hospitalization. Aminophylline did not shorten response time or decrease hospital stay. Readmission rate was decreased by 55% in women given inhaled beclomethasone (33% vs 12%, p < 0.05, odds ratio 3.63, 95% confidence interval 1.01 to 13.08). Pregnancy-induced hypertension and cesarean delivery were increased over those of the general population.

CONCLUSIONS

Intravenous aminophylline offers no therapeutic advantages. Continuous inhaled corticosteroids reduced the need for subsequent admissions.

Fetal effects of prophylactic ephedrine and maternal hypotension during regional anesthesia for cesarean section

The purpose of this study was to evaluate the effects of a prophylactic intravenous bolus of ephedrine on the incidence and severity of maternal hypotension and on neonatal outcome. Term healthy parturients (n = 122) scheduled for elective repeat cesarean section under regional anesthesia were studied. Ninety-two women received 10 mg ephedrine as a prophylactic intravenous bolus prior to intrathecal epidural local anesthesia. Thirty parturients who served as controls did not receive prophylactic ephedrine. Maternal blood pressures, Apgar scores, and umbilical cord blood acid-base status were evaluated. Sixty-three of 92 women (69%) who received intravenous prophylactic ephedrine prior to regional anesthesia developed hypotension compared to 21 (70%) controls. The mean (+/- SD) lowest systolic blood pressure was similar in both groups (95.6 +/- 12.9 vs. 96 +/- 8.9 mmHg; P = 0.86). The mean (+/-SD) fetal pH was significantly lower with prophylactic ephedrine than controls (7.24 +/- 0.07 vs. 7.28 +/- 0.05; P = 0.001). The frequency of umbilical artery blood pH < 7.20 was 10.6% for the ephedrine group vs. 3.2% for controls (P = 0.024). Among newborns of hypotensive mothers, the frequency of umbilical artery blood pH < 7.20 was 30.2% and 4.6% for the ephedrine and control groups, respectively (P = 0.018). Intravenous prophylaxis with ephedrine did not significantly decrease the frequency of hypotension in women receiving regional anesthesia and resulted in a greater proportion of umbilical artery blood pH values < 7.20.

Risk of chromosomal abnormalities, with emphasis on live-born offspring of young mothers

In a large public urban hospital obstetrics service with > 123,000 deliveries in a 10-year period (1980-89), the frequencies (0.12%) of any type of chromosomal abnormality and of trisomy syndromes were analyzed for maternal age-related risk, by logistic regression. Focusing on very young gravidas, we found that in the study period there were 9,332 births (7.5% of all deliveries) to mothers < or = 16 years old. Estimated risks of chromosomal abnormalities among offspring associated with very young maternal age (9-16 years) were similar to those age-associated risks of mothers 20-29 years old. Risks of chromosomal abnormalities increase with advancing maternal age and are independent of ethnicity.

Randomized trial of epidural versus intravenous analgesia during labor

OBJECTIVE

To compare the effects of epidural analgesia with intravenous (IV) analgesia on the outcome of labor.

METHODS

Thirteen hundred thirty women with uncomplicated term pregnancies and in spontaneous labor were randomized to be offered epidural bupivacaine-fentanyl or IV meperidine analgesia during labor.

RESULTS

Comparison of the allocation groups by intent to treat revealed a significant association between epidural allocation and operative delivery for dystocia. However, only 65% of each randomization group accepted the allocated treatment. Four hundred thirty-seven women accepted and received meperidine as allocated, and they were compared with 432 women accepting epidural allocation. Significant associations resulted between epidural administration and prolongation of labor, increased rate of oxytocin administration, chorioamnionitis, low forceps, and cesarean delivery. Because of the high rate of noncompliance with treatment allocation, a multifactorial regression analysis was performed on the entire cohort, and a twofold relative risk of cesarean delivery persisted in association with epidural treatment. The impact of epidural treatment on cesarean delivery was significant for both nulliparous and parous women (risk ratios 2.55 and 3.81, respectively). Epidural analgesia provided significantly better pain relief in labor than did parenteral meperidine.

CONCLUSION

Although labor epidural analgesia is superior to meperidine for pain relief, labor is prolonged, uterine infection is increased, and the number of operative deliveries are increased. A two- to fourfold increased risk of cesarean delivery is associated with epidural treatment in both nulliparous and parous women.

Management of disseminated intravascular coagulopathy

Disseminated intravascular coagulopathy is a process in which aberrant activation of the clotting mechanism results in defective coagulation. Although infrequently encountered during pregnancy, disseminated intravascular coagulopathy is associated with several clinical situations unique to obstetrics. Management consists of treating the underlying cause, restoring and maintaining the circulating blood volume, and replacing deficient clotting factors as indicated.

Acute pancreatitis in pregnancy

OBJECTIVE

Our purpose was to determine the cause and describe the natural history of acute pancreatitis complicating pregnancy and its effect on maternal and perinatal outcomes.

STUDY DESIGN

Over the last decade we admitted 43 pregnant women with acute pancreatitis to our hospital. We reviewed presentation, diagnosis, management, and maternal and perinatal outcomes.

RESULTS

The incidence of acute pancreatitis was one in 3333 pregnancies. The mean age of these 43 women was 24 years, 31 (72%) were multiparous, and pancreatitis was associated with biliary disease in 29 (68%). All had a favorable response to supportive therapy that included bowel rest, intravenous hydration, and antimicrobial therapy. Cholecystectomy was performed for persistent or recurrent biliary or pancreatic disease ante partum in eight women and post partum in another 12. Of 39 women who were delivered at our hospital, 32 were at term and their infants did well. The other six infants were delivered preterm; two were stillborn and another died after birth. One woman underwent a therapeutic abortion.

CONCLUSIONS

Most pregnant women with acute pancreatitis have associated biliary tract disease. With prompt hospitalization, supportive care, and surgical intervention when indicated, maternal and fetal morbidity and mortality are not prohibitive. Fetal death and preterm delivery may result from severe disease.

The correlation between transperineal sonography and digital examination in the evaluation of the third-trimester cervix

OBJECTIVE

To determine the correlation between transperineal or translabial ultrasound and digital examination of the cervix in the third trimester in women presenting to the obstetrical triage area complaining of uterine contractions and/or rupture of membranes.

METHOD

One hundred women were evaluated initially with an ultrasound unit using a 5-MHz glove-covered curvilinear transducer applied to the perineum in the sagittal plane. Immediately after the ultrasound evaluation, another examiner assessed the cervix digitally, blinded to the sonographic results. Cervical dilatation, length, and station were assessed.

RESULTS

Transperineal ultrasound correlated (P < .001) with digital cervical examination in the assessment of dilatation (Pearson correlation coefficient 0.87), length (Pearson correlation coefficient 0.80), and corrected station (Pearson correlation coefficient 0.69).

CONCLUSION

There is a statistically significant correlation between the digital cervical examination and the sonographic assessment of cervical dilatation, length, and station by the transperineal approach.

Markers of acute and chronic asphyxia in infants with meconium-stained amniotic fluid

OBJECTIVE

Cord blood pH, lactate, hypoxanthine, and erythropoietin levels have all been used as markers of either acute or chronic asphyxia. We sought to determine whether these index values were significantly different in infants with or without meconium-stained amniotic fluid.

STUDY DESIGN

Fifty-six pregnant women in spontaneous labor at term were divided into two groups on the basis of the presence or absence of meconium-stained amniotic fluid. All meconium-stained fluid was centrifuged, and the volume percentage of particulate matter (i.e., meconium) was recorded. Umbilical artery blood and mixed arterial and venous cord blood were obtained at each delivery. Lactate, hypoxanthine, and erythropoietin levels were measured. Statistical analysis included Student t test and rank sum statistics where appropriate. Normal and Spearman correlation coefficients were also used.

RESULTS

There were no significant differences in mean umbilical artery pH (7.26 +/- 0.06 vs 7.25 +/- 0.10), lactate levels (32.8 +/- 10 mg/dl vs 30.4 +/- 14.2 mg/dl), and hypoxanthine levels (13.4 +/- 6.7 mumol/L vs 14.0 +/- 6.0 mumol/L) in newborns with meconium (n = 28) compared with controls (n = 28). Erythropoietin levels were significantly greater in newborns with meconium (median 39.5 mIU/ml vs 26.8 mIU/ml, p = 0.039). There was no correlation between the amount of particulate matter and any marker of asphyxia.

CONCLUSIONS

There was no correlation between markers of acute asphyxia (i.e., umbilical artery blood pH, lactate, or hypoxanthine) and meconium. However, erythropoietin levels were significantly elevated in newborns with meconium-stained amniotic fluid. This latter marker may better correlate with chronic asphyxia.

Ultrasonographic diagnosis of uterine rent at 33 weeks' gestation with history of curettage

A 30-year-old pregnant woman with a history of an uncomplicated curettage for incomplete abortion was seen at 33 weeks' gestation with decreased fetal movement and intermittent abdominal pain for 1 week. Ultrasonographic evaluation demonstrated a singleton vertex pregnancy, oligohydramnios, and a fundal uterine rent continuous with a large, fluid-filled cystic mass. Laparotomy revealed a right cornual uterine rent with hourglass amniotic sac and fluid. A healthy infant was delivered by cesarean section.

Erythropoietin use in pregnancy: two cases and a review of the literature

End-stage renal disease complicates only a small percentage of pregnancies, but, of these, virtually all become anemic due to a deficiency in erythropoietin. Erythropoietin has been shown to correct anemia due to renal disease in nonpregnant patients. We report two cases of erythropoietin use during pregnancy complicated by severe anemia due to renal failure. No maternal or fetal side effects were noted. Our two cases exemplify that erythropoietin is an effective means of treating anemia due to renal disease in the gravid patient.

Pneumonia complicating pregnancy

OBJECTIVE

To determine the clinical course and perinatal outcomes of women with pneumonia complicating pregnancy.

METHODS

Between 1989 and 1993, we admitted 71 pregnant women for treatment of community-acquired pneumonia. Exposure and outcome variables as well as characteristics of their clinical course were identified and analyzed. Two-sample Wilcoxon rank-sum and Fisher exact tests were used for statistical analyses.

RESULTS

Five women had adverse pregnancy outcomes related to pneumonia: two maternal-fetal deaths, one preterm delivery, one fetal death, and one early abortion. Compared with women whose pregnancies went to term, these five women had a significantly lower mean oxygen pressure on admission (68 versus 83 mmHg). Other risk factors for adverse outcome included diffuse radiologic pulmonary involvement and current smoking of more than ten cigarettes per day. Neither illicit drug use nor anemia were risk factors. Although 31 of these 71 women had underlying chronic diseases, these were not associated with negative outcomes.

CONCLUSIONS

Despite prompt hospitalization and treatment, antepartum pneumonia is potentially serious, even in young, otherwise healthy women. Although underlying maternal disease appears to be related to the development of antepartum pneumonia, we did not confirm previous reports that suggested its relation to adverse pregnancy outcome.

Comparison of prophylactic angiotensin II versus ephedrine infusion for prevention of maternal hypotension during spinal anesthesia

OBJECTIVE

Our purpose was to study the efficacy of ephedrine versus angiotensin II prophylactic infusions to counter maternal hypotension that occurs during spinal anesthesia at cesarean delivery.

STUDY DESIGN

Healthy pregnant women undergoing elective repeat cesarean delivery at term with spinal anesthesia were randomized either to a control group (n = 10) or to one of two prophylactic infusion groups: angiotensin II (n = 10) or ephedrine (n = 10). Prophylactic infusions were titrated to a maternal diastolic blood pressure 0 to 10 mm Hg above baseline. Maternal and fetal blood samples for angiotensin II levels and acid-base status were obtained. Student's t test, chi 2, and analysis of variance were used.

RESULTS

Mean arterial pressures were maintained after spinal anesthesia in the ephedrine and angiotensin II groups but decreased (p < 0.05) in the control group. Maternal angiotensin II levels rose with angiotensin II infusions but were unaltered in the other groups. Umbilical artery and vein angiotensin II levels were unaltered by angiotensin II infusions. Mean umbilical artery blood pH was lower (p < 0.05) in the ephedrine group than in the angiotensin II and control groups.

CONCLUSIONS

In the healthy term fetus there is an advantage in using angiotensin II to maintain maternal blood pressure during regional anesthesia.

Acid-base significance of meconium discovered prior to labor

Although the significance of meconium in the amniotic fluid diagnosed during labor remains problematic, there is little information regarding the significance of meconium discovered prior to labor. The present study consisted of 40 term pregnancies with meconium found at amniocentesis for lung maturity (n = 7) or elective cesarean section (n = 33) and 40 uncomplicated, control pregnancies with clear amniotic fluid at elective cesarean section. The mean umbilical artery (UA) blood pH was 7.26 in the meconium group and 7.28 in the control group. Overall, the frequency of fetal acidemia (UA pH < 7.20) was 15% (6 of 40) of the infants in the meconium group versus 8% (3 of 40) in the control group (p = 0.24). All nine of these infants had a respiratory acidosis defined as a UA blood pH less than 7.20 with normal bicarbonate and elevated carbon dioxide pressure. Importantly, none of the neonates had metabolic acidemia and all had uncomplicated hospital courses. All of the pregnancies reported were promptly delivered because of meconium and we therefore cannot recommend nonintervention when meconium is diagnosed in the antepartum period. Meconium discovered prior to labor is not necessarily a marker of immediate or chronic fetal compromise.

Survey of forceps delivery in North America in 1990

OBJECTIVE

To determine whether opinions and practice patterns have markedly changed over the past decade and whether clinicians are cognizant of the new ACOG definitions for forceps deliveries.

METHODS

Two hundred ninety-five United States and Canadian residency programs were surveyed via a questionnaire; 203 (69%) responded. Statistical analysis was performed using the chi 2 test, Yates correction factor, and the extended Mantel-Haenszel test.

RESULTS

All but two program directors (99%) were familiar with the new definitions, which were being used by 162 (80%) of the programs. All institutions used outlet and low forceps, although 14% no longer performed midforceps deliveries. Attending faculty were the primary instructors in 67% of United States and 100% of Canadian programs. Simpson forceps were the most commonly used for outlet (46%) and low (43%) forceps deliveries. Kielland (27%) and Simpson (24%) instruments were most commonly used for midforceps deliveries.

CONCLUSION

Although the rate of midforceps use decreased, operative vaginal delivery was still commonly taught in residency programs in North America in 1990.

Sexual assault in postmenopausal women

OBJECTIVE

To examine patient characteristics, patterns of injury, forensic evidence, and the frequency of sexual assault in postmenopausal rape victims from 1986-1991.

METHODS

Medical and forensic records were reviewed from 129 postmenopausal women (50 years of age or older) and 129 women from a comparison group (14-49 years of age) who reported having been sexually assaulted. Statistical analysis was performed by Student t test, chi 2, multiple logistic regression, or Fisher exact test.

RESULTS

Postmenopausal women represented 2.2% of women reporting sexual assault in Dallas County. The postmenopausal victim was more often white (64%), whereas the younger victim was more often black (53%). Drug or alcohol use within the previous 24 hours was more common in the younger group. Trauma, in general, was common, occurring in 67% of the postmenopausal women and 71% of the younger group (P = not significant). Genital trauma was more common in the postmenopausal group (43 versus 18%; P < .001). Nearly one in three postmenopausal women had genital abrasions or edema. Almost one in five older women had genital lacerations, with one in four severe enough to require surgical repair. In contrast, the frequency of extragenital trauma was more common in younger victims (66 versus 49%; P < .01). Forensic findings were similar in both groups; however, in postmenopausal women motile spermatozoa were seen only in those examined within 6 hours of the assault.

CONCLUSION

Postmenopausal women who have been sexually assaulted are more likely to sustain genital trauma than younger victims.

Early repair of episiotomy dehiscence associated with infection

OBJECTIVE

The purpose of our study was to examine early repair of episiotomy dehiscences in a large urban hospital setting serving a predominantly indigent population.

STUDY DESIGN

Since September 1, 1989, we have proceeded with early repair in the immediate postpartum period. The medical records of 34 of 35 patients who underwent early repair were reviewed.

RESULTS

Of the 34 patients, 21 (62%) had midline and 13 (38%) had mediolateral episiotomies. Dehiscence was associated with episiotomy infection in 27 (79%) of the 34 patients: 18 (86%) in the midline group and 9 (69%) in the mediolateral group. Repair was accomplished from 3 to 13 days (mean = 6.4) after dehiscence. Successful repairs were accomplished in 32 (94%) of 34 patients. Two (6%) patients with initial third-degree episiotomies had a subsequent breakdown of their repairs and were allowed to heal by secondary intention.

CONCLUSIONS

Although most dehiscences in our population were associated with infection, early repair in this population is associated with a satisfactory outcome in the vast majority.

The prevalence of sexual assault: a survey of 2404 puerperal women

OBJECTIVE

The purpose of this investigation was to determine the prevalence of sexual assault, to characterize pregnancy complications, and to report pregnancy outcomes of assault victims.

STUDY DESIGN

Puerperal women (n = 2404) were interviewed regarding a history of forced sexual contact. Obstetric, medical, and forensic records were reviewed. Statistical analysis was performed by Student t test, chi 2 test, or Fisher's exact test.

RESULTS

The lifetime prevalence of sexual assault in this obstetric population was 5% (n = 120). Rape victims had a higher incidence of sexually transmitted diseases (9% vs 4%, p < 0.01), urinary tract infections or vaginitis (32% vs 21%, p = 0.02), drug use (9% vs 2%, p < 0.001), and multiple hospitalizations during the index pregnancy (15% vs 8%, p < 0.01). There was no difference between victims and nonvictims in neonatal outcome as reflected by umbilical artery blood pH, gestational age, or birth weight.

CONCLUSIONS

A history of sexual assault is common in an urban indigent obstetric population. These women have more frequent pregnancy complications but achieve normal pregnancy outcomes.