[Induce or not induce labor in gestational diabetes]

The most serious hazard of gestational diabetes is shoulder dystocia, which sometimes is complicated by Erb's palsy and maternal lacerations. This risk is linked to fetal weight, and is more frequent in cases of diabetes. So, a caesarean section performed when macrosomia is present is required and an induction of labor before severe macrosomia is proposed. Unfortunately, estimation of fetal weight is imprecise in spite of formulas from fetal parameters. Abdomen circumference (AC) alone is as effective as complex formulas. So, it is proposed to perform an elective section when AC is equal or above 38 cm, and to induce labor, after 38 weeks of gestation, for limiting the risk of macrosomia when AC is between 35 and 38 cm. Induction is also proposed when pregnancy is complicated by hypertension or when fetal heart septal hypertrophy occurs. The management of gestational diabetes means a strict control of glycemia, which can reduce macrosomia and the need for cesarean section or induction of labor.

[Investigations about kind and frequency of mechanical dystocia in ewes with special regard to the vaginal prolapse ante partum]

The incidence of dystocia from ewes in nine lambing periods (1992-2000) was recorded at an obstetrical clinic. First we analysed parturition difficulties in normal pregnant sheep (group 1, n = 229). In the second group parturitions of ewes with vaginal prolapse ante partum were investigated (n = 129). In group 1 maternal causes of dystocia occurred more often than fetal ones (50% maternal, 45% fetal). In maternal parturition difficulties ringwomb was the dominating reason (64%), while abnormal presentations, position and/or posture of the lambs occurred most frequently in fetal dystocia (67%). But there was no statistical influence of age and number of parturitions in both groups. The average of the first notice of prolapsed vaginal tissue was 11 days before lambing. There was a predominance in the affection of sheep at first and second pregnancy (52%). Only 26% of the group 2 sheep had a spontaneous delivery. In 58% of the cases a dystocia was diagnosed. A preterm caesarean section had carried out in 12%, five ewes died before parturition because of septicemia (4%). Sheep suffering from vaginal prolapse ante partum showed maternal caused dystocia significant more frequently than members of group 1 (p < 0.001), with ringwomb as dominating reason (70%). The number of born lambs was significant higher in group 2 than in group 1 (p = 0.019).

MR imaging pelvimetry: a useful adjunct in the treatment of women at risk for dystocia?

OBJECTIVE

The objective of this study was to test the clinical value of MR imaging for diagnosing cephalopelvic disproportion and for predicting labor outcome in women at risk for dystocia.

SUBJECTS AND METHODS

Antepartum fetal sonography and maternal MR imaging pelvimetry measurements were performed at term in 38 pregnant women at risk for dystocia with a single fetus in cephalic presentation. Various methods used to diagnose cephalopelvic disproportion were evaluated in a blinded manner for their accuracy to predict both the presence of cephalopelvic disproportion and the mode of delivery (vaginal vs cesarean).

RESULTS

None of the methods tested yielded both high sensitivity (15-100%) and high specificity (24-92%) for determining the presence of cephalopelvic disproportion and high levels of accuracy for predicting labor outcome (overall predictability, 50-74%).

CONCLUSION

To achieve increased reliability of MR imaging pelvimetry in the diagnosis and treatment of dystocia and in predicting labor outcome, new methods assessing fetal-pelvic compatibility, including measurements of the pelvic outlet and the shape and configuration of the pelvis, need to be established and prospectively tested before firm recommendations for clinical use can be made.

Gross deciduosis peritonei obstructing labor: a case report and review of the literature

Gross deciduosis peritonei is a rare lesion characterized by the presence of grossly visible peritoneal decidual tissue in pregnant women; we present the clinicopathologic features of one such case. A 24-year-old, G4P1A2, Hispanic female underwent cesarean section at 39 weeks' gestation for dystocia related to pelvic masses. Multiple, light tan peritoneal masses involved the cul-de-sac, both ovaries, pelvic wall, omentum, and the large and small bowel. The intraoperative appearance suggested peritoneal carcinomatosis. A right ovarian mass was excised and biopsies were obtained from other sites. Microscopic examination showed the typical features of decidua in all of the lesions. Two weeks postoperatively, the patient was admitted with nausea and vomiting suggestive of a small bowel obstruction, which resolved after 2 days of medical treatment. After a postpartum visit at 5 weeks, the patient was lost to follow-up.

[Fetal macrosomia: management, obstetrical and neonatal results. Multicenter case-control study in 15 maternity hospitals in Paris and the Ile de France area]

OBJECTIVE

To study the perinatal management of fetal macrosomia (FM) and the obstetrical and neonatal results related to FM in the Ile de France area.

MATERIALS AND METHODS

Case-control study from the fifteenth of July to the fifteenth of September 1999 in fifteen maternity in Paris and the Ile de France area. All singletons, without malformation, weighing more than 4,000 grams, born after 37 weeks of pregnancy during the study were included. The control group had the same inclusion and exclusion criteria (except the birth-weight) and was defined by the next delivery of same parity.

RESULTS

384 FM and 384 controls have been included. Usual risk factors of macrosomia have been found. The screening of gestational diabetes was realised in 56.8% and FM was suspected before delivery in 59.3% in the FM group. In cases of FM, the midwife was alone at the time of delivery in 53.4% of spontaneous vaginal delivery. FM was associated with a longer labour and a more frequent use of oxytocin. There was six times more severe perineal tears (1.7 vs 0.3%; p = 0.05) for women with FM whereas the rate of haemorrhage at delivery was the same in both groups. Cesarean section' rate before and during labor was higher in the FM group whereas instrumental extraction was not different. In this study, FM was not associated with an excess of fetal morbidity (injury, Apgar score, pH cord) even if we found ten times more shoulder dystocia.

CONCLUSION

Complications related to FM were mainly maternal in this study. Some recommendations accounting fetal macrosomia were not widely adopted as screening of gestational diabetes or necessity to have a whole obstetric team at the time of delivery.

Vesical calculus causing dystocia

Vesical calculus is a rare cause of dystocia. We report a case in a 22-year-old primigravida.

[Dystocia: frequency and risk factors in seven areas in West Africa]

OBJECTIVES

1) To measure the incidence of dystocia in six cites and one rural area in West Africa. 2) To identify risk factors of dystocia and analyze their interrelationships with the goal to potentially use them to identify high-risk pregnant women attending antenatal consultations. (3) To assess their usefulness as predictors of dystocia during pregnancy.

METHODS

The MOMA study is a prospective population-based follow-up study of 20,326 pregnant women in West Africa. Due to the likely diagnostic and recall bias for home deliveries, risk factors for dystocia were analyzed only for deliveries in health facilities. A total of 16,318 deliveries were analyzed.

RESULTS

The incidence of dystocia was 18.3% (95%CI: 17.7-18.9). Multivariate analysis using stepwise logistic regression disclosed the following significant risk factors: short stature, scarred uterus, nulliparity. Positive predictive values were very low for both univariate and multivariate analysis.

CONCLUSION

The incidence of dystocia, which occurs mainly at delivery, is high in West Africa. Consequences are often dramatic, both for the fetus and the mother. None of the risk factors studied, even when used in combination, provided a good prediction of dystocia. All pregnant women should therefore be considered at risk of dystocia. Efforts should be made to detect dystocia during labor (partography) and to provide good-quality emergency obstetric care. Emergency obstetric care must be made available to all pregnant women. This goal can be achieved in most of the major West African cities. More facilities offering good-quality cesarean section must be made available.

[Fetotomy in cattle with special reference to postoperative complications--an evaluation of 131 cases]

In the course of this retrospective study on fetotomy of cattle 131 operations were evaluated. The case studies put the cattle 2 to 96 hours into labour (average 13 hours). The cows that exhibited post-operative complications were on average 19.2 hours into labour prior to the operation. Those which had a normal puerperium however were only 8.4 hours, on average, in labour. 79% of the animals showed depressed general health on admission, 8% of which were unable to stand. The main cause of the dystocia was the incorrect position/orientation of the dead foetus (38.9%) as well as relative or absolutely too large calves (25.2%). In 14.5% of the cases the offspring were malformed causing the dystocia. 28 of the protracted births were due to both maternal as well as foetal causes. Mortality of the cows lay by 6.9%, irregularities in the puerperal period ran at 67.2%. The age of the mother did not seem to influence the post operative events. The most common complication was retained placenta (n = 49; 37.4%) followed by lochiometra (n = 21; 16%), vaginal wounds and pelvic phlegmons (each n = 16; 12.2%) and neurotripsy (n = 6; 12.2%). Of these puerperal complications the pelvic phlegmon required the longest post-operative care (14.3 days, retention secundinarum was cured in 13 days, lochiometra in 8.8, cows without complaint were treated for 3.8 days after the operation). The most important factors for the post-operative prognosis are the time in labour and any trauma of the soft birth canal which influence the forming of pelvic phlegmons.

Influence of persistent occiput posterior position on delivery outcome

OBJECTIVE

To evaluate the influence of intrapartum persistent occiput posterior position of the fetal head on delivery outcome and anal sphincter injury, with reference to the association with epidural analgesia.

METHODS

We conducted a prospective observational study of 246 women with persistent occiput posterior position in labor during a 2-year period, compared with 13,543 contemporaneous vaginal deliveries with occiput anterior position.

RESULTS

The incidence of persistent occiput posterior position was significantly greater among primiparas (2.4%) than multiparas (1.3%; P <.001; 95% confidence interval 1.4, 2.4) and was associated with significantly higher incidences of prolonged pregnancy, induction of labor, oxytocin augmentation of labor, epidural use, and prolonged labor. Only 29% of primiparas and 55% of multiparas with persistent occiput posterior position achieved spontaneous vaginal delivery, and the malposition was associated with 12% of all cesarean deliveries performed because of dystocia. Persistent occiput posterior position was also associated with a sevenfold higher incidence of anal sphincter disruption. Despite a high overall incidence of use of epidural analgesia (47% versus 3%), the institutional incidence of persistent occiput posterior position was lower than that reported 25 years ago.

CONCLUSION

Persistent occiput posterior position contributed disproportionately to cesarean and instrumental delivery, with fewer than half of the occiput posterior labors ending in spontaneous delivery and the position accounting for 12% of all cesarean deliveries for dystocia. Persistent occiput posterior position leads to a sevenfold increase in the incidence of anal sphincter injury. Use of epidural analgesia was not related to the malposition.

Clinical impact of mild carbohydrate intolerance in pregnancy: a study of 2904 nondiabetic Danish women with risk factors for gestational diabetes mellitus

OBJECTIVE

The objective was to study the clinical impact of mild carbohydrate intolerance in pregnant women with risk factors for gestational diabetes mellitus.

STUDY DESIGN

This was a historical cohort study of 2904 pregnant women examined for gestational diabetes on the basis of risk factors. Information on oral glucose tolerance test results and clinical outcomes was collected from laboratory charts and medical records.

RESULTS

The following outcomes increased significantly with increasing glucose values during the oral glucose tolerance test: shoulder dystocia, macrosomia, emergency cesarean section, assisted delivery, hypertension, and induction of labor. However, when corrections were made for other risk factors, hypertension and induction of labor were only marginally associated with glucose levels.

CONCLUSION

In a group of nondiabetic pregnant women with risk factors for gestational diabetes, there was a graded increase in the frequency of shoulder dystocia and other maternal-fetal complications with increasing glucose levels during an oral glucose tolerance test.

Maternal and neonatal outcomes in pregestational and gestational diabetes mellitus, and the influence of maternal obesity and weight gain: the DEPOSIT study. Diabetes Endocrine Pregnancy Outcome Study in Toronto

We prospectively studied pregnancy outcome in 428 women with gestational diabetes mellitus (DM) and 196 women with pregestational DM, with particular reference to the influence of maternal obesity and excessive weight gain. These were consecutive singleton pregnancies delivered in our institution over 5 years. After controlling for multiple risk factors, including maternal BMI and pregnancy weight gain, women with pregestational DM were at increased risk (compared to those with gestational DM) for Caesarean delivery (OR 3.6, 95%CI 2.3-5.6), shoulder dystocia or cephalopelvic disproportion (OR 2.2, 95%CI 1.3-3.6), and gestational hypertension or toxaemia (OR 3.0, 95%CI 1.7-5.4). The offspring of these women were also at increased risk for admission to the neonatal intensive care unit (OR 4.0, 95%CI 2.3-6.8), large-for-gestational-age birthweight (OR 3.5, 95%CI 2.2-5.6), and preterm birth before 37 weeks (OR 3.8, 95%CI 2.5-5.9). Maternal obesity, and, to a lesser degree, excessive weight gain, were also independent risk factors for all these adverse maternal and neonatal outcomes, regardless of the type of DM, except for shoulder dystocia/cephalopelvic disproportion.

[Shoulder dystocia--consequences and procedures]

Shoulder dystocia is defined as a standstill of delivery after the birth of the head and is attributed to an insufficient rotation of the shoulder. Risk factors include a history of prior macrosomia or shoulder dystocia, maternal obesity or excessive weight gain during pregnancy, maternal diabetes or postdate pregnancy and prolonged descent or midpelvic operative delivery. Neonatal morbidities associated with traumatic birth include fetal hypoxia with acidosis and permanent brachial plexus injury.

THERAPY

After the recognition of a shoulder dystocia a series of steps should be undertaken beginning with cutting or extending the episiotomy, McRobert's Manoeuvre, Wood's Manoeuvre and delivery of posterior arm. A tocolytic administered as a bolus or general anesthesia also may be needed. Documentation should include the exact time the dystocia was recognized by the midwife and/or obstetrician, the time at which intervention was started and a detailed operative report.

How to predict recurrent shoulder dystocia

OBJECTIVE

Our aim was to determine the rate and risk factors for recurrent shoulder dystocia.

STUDY DESIGN

A retrospective analysis of patients diagnosed with shoulder dystocia was performed by searching a computerized database from January 1, 1993, to June 30, 1999 for the following information: (1) vaginal deliveries, either spontaneous or operative, (2) shoulder dystocia, (3) birth weight, (4) duration of second stage of labor, (5) parity, and (6) gestational diabetes. Statistical analyses included chi(2) and t test.

RESULTS

There were 39,681 vaginal deliveries with 602 (1.5%) complicated by shoulder dystocia. Sixty-six patients underwent a subsequent vaginal delivery, and 11 (16.7%) experienced another shoulder dystocia. The odds ratio for a recurrent shoulder dystocia was 10.98 (P <.000001). Nine of the 11 patients with recurrent shoulder dystocia compared with 28 of 55 without a recurrence were nulliparous women in their index pregnancy (P <.001). The mean fetal weights were 3885 g in the recurrent dystocia group and 3702 g in the group without recurrence (P <.03). Gestational age, operative delivery, and gestational diabetes were similar in the two groups.

CONCLUSION

Factors that appear to increase the recurrence risk of shoulder dystocia include fetal weight and maternal parity. Prior shoulder dystocia is the single greatest predictive factor.

Risk factors for dystocia in farmed red deer (Cervus elaphus)

OBJECTIVE

To analyse data from a study of deer herd health and productivity to identify potential risk factors for the occurrence of dystocia.

DESIGN

A 2-year longitudinal observational study of 14 red deer farms was carried out in New Zealand. About 2700 hinds were monitored each year for individual characteristics including body condition score (BCS), and reproductive performance. Grazing and calving management practices were recorded. During calving, farmers recorded calving difficulties (dystocia) that needed human assistance or caused the death of the hind. Risk factors potentially affecting the occurrence of dystocia were identified and analysed by multivariable statistical techniques.

RESULTS

The percentage of hinds with dystocia was 0.52% (95% CI 0.32 to 0.78). Hinds with a post-winter BCS over 3.5 were 2.7 times as likely to experience dystocia as hinds scoring 3.5 or less. Given the same BCS class, bodyweight gain in late pregnancy was associated with an increased risk of dystocia. Grazing steep paddocks in the last trimester of pregnancy decreased the risk of dystocia in hinds with a BCS over 3.5.

CONCLUSIONS

The risk of dystocia on red deer farms may be reduced if key individual animal, management and environmental factors are optimal.

Management of cervical cerclage at term: remove the suture in labor?

OBJECTIVE

To assess the risks and benefits to patients who carry to term after undergoing a Shirodkar cerclage where the cerclage is not removed until the patient presents in labor.

METHODS

A retrospective analysis was conducted examining all patients who underwent a Shirodkar cerclage employing a 5 mm Mersilene band. All the cerclages were placed by a single operator over a twenty five year span, from 1/01/74 till 10/01/98. Only patients who delivered vaginally or were allowed a trial of labor were included. In all cases, the cerclage was removed under regional anesthesia after the patient presented to the hospital in labor.

RESULTS

Ninety six cerclage procedures were performed over that period. Eighty two pregnancies qualified for review. Sixty two patients delivered vaginally (76%). Nine cesareans were indicated for failure to progress in labor (11%) with cervical dystocia possibly implicated in one. There were no cases of ruptured uteri or the development of uterine windows. Of the 82 pregnancies there were five cases (6%) of minor cervical laceration.

CONCLUSION

Allowing patients to proceed to labor with a Shirodkar, cerclage in place, does not increase the risks of cervical dystocia, cervical laceration, or uterine rupture above the reported incidence for these complications in patients in whom the cerclage is removed prophylactically.

Sacrococcygeal teratoma: 25 year experience

We retrospectively studied all thirty-five children (M 6, F 29) with sacrococcygeal teratomas admitted to Siriraj Hospital between 1974 and 1999. Although an abdominal delivery is recommended for lesions greater than 5 cm to avoid dystocia, the average diameter of masses which required interventions from dystocia (n = 3) was not different from vaginal delivery (n = 27). All except two first presented with sacral masses recognized at birth. One patient presented with an abdominal mass and the last one was diagnosed after suffering from difficulty in urination. Ninety-seven per cent of cases were completely excised initially (32 sacral, 2 abdomino-sacral approaches), however, six patients required other treatment for recurrent diseases. One mature teratoma recurrence was resected. Two patients who had malignant recurrences following complete benign excisions, died from advanced malignancy. Four presented with malignancy initially. Wound infection, bladder atony and UTI were the most common complications postoperatively. Advanced malignancy was the major cause of death. No patient died directly from the procedure.

Management of suspected fetal macrosomia

Fetal macrosomia, arbitrarily defined as a birth weight of more than 4,000 g (8 lb, 13 oz) complicates more than 10 percent of all pregnancies in the United States. It is associated with increased risks of cesarean section and trauma to the birth canal and the fetus. Fetal macrosomia is difficult to predict, and clinical and ultrasonographic estimates of fetal weight are prone to error. Elective cesarean section for suspected macrosomia results in a high number of unnecessary procedures, and early induction of labor to limit fetal growth may result in a substantial increase in the cesarean section rate because of failed inductions. Pregnancies complicated by fetal macrosomia are best managed expectantly. When labor fails to progress as expected, the possibility of fetopelvic disproportion should be considered within the context of the best estimate of the fetal weight.

Fetal abdominal circumference measurements of 35 and 38 cm as predictors of macrosomia. A risk factor for shoulder dystocia

OBJECTIVE

To determine if ultrasound measurements of fetal abdominal circumference (AC) can be used to predict macrosomic infants.

STUDY DESIGN

Using a computer database, 1,996 women at > or = 36 weeks' gestation, delivering a singleton infant and having an ultrasound examination within one week of delivery were studied. Fetal AC was evaluated to determine if it was useful in predicting the birth of a macrosomic infant, > 4,000 or > 4,500 g.

RESULTS

AC predicted infants > 4,500 g better than those > 4,000 g. Almost all macrosomic infants > 4,500 g had an AC of > or = 35 cm (68/69, or 99%), but many nonmacrosomic infants were also in this group (683). AC of > or = 38 cm occurred in 99 infants, and 37 of the 69 (53.6%) weighing > 4,500 g were identified. Most infants (78%) with AC > or = 38 cm weighed > 4,000 g.

CONCLUSION

Fetal AC was very helpful in identifying potential macrosomic infants. If AC was < 35 cm, the risk of infant birth weights > 4,500 g was < 1%. If AC was > or = 38 cm, the risk was 37% (37/99), and > 50% of these infants were identified (37/69, or 53.6%).

Antepartum risks of shoulder dystocia and brachial plexus injury for infants weighing 4,200 g or more

A cohort of 236 vaginally delivered neonates weighing > or = 4,200 g was evaluated. Shoulder dystocia was encountered in 27 deliveries (11.4%) and brachial plexus injury was diagnosed in 3 infants (1.3%). The 'traditional' antepartum risk factors could not be associated with shoulder dystocia. In this cohort, primiparity was significantly more frequent among the dystocia cases (OR = 8.58, 99% CI = 1.35-54.35, p = 0.021). Shoulder dystocia could not be attributed to a particular difference between the current and the previous heaviest birth weight. A policy of cesarean section for all infants weighing > or = 4,200 g would result in at least 5- to 6-fold increase in cesarean rate in this group of patients. Our data reconfirm that shoulder dystocia and brachial plexus injury are unpredictable, even in macrosomic infants. It is a matter of policy whether to accept the expected 1:9 and 1:79 respective risks associated with vaginal births.