Management options in women with preterm uterine contractions: a randomized clinical trial

OBJECTIVE

Our purpose was to evaluate three management strategies and to assess pregnancy outcomes in women with preterm uterine contractions.

STUDY DESIGN

Consenting women seen in our hospital triage area with preterm uterine contractions were randomly assigned to observation alone, intravenous hydration, or one dose of subcutaneous terbutaline sulfate (0.25 mg). Eligible women had a singleton gestation between 20 and 34 weeks, intact membranes, more than three contractions in 30 minutes, and a cervical dilation < or = 1 cm and effacement < 80%. Women who had progressive cervical change at < 34 weeks were treated with intravenous tocolysis. Women with recurrent preterm uterine activity remained in their assigned group during subsequent triage visits.

RESULTS

One hundred seventy-nine women were randomized: observation (56), hydration (62), and terbutaline (61). Women in these three groups were similar with respect to maternal age, race, parity, prior preterm births, gestational age at randomization, contraction frequency, and mean cervical dilatation. There were no intergroup differences in the mean days to delivery, the number of repeat triage visits, the incidence of preterm labor at < 34 weeks, or the frequency of preterm deliveries at < 34 weeks and < 37 weeks. Women assigned to terbutaline had contractions stopped and were discharged earlier (terbutaline 4.1 +/- 5.1 hours, observation 5.2 +/- 5.3 hours, hydration 6.0 +/- 5.7 hours; p = 0.006). No complications of therapy were observed.

CONCLUSIONS

The use of intravenous hydration in the management of preterm contractions was of no benefit. The use of one dose of subcutaneous terbutaline resulted in the shortest length of triage stay but did not affect pregnancy outcome.

Free beta-hCG subunit versus intact hCG in Down syndrome screening

OBJECTIVE

To assess the ability of second-trimester maternal serum free beta-hCG to detect fetal Down syndrome and to compare free beta-hCG to intact hCG in the multiple-marker screening test for Down syndrome.

METHODS

From our bank of stored maternal sera, we selected 40-50 samples from euploid pregnancies at each week of gestation from 14 to 20 weeks and 31 samples from Down syndrome pregnancies. Free beta-hCG was measured by enzyme-linked immunosorbent assay, and week-specific multiples of the median (MoM) were derived. The free beta-hCG Down syndrome detection and false-positive rates were determined. Free beta-hCG was then substituted for intact hCG in the multiple-marker screening test, and the Down syndrome detection and false-positive rates at various risk cutoffs were compared.

RESULTS

The mean (+/-standard deviation) maternal age of all study samples was 35.6 +/- 5.3 years. The mean Down syndrome free beta-hCG MoM was significantly higher than the mean euploid MoM (2.4 +/- 1.1 versus 1.2 +/- 1.0; P < .001). A free beta-hCG level of at least 1.7 MoM identified 68% of Down syndrome pregnancies at a false-positive rate of 20%. When intact hCG was replaced with free beta-hCG in the multiple-marker screening test, a higher Down syndrome detection rate was achieved at a lower false-positive rate at each of several screen positive risk cutoffs.

CONCLUSION

Elevated free beta-hCG levels identify Down syndrome pregnancies. Replacing intact hCG with free beta-hCG in the multiple-marker screening test results in a higher Down syndrome detection rate at a lower false-positive rate.

Second-trimester maternal serum CA-125 versus estriol in the multiple-marker screening test for Down syndrome

OBJECTIVE

To determine the ability of second-trimester maternal serum CA-125 levels to detect fetal Down syndrome.

METHODS

From stored, second-trimester maternal serum analyzed previously with the multiple-marker screening test for fetal Down syndrome, we selected 306 samples from euploid pregnancies and 22 samples from Down syndrome pregnancies at 14-20 weeks' gestation. CA-125 levels were measured by enzyme-linked immunosorbent assay and converted to gestational week-specific multiples of the median (MoM).

RESULTS

The mean maternal age (+/- standard deviation) of the study population was 35.5 +/- 5.3 years. The Down syndrome group CA-125 mean MoM was significantly higher than the euploid group mean MoM (1.47 +/- 0.51 MoM versus 1.05 +/- 0.44 MoM; P < .001). CA-125 at or above 1.5 MoM identified 10 of 22 (45%) Down syndrome cases. Substituting CA-125 for estriol (E3) in the multiple-marker screening test resulted in a lower screen-positive rate (67 of 328, 20% [95% confidence interval {CI} 16, 25] versus 91 of 328, 28% [95% CI 23, 33]) with a similar Down syndrome detection rate (18 of 22, 82%). Alternatively, when the screen-positive rate was held constant, the Down syndrome detection rate improved (20 of 22, 91% [95% CI 71, 99] versus 18 of 22, 82% [95% CI 60, 95]).

CONCLUSIONS

Down syndrome pregnancies have higher second-trimester maternal serum CA-125 levels than euploid pregnancies. CA-125 may be superior to E3 in the multiple-marker screening test for fetal Down syndrome.

One- versus two-layer closure of a low transverse cesarean: the next pregnancy

OBJECTIVE

To determine whether a low transverse cesarean closure method in one or two layers affects subsequent pregnancy outcome.

METHODS

In a prospective trial reported previously, 906 women were assigned randomly to either one- or two-layer uterine closure. One hundred sixty-four women had a subsequent pregnancy and delivery (18 weeks' gestation or longer) at our institution. Maternal and neonatal outcomes were ascertained by medical chart review and compared between the one- and two-layer closure groups.

RESULTS

Of the 164 subsequent deliveries, 83 had previous closure in one layer, whereas 81 had involved a two-layer closure. The demographic characteristics of these two groups were similar. Nineteen women (12%) underwent elective repeat cesareans without labor, and the remaining 145 experienced labor. Length of labor, mode of delivery, duration of hospital stay, gestation at delivery, and the incidences of uterine scar dehiscence, chorioamnionitis, postpartum metritis, hemorrhage, transfusion, and abnormal placentation did not differ significantly between the groups. Selected neonatal outcomes, including Apgar scores, cord pH, birth weight, and perinatal death, were similar between groups as well.

CONCLUSIONS

These findings suggest that the type of low transverse cesarean closure does not significantly affect the outcome of the next pregnancy.

Preterm delivery after indomethacin. A risk factor for neonatal complications?

OBJECTIVE

To determine if tocolytic therapy with indomethacin is associated with an increased risk of neonatal complications in infants born prior to 32 weeks' gestation.

STUDY DESIGN

We performed a retrospective matched cohort study of infants born between 24 and 31(6)/7 weeks' gestation. The 62 cases (indomethacin treatment) and the 62 controls were matched by week of gestation, prenatal betamethasone exposure and multifetal gestation.

RESULTS

The mean gestational age of the two groups was 28.5 +/- SD weeks. The median total dose of indomethacin was 425 mg, the median treatment duration was three days, and the median interval from the last dose of indomethacin until delivery was one day. There was no significant difference between the groups in the incidence of necrotizing enterocolitis, intraventricular hemorrhage, patent ductus arteriosis, sepsis or neonatal death.

CONCLUSION

The use of indomethacin for tocolysis was not associated with an increased risk of neonatal complications in infants born between 24 and 31(6)/7 weeks' gestation.

Second-trimester cystic hygroma: prognosis of septated and nonseptated lesions

OBJECTIVE

To compare karyotypic, ultrasonographic, and prognostic features of septated cystic hygromas and nonseptated cystic hygromas in second-trimester fetuses.

METHODS

A computerized ultrasound data base was used to identify fetuses diagnosed with cystic hygromas at 14-22 weeks' gestation. Photographs from the initial ultrasound were reviewed retrospectively for hygroma type (septated or nonseptated) and any abnormal structural findings. Fetal karyotypes were obtained from amniotic fluid, aspiration of hygroma pouches, or fetal tissue culture. Pregnancy outcome information was obtained from hospital charts and physician office records. Ultrasound findings were then compared with fetal karyotype results and pregnancy outcome data.

RESULTS

From 1990 to 1995, 61 fetuses with cystic hygromas were identified. Karyotypes were obtained in 55 fetuses, and pregnancy outcome was available for 59. Abnormal karyotype was present in 42 of 55 fetuses (76%). The most common chromosomal abnormality in septated hygromas was the 45,X karyotype. Trisomy 21 was the most common chromosomal abnormality in nonseptated hygromas. Compared with fetuses with nonseptated cystic hygromas, those with septated cystic hygromas were more likely to be aneuploid (33 of 39 [85%] versus nine of 16 [56%]; P = .03), more likely to develop hydrops (27 of 45 [60%] versus three of 16 [19%]; P = .005), and less likely to be live-born (one of 44 [2%] versus four of 15 [27%]; P = .01).

CONCLUSIONS

Fetuses with septated cystic hygromas are more likely to be aneuploid and to develop hydrops, and thus are less likely to be survive than fetuses with nonseptated hygromas.

The effectiveness and costs of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound

OBJECTIVE

To quantitate the potential effectiveness and monetary costs of a policy of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound.

DESIGN

A decision analytic model was constructed to compare 3 policies: (1) management without ultrasound; (2) ultrasound and elective cesarean delivery for estimated fetal weight of 4000 g or more (4000-g policy); and (3) ultrasound and elective cesarean delivery for estimated fetal weight of 4500 g or more (4500-g policy). The impact of maternal diabetes was analyzed separately. Probability data used in the decision analytic model were summarized from the literature and supplemented with unpublished data from the Collaborative Trial of Preterm Birth Prevention. Costs were estimated from the literature, regional reimbursements, and clinical practice data.

MAIN OUTCOME MEASURES

Rates of shoulder dystocia and permanent brachial plexus injury, and both the number of additional cesarean births and monetary costs per permanent brachial plexus injury averted.

RESULTS

In the baseline analysis for nondiabetic women, the ultrasound policies increased both the cesarean delivery rate and costs, while decreasing the rate of shoulder dystocia and brachial plexus injury. For each permanent brachial plexus injury prevented by the 4500-g policy, 3695 cesarean deliveries were performed at an additional cost of $8.7 million, vs 2345 cesarean deliveries and $4.9 million with the 4000-g policy. In the baseline analysis for diabetic women, with all 3 policies, rates of cesarean delivery, shoulder dystocia and brachial plexus injury, and total costs were higher than for nondiabetic women. However, more favorable ratios for both cesarean deliveries and cost per permanent injury avoided were observed: 443 deliveries and $930 000, respectively, with the 4500-g policy, and 489 deliveries and $880 000, respectively, with the 4000-g policy. Sensitivity analysis confirmed the general robustness of these findings.

CONCLUSIONS

For the 97% of pregnant women who are not diabetic, a policy of elective cesarean delivery for ultrasonographically diagnosed fetal macrosomia is medically and economically unsound. In pregnancies complicated by diabetes, such a policy appears to be more tenable, although the merits of such an approach are debatable.

Rhabdomyolysis and hemolysis associated with sickle cell trait and glucose-6-phosphate dehydrogenase deficiency

We report a case of severe oxidative hemolysis and rhabdomyolysis in a patient with sickle cell trait and glucose-6-phosphate dehydrogenase (G6PD) deficiency. The patient was a 34-year-old black man admitted 24 hours after vigorous exercise with myalgias, malaise, myoglobinuria, anemia, low haptoglobin, and a peripheral blood smear with bite cells consistent with oxidative hemolysis. He had two similar episodes within 21 months of the initial admission. Subsequent evaluation resulted in the diagnosis of sickle cell trait and G6PD deficiency; muscle enzyme levels were normal. G6PD deficiency and sickle cell trait can be expected to occur simultaneously in up to 1% of black males. A second red blood cell defect should be considered when severe hemolysis is seen in a person with sickle cell trait.

The synergistic relationship between ethics and quality improvement: thriving in managed care

Financial issues are encroaching upon health care decisions at a rapid pace in today's managed care arena. An examination of the parallel historical perspectives of bioethics, health care reimbursement, and quality improvement reveals that, by integrating an ethical framework with the quality improvement process, health care professionals can preserve patient-centered care. The article demonstrates the strength of this combined approach using restraints as an example.

Complications of midtrimester pregnancy termination: the effect of prior cesarean delivery

OBJECTIVE

Our purpose was to determine whether a prior cesarean delivery affects the incidence of complications in women having an indicated midtrimester medical pregnancy termination.

STUDY DESIGN

A retrospective review of women who underwent a midtrimester medical termination of pregnancy from January 1980 to July 1995 ascertained obstetric history, uterotonic agent(s), and the occurrence of uterine rupture, blood transfusion, or curettage. The frequencies of maternal complications were compared in women with and without a prior cesarean section.

RESULTS

Our study population included 606 women with a mean gestational age of 21.1 +/- 3.1 weeks and a mean maternal age of 26.3 +/- 7 years. Seventy-nine (13%) had undergone a prior cesarean section. There was no significant difference in the need for curettage between women with and without a prior cesarean section. However, there was an increased need for blood transfusions in women with a prior cesarean delivery (11.4% vs 5.3%, odds ratio 2.3, 95% confidence interval 1.1 to 5.0, p = 0.04). The incidence of uterine rupture was significantly higher among women with a prior cesarean (3.8% vs 0.2%, odds ratio 20.8, 95% confidence interval 14.1 to 104, p = 0.008).

CONCLUSION

Our data suggest that a prior cesarean section is a risk factor for uterine rupture and blood transfusion in women having a midtrimester pregnancy termination.