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Hoffmann J, Dresbach T, Hagenbeck C, Scholten N. Factors associated with the closure of obstetric units in German hospitals and its effects on accessibility. BMC Health Serv Res 2023; 23:342. [PMID: 37020222 PMCID: PMC10077609 DOI: 10.1186/s12913-023-09204-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/20/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND An increase in regionalization of obstetric services is being observed worldwide. This study investigated factors associated with the closure of obstetric units in hospitals in Germany and aimed to examine the effect of obstetric unit closure on accessibility of obstetric care. METHODS Secondary data of all German hospital sites with an obstetrics department were analyzed for 2014 and 2019. Backward stepwise regression was performed to identify factors associated with obstetrics department closure. Subsequently, the driving times to a hospital site with an obstetrics department were mapped, and different scenarios resulting from further regionalization were modelled. RESULTS Of 747 hospital sites with an obstetrics department in 2014, 85 obstetrics departments closed down by 2019. The annual number of live births in a hospital site (OR = 0.995; 95% CI = 0.993-0.996), the minimal travel time between two hospital sites with an obstetrics department (OR = 0.95; 95% CI = 0.915-0.985), the availability of a pediatrics department (OR = 0.357; 95% CI = 0.126-0.863), and population density (low vs. medium OR = 0.24; 95% CI = 0.09-0.648, low vs. high OR = 0.251; 95% CI = 0.077-0.822) were observed to be factors significantly associated with the closure of obstetrics departments. Areas in which driving times to the next hospital site with an obstetrics department exceeded the 30 and 40 min threshold slightly increased from 2014 to 2019. Scenarios in which only hospital sites with a pediatrics department or hospital sites with an annual birth volume of ≥ 600 were considered resulted in large areas in which the driving times would exceed the 30 and 40 min threshold. CONCLUSION Close distances between hospital sites and the absence of a pediatrics department at the hospital site associate with the closure of obstetrics departments. Despite the closures, good accessibility is maintained for most areas in Germany. Although regionalization may ensure high-quality care and efficiency, further regionalization in obstetrics will have an impact on accessibility.
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Affiliation(s)
- Jan Hoffmann
- Faculty of Medicine and University Hospital Cologne, Faculty of Human Sciences, Institute for Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Eupener Str. 129, 50933, Cologne, Germany.
| | - Till Dresbach
- University Hospital Bonn, Department of Neonatology and Pediatric Intensive Care Medicine, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Carsten Hagenbeck
- Department of Obstetrics and Gynecology, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Nadine Scholten
- Faculty of Medicine and University Hospital Cologne, Faculty of Human Sciences, Institute for Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Eupener Str. 129, 50933, Cologne, Germany
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Wan S, Yang M, Pei J, Zhao X, Zhou C, Wu Y, Sun Q, Wu G, Hua X. Pregnancy outcomes and associated factors for uterine rupture: an 8 years population-based retrospective study. BMC Pregnancy Childbirth 2022; 22:91. [PMID: 35105342 PMCID: PMC8805328 DOI: 10.1186/s12884-022-04415-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022] Open
Abstract
Background Uterine rupture is an obstetrical emergency with serious undesired complications for laboring mothers resulting in fatal maternal and neonatal outcomes. The aim of this study was to assess the incidence of uterine rupture, its association with previous uterine surgery and vaginal birth after caesarean section (VBAC), and the maternal and perinatal implications. Methods This is a population-based retrospective study. All pregnant women treated for ruptured uterus in one center between 2013 and 2020 were included. Their information retrieved from the medical records department were reviewed retrospectively. Results A total of 209,112 deliveries were included and 41 cases of uterine rupture were identified. The incidence of uterine rupture was 1.96/10000 births. Among the 41 cases, 16 (39.0%) had maternal and fetal complications. There were no maternal deaths secondary to uterine rupture, while perinatal fatality related to uterine rupture was 7.3%. Among all cases, 38 (92.7%) were scarred uterus and 3 (7.3%) were unscarred uterus. The most common cause of uterine rupture was previous cesarean section, while cases with a history of laparoscopic myomectomy were more likely to have serious adverse outcomes, such as fetal death. 24 (59.0%) of the ruptures occurred in anterior lower uterine segment. Changes in Fetal heart rate monitoring were the most reliable signs for rupture. Conclusions Incidence of uterine rupture in the study area, Shanghai, China was consistent with developed countries. Further improvements in obstetric care and enhanced collaboration with referring health facilities were needed to ensure maternal and perinatal safety. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04415-6.
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Affiliation(s)
- Sheng Wan
- Department of Obstetrics, Shanghai First Maternity and infant hospital, Shanghai Tongji University School of Medicine, 2699 West Gaoke Road, Shanghai, 201204, China
| | - Mengnan Yang
- Department of Obstetrics, Shanghai First Maternity and infant hospital, Shanghai Tongji University School of Medicine, 2699 West Gaoke Road, Shanghai, 201204, China
| | - Jindan Pei
- Department of Obstetrics, Shanghai First Maternity and infant hospital, Shanghai Tongji University School of Medicine, 2699 West Gaoke Road, Shanghai, 201204, China
| | - Xiaobo Zhao
- Department of Obstetrics, Shanghai First Maternity and infant hospital, Shanghai Tongji University School of Medicine, 2699 West Gaoke Road, Shanghai, 201204, China
| | - Chenchen Zhou
- Department of Obstetrics, Shanghai First Maternity and infant hospital, Shanghai Tongji University School of Medicine, 2699 West Gaoke Road, Shanghai, 201204, China
| | - Yuelin Wu
- Department of Obstetrics, Shanghai First Maternity and infant hospital, Shanghai Tongji University School of Medicine, 2699 West Gaoke Road, Shanghai, 201204, China
| | - Qianqian Sun
- Department of Obstetrics, Shanghai First Maternity and infant hospital, Shanghai Tongji University School of Medicine, 2699 West Gaoke Road, Shanghai, 201204, China
| | - Guizhu Wu
- Department of Gynecology, Shanghai First Maternity and infant hospital, Shanghai Tongji University School of Medicine, 2699 West Gaoke Road, Shanghai, 201204, China.
| | - Xiaolin Hua
- Department of Obstetrics, Shanghai First Maternity and infant hospital, Shanghai Tongji University School of Medicine, 2699 West Gaoke Road, Shanghai, 201204, China.
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Zhang H, Liu H, Luo S, Gu W. Oxytocin use in trial of labor after cesarean and its relationship with risk of uterine rupture in women with one previous cesarean section: a meta-analysis of observational studies. BMC Pregnancy Childbirth 2021; 21:11. [PMID: 33407241 PMCID: PMC7786988 DOI: 10.1186/s12884-020-03440-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 11/18/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Trial of labor after a previous cesarean delivery (TOLAC) has reduced the rate of cesarean sections (CS). Nevertheless, the widespread use of TOLAC has been limited by an increase in adverse outcomes, the most serious one being the risk of symptomatic uterine rupture, which is possibly associated with oxytocin. In this meta-analysis, we explored the risk association between oxytocin use and uterine rupture in TOLAC. METHODS Multiple electronic databases (PubMed, Embase, Web of Science, and Google Scholar) were searched for cross-sectional studies reporting on TOLAC, oxytocin and uterine rupture, which were published between January 1986 and October 2019. The bias-corrected Hedge's g was calculated as the effect size using the random-effects model. A two-sample Z test was used to compare the differences in synthetic rates between groups. The Newcastle-Ottawa Scale (NOS) was used to evaluate the risk of bias. Quality of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) certainty ratings system. RESULTS A total of 14 studies, which included 48,457 women who underwent TOLAC, met the inclusion criteria. The pooled rate of vaginal birth after a cesarean section (VBAC) and the rate of uterine rupture in spontaneous labor were 74.3 and 0.7%, respectively. In addition, the pooled rate of VBAC and the rate of uterine rupture in the induction labor group was 60.7 and 2.2%, respectively. The women who had spontaneous labor had a significantly higher rate of VBAC (p = 0.001) and a lower rate of uterine rupture (p = 0.0003) compared to induced labor. The pooled rates of uterine rupture in women using oxytocin and women not using oxytocin in TOLAC were 1.4% and 0.5%, respectively, and the difference was significant (p = 0.0002). Also, the synthetic rate of uterine rupture in oxytocin augmentation among women with spontaneous labor and women who had a successful induction of labor were 1.7% and 2.2%, respectively, without significant difference (p = 0.443). CONCLUSIONS Women with induced labor had a higher risk of uterine rupture compared to women with spontaneous labor following TOLAC. Oxytocin use may increase this risk, which could be influenced by the process of induction or individual cervix condition. Consequently, simplified and standardized intrapartum management, precise protocol, and cautious monitoring of oxytocin use in TOLAC are necessary.
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Affiliation(s)
- Huan Zhang
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200011, China
| | - Haiyan Liu
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200011, China
| | - Shouling Luo
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200011, China
| | - Weirong Gu
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200011, China.
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5
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Dane B, Dane C. Maternal Death After Uterine Rupture in an Unscarred Uterus: A Case Report. J Emerg Med 2009; 37:393-5. [DOI: 10.1016/j.jemermed.2007.10.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Revised: 03/12/2007] [Accepted: 10/28/2007] [Indexed: 11/30/2022]
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6
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Intrapartal posterior cervicoisthmic uterine rupture. Open Med (Wars) 2008. [DOI: 10.2478/s11536-008-0020-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractA case is presented of complete intrapartal rupture of an intact, nonscarred uterus in the cervicoisthmic region in a quadripara without a history of cesarean section or other uterine operation, with dorsoposterior high longitudinal fetal head position.
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Abstract
The purpose of this article is to familiarize the reader with the concept of causation and the role of the concept of foreseeability of harm in obstetric malpractice lawsuits. These concepts are incorporated into several hypothetical fetal brain injury and uterine rupture cases. The discussion involves an overview of available scientific evidence used to substantiate or refute whether a child's brain damage or a maternal uterine rupture was in fact related to the obstetric care in question. In the event of the delivery of a depressed newborn, a checklist of scientific evidence to be gathered at the time of delivery is also provided.
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Affiliation(s)
- Jeffrey P Phelan
- Department of Obstetrics and Gynecology, Citrus Valley Medical Center, West Covina, CA 91746, USA.
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8
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Abstract
OBJECTIVE Uterine rupture is potentially a life-threatening condition for both mother and infant. In this article, we report a rare occurrence of uterine rupture due to traumatic assisted fundal pressure associated with hydrops fetalis and shoulder dystocia. CASE REPORT A 29-year-old woman was admitted for termination of pregnancy at 34 weeks' gestation because of fetal hydrops. Assisted uterine fundal pressure was done during delivery because of coexistent shoulder dystocia. After a series of assisted uterine fundal pressure, a dead hydropic baby weighing 4,000 g was delivered, and persistent postpartum hemorrhage occurred. An emergency laparotomy was performed, which revealed a large left broad ligament hematoma with multiple bleeding points. The bleeders were safely sutured and the tears of the left lateral uterine wall were primarily restored. The patient was discharged 8 days later. CONCLUSION Assisted fundal pressure during painful delivery can be traumatic and results in uterine rupture. In this article, we suggest that uterine rupture should be considered whenever a pregnant woman experiences a sudden onset of abdominal pain during the course of assisted uterine fundal pressure.
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Affiliation(s)
- Shen-Chuan Wei
- Department of Obstetrics and Gynecology, Li Shin Hospital, Taoyuan, Taiwan
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Rivlin ME, Carroll CS, Morrison JC. Infectious necrosis with dehiscence of the uterine repair complicating cesarean delivery: a review. Obstet Gynecol Surv 2005; 59:833-7. [PMID: 15572961 DOI: 10.1097/01.ogx.0000146198.55363.5a] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED The authors summarize current knowledge about infectious uterine incisional necrosis/dehiscence, an uncommon but serious complication of cesarean delivery. A MEDLINE search of the literature from 1966 to the present did not identify any previous review of this entity. From case reports, small case series, and textbook descriptions, the evidence regarding the definition of the disorder, its prevalence, etiology, pathogenesis, diagnosis, prognosis, and management is presented. The paucity of reports in the modern literature indicate the need for further studies to more precisely characterize this entity for cross-study comparisons and aggregation to provide clearer management guidelines, especially as it regards diagnosis, and the safety of conservative surgery in well-selected cases. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader should be able to define the condition infectious uterine incisional necrosis, and to outline potential management options.
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Affiliation(s)
- Michel E Rivlin
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi 39216-4505, USA.
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Abstract
Pregnancy is a normal biologic process, but because of a variety of physiologic factors, it increases a woman's risk for death. Maternal deaths in pregnancy may be due to conditions unique to pregnancy, conditions associated with pregnancy, or conditions unrelated to but exacerbated by pregnancy. Death may occur during any trimester, during labor/birth, or postpartum. In this report, we present 45 cases of pregnancy-related maternal deaths that were investigated and autopsied at the Dallas County Medical Examiners office between 1977 and 1999, and we review the topic of pregnancy-related maternal death.
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Affiliation(s)
- Joseph A Prahlow
- South Bend Medical Foundation, Indiana University School of Medicine--South Bend Center for Medical Education at the University of Notre Dame, South Bend, Indiana, USA.
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11
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Abstract
Uterine rupture complicates approximately 1% of trials of labor after cesarean. Classic signs and symptoms include loss of station, cessation of labor, vaginal bleeding, fetal distress, and abdominal pain. Other signs are also possible. We report a case of uterine rupture at VBAC trial that includes an unusual clinical sign of uterine rupture: vernix caseosa observed in the urine of the parturient. During labor, a bladder catheter was inserted to evaluate oliguria. Vernix caseosa and blood were found in the tubing. Prompt cesarean delivery followed. A tear extending from the original transverse scar into the bladder dome was found. Vernixuria is an additional sign of uterine rupture.
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Affiliation(s)
- John Patrick O'Grady
- Department Of Obstetrics & Gynecology, Baystate Medical Center, Springfield, MA 01199, USA
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12
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Blinder E, MacKenzie JD, Cranmer HH, Ledbetter S, Rybicki F. Uterine rupture with peritonitis in a nongravid uterus eight weeks after cesarean section. Emerg Radiol 2003; 10:57-9. [PMID: 15290535 DOI: 10.1007/s10140-002-0260-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2002] [Accepted: 11/27/2002] [Indexed: 10/25/2022]
Abstract
The CT findings of uterine rupture are critical to recognize so that early surgical intervention can improve survival and potentially avoid hysterectomy. We report a case of uterine rupture in a nongravid uterus.
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Affiliation(s)
- Elise Blinder
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Adanu RMK, Obed SA. Ruptured uterus: a seven-year review of cases from Accra, Ghana. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2003; 25:225-30. [PMID: 12610675 DOI: 10.1016/s1701-2163(16)30110-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the incidence, causes, management, and the means of prevention of uterine rupture, as well as the characteristics of women with the condition, recorded in the Department of Obstetrics and Gynaecology at Korle-Bu Teaching Hospital in Accra, Ghana. DESIGN A retrospective study between January 1, 1995, and December 31, 2001. RESULTS During the study period, of 82061 deliveries at the Korle-Bu Teaching Hospital, 193 women developed uterine rupture, an incidence of 2.4 per 1000 deliveries. Of these 193 women, 24.6% had had a previous Caesarean section. The most frequent associated factor of uterine rupture was prolonged labour (33.6%). The perinatal mortality rate was 74.3%. Almost 70% (66.9%) of women underwent a total abdominal hysterectomy as management. The case fatality rate was 1.0%. CONCLUSION A more vigilant approach to preventing prolonged and obstructed labour in delivery units within and around Accra, Ghana, is required to reduce the incidence of this condition.
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Affiliation(s)
- R M K Adanu
- Department of Obstetrics and Gynaecology, Korle-Bu Teaching Hospital, Accra, Ghana
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14
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Mizunoya F, Nakata M, Kondo T, Yamashita S, Inoue S. Management of vaginal birth after cesarean. J Obstet Gynaecol Res 2002; 28:240-4. [PMID: 12428692 DOI: 10.1046/j.1341-8076.2002.00049.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To raise the success rate of vaginal birth after cesarean (VBAC) without increasing maternal or perinatal morbidity and mortality rates. METHODS Of 468 women with a prior scar, 365 gave valid informed consent for our management of VBAC at Akashi Municipal Hospital during 1986-1999. Trials of labor (TOL) were attempted in 322 cases principally by waiting for spontaneous labor onset and teaching the patients a breathing method to avoid straining until expulsion by vacuum extraction become possible, controlling the intrauterine pressure. Our selection criteria for TOL changed during the trial; from 1991-1999 patients with a prior scar extending into fundus were excluded. RESULTS Of the 322 TOL, 88.2% were successful, and VBAC was successful in 77.8% (284 of the 365 patients). Uterine rupture was observed in 2 cases (0.62%). Fetal death occurred in 1 case. Three women gave birth to neonates with a 1-minute Apgar score < or = 6. CONCLUSION The rate of VBAC was 77.8% in all women with a prior scar. During our management of VBAC, maternal or perinatal morbidity and mortality rates did not increase significantly.
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Affiliation(s)
- A Khan
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8, Canada
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Suner S, Jagminas L, Peipert JF, Linakis J. Fatal spontaneous rupture of a gravid uterus: case report and literature review of uterine rupture. J Emerg Med 1996; 14:181-5. [PMID: 8740749 DOI: 10.1016/0736-4679(95)02091-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Spontaneous uterine rupture is a life-threatening obstetrical emergency encountered infrequently in the emergency department. The diagnosis of spontaneous uterine rupture is often missed or delayed, leading to maternal and fetal mortality. Emergency physicians must consider this diagnosis when presented with a pregnant patient in shock with abdominal pain. We present the case of a 38-year-old gravid female who presented to the emergency department in cardiac arrest 24 hours after an initial complaint of abdominal pain. We review the uterine rupture literature with specific focus on risk factors, signs and symptoms, diagnosis, treatment, and outcome.
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Affiliation(s)
- S Suner
- Department of Emergency Medicine, Rhode Island Hospital, Providence 02903, USA
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Phelan JP, Ahn MO, Korst LM, Martin GI. Nucleated red blood cells: a marker for fetal asphyxia? Am J Obstet Gynecol 1995; 173:1380-4. [PMID: 7503172 DOI: 10.1016/0002-9378(95)90620-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Our purpose was to determine whether a relationship exists between the presence of nucleated red blood cells, hypoxic ischemic encephalopathy, and long-term neonatal neurologic impairment. STUDY DESIGN Nucleated red blood cell data from 46 singleton term neurologically impaired neonates were compared with cord blood nucleated red blood cells of 83 term nonasphyxiated newborns. The neurologically impaired neonates group was also separated as follows: nonreactive, nonreactive fetal heart rate from admission to delivery; tachycardia, reactive fetal heart rate on admission followed by tachycardia with decelerations; rupture, uterine rupture. The first and highest nucleated red blood cells value and the time to nucleated red blood cells disappearance were assessed. RESULTS The neurologically impaired neonates group exhibited a significantly higher number of nucleated red blood cells per 100 white blood cells (34.5 +/- 68) than did the control group (3.4 +/- 3.0) (p < 0.00001). When the neurologically impaired neonates are separated as to the basis for the neurologic impairment, distinct nucleated red blood cell patterns were observed. Overall, the nonreactive group exhibited the highest mean nucleated red blood cell (51.4 +/- 87.5) count and the longest clearance times (236 +/- 166 hours). CONCLUSION In this limited population, nucleated red blood cell data appear to aid in identifying the presence of fetal asphyxia. When asphyxia was present, distinct nucleated red blood cells patterns were identified that were in keeping with the observed basis for the fetal injury. In general, the closer the birth was to the asphyxial event, the lower was the number of nucleated red blood cells. Thus our data suggest that cord blood nucleated red blood cells could assist in the timing of fetal neurologic injury.
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Affiliation(s)
- J P Phelan
- Department of Obstetrics and Gynecology, Pomona Valley Hospital Medical Center, Pasadena, CA, USA
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