Obstetrical correlates and perinatal consequences of neonatal hypoglycemia in term infants

OBJECTIVE

To determine independent perinatal and intrapartum factors associated with neonatal hypoglycemia.

METHOD

Of singleton pregnancies delivered at term in 2013; 318 (3.8%) neonates diagnosed with hypoglycemia were compared to 7955 (96.2%) neonate controls with regression analysis.

RESULTS

Regression analysis showed that independent prenatal factors were multiparity (odds-ratio [OR] = 1.61), gestational age (OR = 0.68), gestational diabetes (OR = 0.22), macrosomia (OR = 4.87), small for gestational age neonate [SGA] (OR = 6.83) and admission cervical dilation (OR = 0.79). For intrapartum factors, only cesarean section (OR = 1.57) and last cervical dilation (OR = 0.92) were independently significantly associated with neonatal hypoglycemia. For biologically plausible risk factors, independent factors were cesarean section (OR = 4.18), gentamycin/clindamycin in labor (OR = 5.35), gestational age (OR = 0.59) and macrosomia (OR = 5.62). Mothers of babies with neonatal hypoglycemia had more blood loss and longer hospital stays, while neonates with hypoglycemia had worse umbilical cord gases, more neonatal hypoxic conditions, neonatal morbidities and NICU admissions.

CONCLUSION

Diabetes was protective of neonatal hypoglycemia, which may be explained by optimum maternal glucose management; nevertheless macrosomia was independently predictive of neonatal hypoglycemia. Cesarean section and decreasing gestational age were the most consistent independent risk factors followed by treatment for chorioamnionitis and SGA. Further studies to evaluate these observations and develop preventive strategies are warranted.

Demographic, institutional and obstetrical risk factors for postpartum haemorrhage mortality

This study, initially presented at the SMFM Annual Conference in San Diego on 29 January 2009, sought to explore the risk factors for mortality from postpartum haemorrhage (PPH). A total of 138,316 cases of PPH from 1991 to 2000 were identified using the California Health Discharge Database. Data analysed included demographic information and clinical risk factors. PPH increased from 1.9% to 2.8%, while mortality rate decreased during the study period (1991-2000). Logistic regression showed that hysterectomy, hypertensive disorders, abruption, transverse caesarean delivery, and classical caesarean delivery, increased risk for PPH mortality, while manual placental extraction, episiotomy, and laceration repairs decreased risk. Two geographical regions, Inland Empire and Orange County, were associated with increased PPH mortality, despite having lower incidence of PPH. Teaching status and investor ownership of hospitals increased the risk of PPH mortality. There was no associated change in mortality based on hospital quality rating.

The impact of antenatal cocaine use on maternal characteristics and neonatal outcomes

OBJECTIVE

To determine the risk factors and evaluate maternal and neonatal outcomes associated with antenatal cocaine use.

METHODS

This was a retrospective case-control study of 200 cocaine-exposed maternal-neonatal pairs and 200 controls from 1991 to 2000.

RESULTS

Cocaine-using mothers tended to be older, African American, multiparous and incarcerated and they utilized less prenatal care. However, 79% of Hispanics abusing cocaine were primarily English speaking. Cocaine use correlated with syphilis (36 vs. 1%, p = 0.000) and premature rupture of membranes (23 vs. 0%, p = 0.000), fetal demise (5 vs. 0%, p = 0.004), preterm delivery (40 vs. 6%, p = 0.000). Cocaine-exposed infants delivered earlier (36 vs. 39 weeks, p = 0.000), had lower birth weights (2660 vs. 3305 g, p = 0.000), more respiratory distress syndrome (14 vs. 4%, p = 0.001), congenital syphilis (12 vs. 1%, p = 0.000) and longer hospital stays (10 vs. 3 days, p = 0.000); 75% were placed in foster care or adoption and 37.5% had neonatal withdrawal syndrome. There was a stronger positive correlation between neonatal withdrawal and maternal urine toxicology (rho = 0.443, p = 0.000) than with neonatal urine screen (rho = 0.278, p = 0.003).

CONCLUSION

Cocaine use in pregnancy is associated with acculturation, lack of prenatal care, and significant social and obstetric complications resulting in increased neonatal morbidity secondary to prematurity, congenital infection and withdrawal syndrome.

A comparison of the effectiveness of single-dose vs multi-dose antenatal corticosteroids in pre-term neonates

The purpose of this study was to compare the outcome between exposure to single vs multiple courses of antenatal corticosteroids (AC) in pre-term births. The study involved 704 neonates delivered between 24-32 weeks. Maternal and perinatal outcome were compared between 294 (42%) neonates who received no AC; 257 (36%) who received single AC and 153 (22%) who received multiple AC. Any AC compared with no AC showed decreased composite neonatal morbidity (51% vs 62%, p = 0.004, odds ratio (OR) = 0.6), neonatal death (52% vs 62%, p = 0.004, OR = 0.6) and hyaline membrane disease (45% vs 57%, p = 0.002, OR = 0.6) with increased chorioamnionitis (17% vs 11%, p = 0.037, OR = 1.6) and pulmonary oedema (12% vs 1%, p = 0.0001, OR = 13). Multiple AC compared with single AC was associated with increased positive maternal cultures (44% vs 31%, p < or =0.005, OR = 1.8), small for gestational age infants (35% vs 21%, p = 0.001, OR = 2) and intraventricular haemorrhage (45% vs 34%, p <0.05, OR = 1.6). Multiple corticosteroid courses when compared with single corticosteroid course did not further reduce composite neonatal morbidity but increased the risk of positive maternal cultures and neonatal small for gestational age and intraventricular haemorrhage.

The relationship between placental histopathology findings and perinatal outcome in preterm infants

OBJECTIVE

To determine the correlation between placental histopathology findings and perinatal outcome in preterm infants.

METHODS

Placental histopathology in 774 neonates delivered at 24-32 weeks between 1992 and 2000 was classified as follows: 254 (33%) had histological chorioamnionitis, 263 (34%) had coagulation-related lesions, 228 (30%) had vasculopathy. Perinatal outcome was compared between cases positive and negative for each histopathological classification.

RESULTS

Histological chorioamnionitis occurred in 46% of cases with premature rupture of membranes and 45% with preterm labor. Positivity versus negativity for histological chorioamnionitis was associated with earlier presentation (191 vs. 205 days, p = 0.0001) and delivery (199 days vs. 209 days, p = 0.0001), increased risk of intraventricular hemorrhage (71% vs. 23%, p = 0.001, odds ratio (OR) 2.2), bronchopulmonary dysplasia (26% vs. 15%, p = 0.0001, OR 2), retinopathy (36% vs. 24%, p = 0.001, OR 1.8), neonatal sepsis (28% vs. 13%, p = 0.0001, OR 2.5) and neonatal death (12% vs. 7%, p = 0.012, OR 2). Vasculopathy versus no vasculopathy was associated with decreased birth weight (1245 g vs. 1341 g, p = 0.011), decreased Apgar score at 5 min (20% vs. 13%, p = 0.011, OR 1.7) and necrotizing enterocolitis (6% vs. 2%, p = 0.001, OR 4). Cases positive for coagulation-related lesions correlated only with necrotizing enterocolitis (5% vs. 2%, p = 0.02, OR 2.6).

CONCLUSIONS

The presence of histological chorioamnionitis significantly increases the risk of earlier delivery and neonatal mortality. Vascular and coagulation placental findings increase the risk of necrotizing enterocolitis.

Prenatal sonographic diagnosis of bladder outlet obstruction caused by a ureterocele associated with hydrocolpos and imperforate hymen

We report a case of prenatal bladder obstruction due to a single system ureterocele associated with hydrocolpos. Ultrasound at 22 weeks demonstrated an enlarged bladder. Serial scans showed progressive ipsilateral obstructive uropathy, contralateral hydronephrosis, and oligohydramnios. Neonatal endoscopic decompression and hymenotomy was performed with residual decreased ipsilateral renal function and dilation. Prenatal bladder obstruction may cause permanent renal damage.

Gastroschisis complicated by midgut atresia, absorption of bowel, and closure of the abdominal wall defect

We present a case of gastroschisis that was associated with progressive resorption of the extra-abdominal bowel loops and dilation of intra-abdominal bowel loops. After preterm delivery at 32 weeks, a small paraumbilical remnant was present. There was complete atresia of most of the jejunum, ileum, cecum, and the proximal half of the transverse colon. At laparotomy, the jejunum was anastomosed to the transverse colon. The neonate developed short gut syndrome and eventually received a liver and intestinal transplant.

Serial sonographic findings in a fetus with congenital hiatal hernia

A continuum of prenatal findings in a case of hiatal hernia is described. Second-trimester scans showed absence of fetal stomach and polyhydramnios suggestive of esophageal atresia. Third-trimester scans revealed a dilated tubular structure in the thoracic cavity with intermittent visualization of an intra-abdominal small stomach. A diagnosis of hiatal hernia was entertained. After birth, the diagnosis of a dilated esophagus with the stomach herniated into the thoracic cavity through a very lax esophageal hiatus was confirmed and the baby underwent corrective surgery.

Prenatal diagnosis of fetal anomalies in a regional tertiary center: the role of a maternal fetal medicine unit--a review of 6,877 deliveries

OBJECTIVE

To determine the accuracy of anomalies detection and to evaluate the role of maternal-fetal medicine (MFM) specialists.

METHODS

This was a retrospective study of birth defects. Patients were divided into: 1) if ultrasound was reviewed by MFM specialists; 2) Others, if reviewed by other ultrasonologists. Fisher's exact test or Pearson's chi2 test were used for statistical analysis.

RESULTS

Birth defects occurred in 204/6,877 (3%) neonates with 291 distinct birth defects. Prenatal diagnosis was possible in 181 (62%). In 16 (5.5%) late prenatal diagnosis was possible. MFM specialists correctly diagnosed 53/62 (85%) vs. 56/132 (42%) in Others (P < 0.001). Late diagnosis was possible in 12 cases of gastrointestinal anomalies, three of hydrocephaly and one of skeletal dysplasia; five were correctly diagnosed by MFM specialists and two by Others.

CONCLUSIONS

Involvement of ultrasonologists with particular expertise in fetal scanning may improve accuracy of prenatal diagnosis. A repeat third trimester ultrasound may be useful in detecting late-evolving anomalies.

Clinical and pathologic correlates of stillbirths in a single institution

BACKGROUND

To evaluate risk factors, placental and pathologic determinants of stillbirths.

METHODS

A retrospective analysis of stillbirths > or = 25 weeks was performed. Clinical data was compared to a randomized control group. Statistical analysis included chi square test, student t test, and logistic regression.

RESULTS

One hundred and fifteen stillbirths and 193 controls were analyzed. Maternal age, nulliparity, tobacco use, previous induced abortions, anticardiolipid antibodies, elevated maternal serum alpha feto protein, twins, and amniocentesis, were significantly associated with stillbirth. Logistic regression analysis showed only maternal age, tobacco use, small for gestational age (SGA), previous induced abortions, decreasing gestational age as independent significant variables. The stillbirth baby was 6.8 times more likely to be SGA and 11.9 times more likely to be preterm. Primary pathologic diagnoses were placental factors (37%), cord complications (28%), and fetal causes (15%), 17% had maternal risk factors only and 3% had no known risk factors. Diagnosis was suggested by pathology in 40% of cases.

CONCLUSIONS

Stillbirth delivery is associated with older, nulliparous patients with prenatal complications resulting in intrauterine growth retardation and prematurity. Perinatal histopathologic examination is important in diagnosis. Utilizing an extensive testing protocol will reduce the diagnosis of unexplained stillbirth.

Prepregnancy body mass index, weight gain during pregnancy, and perinatal outcome in a rural black population

Relationships between body mass index (BMI) and weight gain with perinatal outcome and birthweight were examined. BMI was calculated on 582 consecutive pregnant women who delivered at or >37 weeks gestational age. Statistical analysis was done using Chi-square tests, analysis of variance, and multiple logistic regression. Of those studied, 13% were underweight, 39% normal, 13% overweight, and 35% obese. Obesity was associated with increasing age (P < .01), multiparity (P < .01), previous cesarean delivery (P < .01), previous macrosomia (P = .01), previous fetal death (P = .03), hypertensive disorders (P < .01), gestational diabetes (P = .02), cesarean delivery (P = .03), and neonatal intensive care unit admission (NICU) (P = .01). The underweight group had the most low birthweight (LBW) infants and the lowest mean birthweight. Ideal weight gain occurred in 31%, inadequate weight gain in 34%, and excessive weight gain in 35%. Inadequate weight gain had increased asthma (P < .05), and hyperemesis (P = .03). Women with ideal weight gain had less smokers (P < .01), fetal distress (P < .05), cesarean delivery (P = .02), and preeclampsia (P < .001). The mean birthweight was highest in the excessive weight gain (P < .01). With multivariate analysis, previous LBW, BMI, and tobacco use were significant predictors of LBW. Normal BMI and ideal weight gain in pregnancy is associated with decreased perinatal complications and an optimum birthweight.

Adenosine mediates metabolic and cardiovascular responses to hypoxia in fetal sheep

1. In seven unanaesthetized fetal sheep (> 80% term), isocapnic hypoxia (arterial partial pressure of O2, Pa,O2, approximately 15 mmHg) was induced for 1 h by lowering maternal inspired PO2. Fetal hypoxia was also produced during intra-arterial administration of the adenosine receptor antagonist 8-(p-sulphophenyl)-theophylline (8-SPT). The fetal 8-SPT infusion was begun just prior to hypoxia and was stopped when fetal Pa,O2 was returned to normal. 2. Hypoxia induced a progressive fetal acidosis, a rise in mean arterial pressure, a transient fall in heart rate and a decrease in breathing movements. 8-SPT significantly reduced the metabolic acidosis and abolished the hypertension and bradycardia without altering hypoxic inhibition of fetal breathing. Administration of the vehicle for 8-SPT during hypoxia did not significantly affect the normal fetal metabolic and cardiovascular responses to acute O2 deprivation. 3. It is concluded that adenosine mediates the fetal bradycardia and hypertension produced by hypoxia, indicating that adenosine modulates fetal autonomic responses to acute oxygen deficiency. Secondly, adenosine contributes to fetal metabolic acidaemia, suggesting that adenosine also modulates fetal glycolytic responses to hypoxia.

Maternal and fetal cardiorespiratory responses to adenosine in sheep

OBJECTIVE

We determined the cardiorespiratory effects of maternal adenosine administration on the ewe and fetus.

STUDY DESIGN

Adenosine was infused intravenously to five pregnant ewes as graded (25 to 400 micrograms/min per kilogram) and constant (200 micrograms/min per kilogram) infusions and as a single injection (200 micrograms/kg). Heart rate, arterial pressure, and arterial blood gases and pH were monitored in the ewe and fetus; the data were analyzed with two-way analysis of variance with Duncan's test.

RESULTS

Graded adenosine infusion produced a dose-dependent rise in maternal heart rate and hemoglobin concentration and a fall in diastolic and mean arterial pressures, effects that were maintained during 1 hour of constant infusion. Single injections transiently lowered diastolic pressure and induced a biphasic change in heart rate consisting of a bradycardia followed by a tachycardia with a return to control values. Adenosine administration to the ewe did not affect maternal arterial blood gases and systolic pressure nor alter fetal heart rate, arterial pressure, or arterial blood gases.

CONCLUSION

Although adenosine causes cardiovascular changes in pregnant ewes, the effects are well tolerated and do not significantly affect the cardiorespiratory status of the fetus.

Cigarette smoking during pregnancy: acute effects on uterine flow velocity waveforms

OBJECTIVE

To determine the acute effects of smoking during pregnancy on selected characteristics of the flow velocity waveform of the uterine artery.

METHODS

We studied 19 chronic smokers at a mean (+/- standard error) gestational age of 28 +/- 1 weeks. After informed consent was given, the uterine artery was located using ultrasound imaging with color flow mapping. The characteristic waveform was imaged by pulsed Doppler ultrasonography. Maternal heart rate and blood pressure and the systolic-diastolic ratio (S/D) and resistance index of the uterine artery were measured before (-10 and -1 minutes), during (+5 and +10 minutes), and after (+20 and +30 minutes) smoking two standard cigarettes in succession.

RESULTS

Maternal heart rate increased 27%, systolic blood pressure increased 8%, and diastolic blood pressure increased 19% with smoking (P < .001). The uterine artery S/D and resistance index decreased from 2.33 to 2.02 and from 0.55 to 0.49, respectively (P < .001).

CONCLUSION

The acute effects of smoking on maternal systemic hemodynamics probably influence the flow velocity waveform of the uterine artery and preclude any definitive interpretation of acute changes in downstream resistance.

Umbilical artery velocimetry in predicting perinatal outcome with intrapartum fetal distress

The aim of this study was to see whether umbilical artery Doppler velocimetry predicts intrapartum fetal distress evidenced by poor perinatal outcome. Umbilical velocimetry was performed on 102 parturients with a presumptive diagnosis of fetal distress based on fetal heart rate (FHR) patterns. A mean systolic-diastolic ratio (S/D) of 3 or more after 30 weeks' gestation was considered abnormal. Poor perinatal outcome was defined by any of the following: small for gestational age, low Apgar score, acidosis, meconium below the vocal cords, prolonged neonatal hospital stay, neonatal intensive care unit admission, and neonatal morbidity. Eighty-two patients had normal S/Ds and 20 had abnormal ratios. Eighteen neonates (90%) in the abnormal-SD group had at least one adverse outcome, compared with only 13 (15.8%) of those with a normal S/D, a statistically significant difference (P less than .001). Umbilical artery S/D used as a screening tool to detect poor perinatal outcome had a sensitivity of 65-100%, specificity of 83-92%, positive predictive value of 20-81%, negative predictive value of 91-100%, and a kappa index of 0.24-0.63. These findings suggest that umbilical artery Doppler velocimetry may be useful as an adjunct in the assessment of intrapartum FHR patterns suggesting fetal distress.

A beltless tocodynamometer--a preliminary report

The clinical usefulness of a newly developed beltless external tocodynamometer system was evaluated in a group of 56 patients in active, early, premature, or false labor. The uterine activity records so obtained were compared with those made in the same patients using the tocodynamometer with belt (49 patients) and the intrauterine pressure catheter (seven patients). The records were classified as "usable" if the baseline was above zero and the peak of the recorded contraction was at least 15 mmHg above the baseline. Both systems were studied under similar clinical conditions. Overall, of the 7434 minutes of recordings in 49 patients using the beltless system, 7008 minutes (94%) were usable. In contrast, only 2515 out of 5667 minutes (45%) of recordings made with the belted system were usable (P less than .001). Seven additional patients were monitored simultaneously with the beltless tocodynamometer and the intrauterine pressure catheter systems. Of the 1367 minutes' total monitoring time, the recovery rates of usable data for the beltless and intrauterine pressure catheter systems were 85 and 87%, respectively (P = not significant). These preliminary results indicate that the beltless system is a convenient, simple-to-use external tocodynamometric system that assesses uterine activity more efficiently than the belted system.

Lipid changes in the residual yolk and liver of the chick immediately after hatching

A study has been made of the changes in the weights, lipid and fatty acid compositions of the liver and residual yolk complex of the chick during the immediate period following hatching. By the 5th day after hatching about 85% of the gross weight and 90% of the lipid associated with the yolk complex had been absorbed. During this period, the composition of the yolk lipid displayed a marked increase in its proportion of cholesteryl esters and decreases in the triacylglycerides and phosphoglycerides. Whereas, in the triacylglycerides of the residual yolk after hatching there were changes in the proportions of the saturated fatty acids, in the phosphoglycerides there were distinctive changes in the proportions of the polyunsaturated fatty acids. Growth of the liver after hatching was associated with a substantial accumulation of fat. The very high level of cholesteryl esters associated with the embryonic liver was rapidly replaced by triacylglycerides in particular, and phosphoglycerides. The accumulation of the triacylglycerides was accompanied by a rapid change in their fatty acid composition away from that associated with embryonic development and differing markedly from that of the triacylglycerides being absorbed from the yolk. The changes in the lipid and fatty acid composition of the liver were indicative of the rapid alteration for the role of the liver in the lipid metabolism of the newly hatched chick.

Donor insemination in Lagos

The results of AID in a population with a high incidence of female factors is reported. Thirty-one patients started AID on 35 occasions resulting in 25 pregnancies and a cumulative conception rate of 71% at 8 months. Eleven patients with female factors present became pregnant. Some problems of AID practice in Lagos are highlighted.