Active management of labor: a cost analysis of a randomized controlled trial

OBJECTIVE

To compare the costs of a protocol of active management of labor with those of traditional labor management.

DESIGN

Cost analysis of a randomized controlled trial.

METHODS

From August 1992 to April 1996, we randomly allocated 405 women whose infants were delivered at the University of New Mexico Health Sciences Center, Albuquerque, to an active management of labor protocol that had substantially reduced the duration of labor or a control protocol. We calculated the average cost for each delivery, using both actual costs and charges.

RESULTS

The average cost for women assigned to the active management protocol was $2,480.79 compared with an average cost of $2,528.61 for women in the control group (P = 0.55). For women whose infant was delivered by cesarean section, the average cost was $4,771.54 for active management of labor and $4,468.89 for the control protocol (P = 0.16). Spontaneous vaginal deliveries cost an average of $27.00 more for actively managed patients compared with the cost for the control protocol.

CONCLUSIONS

The reduced duration of labor by active management did not translate into significant cost savings. Overall, an average cost saving of only $47.91, or 2%, was achieved for labors that were actively managed. This reduction in cost was due to a decrease in the rate of cesarean sections in women whose labor was actively managed and not to a decreased duration of labor.

Impact of antenatal corticosteroid therapy in very low birth weight infants on chronic lung disease and other morbidities of prematurity

OBJECTIVE

To assess the effect of antenatal corticosteroids on very low birth weight (VLBW) infants through 36 weeks' postconceptional age.

STUDY DESIGN

Data were collected prospectively on all VLBW (< or = 1500 gm) infants (n = 670) admitted to a single newborn intensive care unit from 1991 to 1996. Mortality rate and the frequency of medical morbidities attributable to prematurity were compared between VLBW infants who received antenatal corticosteroid therapy and those who did not.

RESULTS

Antenatal steroid therapy was associated with a significantly lower rate of mortality (p = 0.02) and of mortality due to respiratory causes (p = 0.01). Although the frequency of chronic lung disease (oxygen requirement at 36 weeks' postconceptional age) was not significantly different between the groups (p = 0.48), the frequency of infants surviving without chronic lung disease was significantly greater in the steroid-exposed group (p = 0.02). There were no significant differences between the groups in the frequency of sepsis, necrotizing enterocolitis, length of hospital stay, or retinopathy of prematurity requiring surgery.

CONCLUSION

In our study, antenatal corticosteroid therapy was associated with a beneficial effect on mortality and respiratory morbidity for VLBW infants and was not associated with any known increased risks.

Antenatal corticosteroids in pregnancies complicated by preterm premature rupture of membranes

In 1994, the National Institutes of Health Consensus Development Conference on Antenatal Steroids recommended corticosteroids between 24 and 30-32 weeks' gestation in pregnancies complicated by preterm premature rupture of membranes (PROM). Since the Consensus Conference, the use of antenatal corticosteroids has increased to approximately 60% of potential treatment candidates. Some of the remaining 40% of pregnant candidates may go untreated because of concern that corticosteroids could increase the risk of neonatal infection. Using decision-analysis techniques, we compared the potential benefit of antenatal corticosteroids in reducing the incidence of severe intraventricular hemorrhage with the potential risk of increasing the rate of neonatal sepsis. Our analysis indicates that the benefit of a small decrease in severe intraventricular hemorrhage outweighs the potential harm of a large increase in the rate of neonatal sepsis. Therefore, we support the Consensus Conference panel's recommendation that antenatal corticosteroids be used in pregnancies complicated by preterm PROM.

Rhabdomyosarcoma treated with chemotherapy during the third trimester

BACKGROUND

Rhabdomyosarcoma is an aggressive tumor that is rarely found in pregnancy, and is usually treated with multiagent chemotherapy. Chemotherapy given during pregnancy is associated with several maternal-fetal complications, including risks for mutagenicity, myelosuppression, and fetal death.

CASE

An 18-year-old woman had stage III facial rhabdomyosarcoma diagnosed early in the third trimester. She achieved clinical remission with multiagent chemotherapy given during pregnancy, with no fetal complications.

CONCLUSION

Invasive rhabdomyosarcoma is biologically predisposed to metastasize, and in the absence of effective chemotherapy, most patients will develop sites of distant recurrence. Chemotherapy plays an important role as frontline treatment in pregnant women with rhabdomyosarcoma.

Maternal serum concentrations of human placental lactogen, estradiol and pregnancy specific beta 1-glycoprotein and fetal growth retardation

BACKGROUND

To determine if maternal serum levels of human placental lactogen (hPL), estradiol, and pregnancy-specific beta 1-glycoprotein (SP1) measured at approximately 18 weeks' gestation were associated with fetal growth retardation (FGR) in infants delivered at or after 37 weeks.

METHODS

Serum samples were obtained at a mean of 18 weeks' gestational age from 200 multiparous women with risk factors for FGR. Maternal serum concentrations of hPL, estradiol and SP1 were correlated with FGR.

RESULTS

A total of 59 (29.5%) of the 200 infants were diagnosed postnatally with FGR. There were no significant differences in the prevalence of FGR among the lowest quartiles of estradiol, hPL or SP1. However, pregnancies in the highest quartile of estradiol levels at 18 weeks' (> 580 pg/ml) were associated with a significantly lower risk of FGR than those in the lower three quartiles, 8 out of 50 (16%) vs 51 of 150 (34%) (p = < 0.05). The prevalence of FGR associated with the highest quartile of hPL (> 1.73 micrograms/ml) was 12.2% compared to 35% in the lower three quartiles (p = 0.025) and the prevalence of FGR associated with the highest quartile of SP1 (> 43 ng/ml) was 14% compared to 34.7% in the lower three quartiles (p = 0.018). Only one out of 21 infants (4.5%) whose mothers had each value in the highest quartile of hPL, estradiol, and SP1 was diagnosed with FGR compared to 58 out of 178 (32.6%) of the remaining infants (p = 0.007).

CONCLUSIONS

In pregnancies of women at high risk for FGR, higher levels of estradiol, hPL, and SP1 at 18 weeks are associated with a decreased prevalence of FGR. This finding indicates that high levels of these hormones are related to a lower risk of FGR, but that low levels do not predict FGR.

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.

Physician opinions of preterm infant outcome and their effect on antenatal corticosteroid use

Our purpose was to compare physician opinions about the appropriate use of corticosteroids with physician perceptions of preterm infant outcome. A total of 409 obstetricians and family physicians who provide maternity care in Alabama were surveyed to determine whether (and how) their perceptions of preterm infant outcome influenced their decision to use antenatal corticosteroids. Results were compared with those of a similar survey of Alabama physicians conducted in 1979. A total of 85% of physicians in 1992 versus 61% in 1979 reported that situations existed in which they would prescribe antenatal corticosteroids (p < 0.001). In 1992 physicians who underestimated preterm infant survival began corticosteroid use at later gestational ages than those physicians who did not underestimate survival (p < 0.02). In addition, 54% of physicians who underestimated preterm infant survival reported giving corticosteroids between 23 and 28 weeks' gestational age versus 73% of physicians with more accurate perceptions (p < 0.03). We conclude that in 1992, compared within 1979, more Alabama physicians reported antenatal corticosteroid use. Use of this treatment was influenced by each physician's perceptions of the probable outcome of the preterm infant.

Ethnicity and sources of prenatal care: findings from a national survey

BACKGROUND

Improving pregnancy outcomes for minorities is a major goal of health providers and policy makers. Since most strategies involve an intervention during pregnancy, it is important to know where minority women with various characteristics receive prenatal care and why. Our purpose was to evaluate services of prenatal care for white, African-American, Mexican-American, and Puerto Rican women.

METHODS

The National Maternal and Infant Health Survey (1988) was used to ascertain age, income, marital status, education level, and source of funding of the study population of 21,000 women, who were assigned to an ethnic group based on self-indentification in the survey. The sources of prenatal care were classified as private (private physician, nurse-midwife, health maintenance organization) or public (state or local health department, community health center, hospital-based clinic).

RESULTS

When categorized by ethnic group alone, 78 percent of white women received private care compared with 51 percent of Mexican-American women, 44 percent of African-American women, and 37 percent of Puerto Rican women. Private health insurance was held by 78 percent of white, 50 percent of African-American, 49 percent of Mexican-American, and 47 percent of Puerto Rican women. Of those with private insurance, 86, 62, 69, and 59 percent, respectively, received private care. Of white women with Medicaid funding, 52 percent received private care as opposed to a range of 20 to 42 percent for minority women.

CONCLUSIONS

Substantial differences in sources of prenatal care exist between white and minority women and between different minority groups, suggesting that policy makers and health caregivers should tailor prenatal care intervention to the needs of specific minority populations.

Use of antenatal corticosteroids for fetal maturation

Corticosteroids used to enhance fetal maturation are one of the best studied interventions in perinatal medicine. The treatment has been shown to reduce neonatal morbidity and mortality. The intervention is also highly cost-effective. In this article, we review the evidence supporting the benefits of corticosteroids, controversial issues concerning their use, and current practice recommendations. The review will highlight the research presented at the recent National Institutes of Health Consensus Conference concerning corticosteroids. This research led the National Institutes of Health to advocate clinical practice guidelines on the appropriate use of corticosteroids.

The origin and outcome of preterm twin pregnancies

OBJECTIVE

To define the etiology of preterm twin births and determine the contribution of twin births to preterm birth and related morbidity and mortality.

METHODS

The March of Dimes Multicenter Prematurity and Prevention Study included a total of 33,873 women who delivered between 1982-1986, 432 (1.3%) of which delivered twins. Women were classified by reason for preterm birth and ethnicity. Neonates were classified as to stillbirth, neonatal death, and various short-term morbidities. A second data set from one center consisted of infants who weighed 1000 g or less, were born between 1979-1991, and survived to 1 year of age (n = 386, 15% twins); this was used to determine if twins and singletons born at comparable gestational ages have a similar risk for major developmental handicaps.

RESULTS

Of the deliveries in the data set, 54% of twins were preterm compared with 9.6% among singletons. Of those born preterm, twins were born at a significantly earlier gestational age than were singletons. Only 2.6% of all neonates born were twins, but they represented 12.2% of all preterm infants, 15.4% of all neonatal deaths, and 9.5% of all fetal deaths. Spontaneous labor accounted for 54% of twin births, premature rupture of membranes accounted for 22%, and indicated deliveries accounted for 23%. Of the indicated preterm births in twins, 44% were due to maternal hypertension, 33% to fetal distress or fetal growth restriction, 9% to placental abruption, and 7% to fetal death. Comparing infants of similar gestational age, twins weighed less, but had a mortality equivalent to that of singletons after 29 weeks. Between 26-28 weeks' gestation, the risk of mortality for twins versus singletons was 1.6 (95% confidence interval 1.1-2.5). Preterm twins did not have significantly more respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, or other short-term morbidity than did preterm singletons. Twins who weighed 500-1000 g and survived to 1 year had a 25% rate of major developmental handicaps. However, when gestational age was controlled, the rate of major handicaps was not higher in twins than in singletons.

CONCLUSIONS

Twins accounted for a disproportional amount of preterm birth and associated morbidity and mortality. Also, when preterm twins were compared with preterm singletons and corrected for their gestational ages, the rates of morbidity were similar. Preterm twins weighing less than 1000 g did not have an increased prevalence of major handicaps at 1 year of age compared with preterm singletons.

Predicting low Apgar scores of infants weighing less than 1000 grams: the effect of corticosteroids

OBJECTIVE

To evaluate maternal and neonatal factors that predict low Apgar scores in newborns weighing less than 1000 g.

METHODS

From a data set of all live-born infants who were delivered between 1979-1991 and who weighed 1000 g or less, we reviewed the records of 837 neonates born at 24-28 weeks' gestation. Potential risk factors were evaluated for associations with a 1-minute Apgar score of 3 or less and a 5-minute Apgar score of 6 or less. Analyses used chi 2 test and multiple logistic regression.

RESULTS

The prevalence of 1-minute Apgar scores of 3 or less decreased from 65.9% at 24 weeks to 38.2% at 28 weeks, and the prevalence of 5-minute Apgar scores of 6 or less decreased from 83.3% at 24 weeks to 51.2% at 28 weeks. As the birth weight increased from 500-599 g to 900-1000 g, 1-minute Apgar scores of 3 or less decreased from 77.0% to 39.6%, and 5-minute Apgar scores of 6 or less decreased from 89.2% to 56.4%. Aside from gestational age and birth weight, corticosteroid use was the strongest predictor of Apgar scores above 3 at 1 minute and above 6 at 5 minutes. Male and nonvertex-presenting infants had an increased likelihood of low Apgar scores, as did infants with cord blood pH less than 7.05 or bicarbonate value less than 17 mEq/L.

CONCLUSION

Neonates at very low gestational ages and birth weights are more likely than larger or more mature infants to have low Apgar scores. Males, nonvertex-presenting infants, and those who are acidotic at birth also have an increased prevalence of low scores. Infants born to mothers treated with antenatal corticosteroids are less likely to have low Apgar scores. This finding indicates that antenatal corticosteroids may benefit the newborn at birth, before respiratory distress syndrome becomes apparent.

Effects of prenatal care on twin gestations

Twin pregnancies are known to have a higher risk of prematurity, uteroplacental insufficiency and increased perinatal mortality. An almost universally held tenet is that prenatal care is helpful in reducing those risks. In an attempt to support that belief, the records of all twins delivered at R. E. Thomason General Hospital between 1982 and 1985 were reviewed. Thirty-seven twin pregnancies received appropriate antepartum care, and 25 did not. There were statistically significant differences in the perinatal mortality rate of the clinic patients (68/1,000) versus the nonclinic patients (160/1,000). Also, significant differences were demonstrated between the mean birth weights: 2,007 g in the nonclinic group and 2,546 in the clinic group. The results suggest that intensive prenatal care in twin gestations promotes fetal growth and improves perinatal outcome.