Comparison of active phase labor between triplet, twin, and singleton gestations

OBJECTIVE

To characterize the active phase of labor in triplet pregnancies and compare it with gestational age-matched twins and singletons.

METHODS

Active phase rates were calculated beginning at 5 cm of dilation for women with triplet gestations longer than 24 weeks who labored and reached the second stage. Twin and singleton cohorts that also completed the first stage of labor were matched for gestational age at delivery (+/-1 week), parity, and epidural use. Intrapartum variables included oxytocin use (induction or augmentation, duration of infusion, and maximum dosage), cervical dilation at membrane rupture, and active phase dilation rate.

RESULTS

Thirty-two triplet pregnancies met inclusion criteria between January 1994 and September 1998 and were each compared with twin and singleton cases in a 1:2 ratio. Triplet and twin active phase rates, while similar (1.8 versus 1.7 cm/hour, respectively), were significantly lower than the mean singleton dilation rate (2.3 cm/hour, P =.02). No other intrapartum variables differed between the three groups. Despite controlling for gestational age at delivery, mean birth weights were significantly higher in singletons and correspondingly lower in twins and triplets (2,493 versus 2,112 and 1,968 g, respectively; P =.001). An analysis of active phase dilation rates as a function of the cumulative birth weight per pregnancy demonstrated an inverse correlation, with slower progress in active labor associated with increasing total fetal weight (R = -.24; P =.002).

CONCLUSIONS

Triplet and twin active phase dilation proceeds at a slower rate than that observed in singleton pregnancies. The rate of active phase dilation is inversely correlated to total fetal weight.

Ultrafast magnetic resonance imaging of cephalopagus conjoined twins

BACKGROUND

Ultrafast magnetic resonance imaging (MRI) has been used successfully in antenatal diagnosis.

CASE

We report a case of cephalopagus conjoined twins in which ultrafast MRI clarified how the twins were united, especially the neuroanatomy, and helped with antenatal counseling.

CONCLUSION

Ultrafast MRI can provide superior image quality to two-dimensional ultrasonography and should be considered an adjunct to ultrasound for antenatal characterization of some anomalies.

Prospective evaluation of bone density in pregnant women receiving the low molecular weight heparin enoxaparin sodium

OBJECTIVE

To evaluate changes in bone density in women receiving enoxaparin sodium during pregnancy.

METHODS

Bone density in the proximal femur was serially measured in 16 women receiving enoxaparin sodium (40 mg daily) during pregnancy. Baseline measurements were taken within 2 weeks of starting therapy and then at 6-8 weeks postpartum and 6 months postpartum.

RESULTS

Patients received enoxaparin sodium for a mean duration of 25 weeks (range, 19-32 weeks). There was no significant change in mean bone density measurement from baseline measurements to the conclusion of therapy at 6 weeks postpartum and no patient experienced a decrease in bone mass of >10% at 6 weeks postpartum. By 6 months postpartum, there was a significant mean decrease in bone density (P = 0.02) and two of the 14 patients evaluated (14%) experienced an overall bone loss of >10%.

CONCLUSION

The prolonged used of enoxaparin sodium may not cause significant bone loss during pregnancy.

Changes in the pharmacokinetics of the low-molecular-weight heparin enoxaparin sodium during pregnancy

OBJECTIVE

We sought to evaluate the pharmacokinetics of subcutaneously administered enoxaparin sodium during and after pregnancy.

STUDY DESIGN

Daily subcutaneous injections of enoxaparin sodium (40 mg) were administered to 13 pregnant women. On 3 separate occasions, once early in pregnancy (12-15 weeks), once late in pregnancy (30-33 weeks), and once in the nonpregnant state (6-8 weeks post partum), serial blood samples were collected, and plasma was analyzed for antifactor Xa activity. Analysis of variance was used for statistical analysis. P <.05 was significant.

RESULTS

The time to maximum concentration and the mean residence time in pregnancy compared with the postpartum state were not significantly different. During early and late pregnancy, maximum concentration and the last measurable anti-factor Xa activity level were lower than in the nonpregnant state (P <.05). The area under the plasma activity-versus-time curve was significantly lower in pregnancy than in the postpartum state (P <.05).

CONCLUSION

The pharmacokinetics of enoxaparin sodium are significantly different during pregnancy than in the same women when nonpregnant. The observed difference is likely because of increased renal clearance of enoxaparin during pregnancy. This finding has significant implications for appropriate dosing of enoxaparin in pregnancy.

Factors influencing preconception control of glycemia in diabetic women

BACKGROUND

Although periconceptional glycemic control directly impacts perinatal outcome for pregestational diabetic women, these women still frequently enter pregnancy with suboptimal control of glycemia.

OBJECTIVES

To determine how frequently diabetic women enter pregnancy with suboptimal glycemic control and to identify factors associated with not achieving optimal periconceptual control of glycemia.

PATIENTS AND METHODS

Pregestational diabetic women (n = 55) who attended the Maternal Fetal Medicine Faculty Practice or the Resident Medical Complications Obstetric Clinic, Magee Women's Hospital, Pittsburgh, Pa, were administered a brief questionnaire pertaining to periconceptional education and control of glycemia. Levels of periconceptional hemoglobin A1c, were measured in all patients.

RESULTS

Sixty-one percent of pregestational diabetic women presented for prenatal care with suboptimal control of their blood glucose levels (hemoglobin A1c measurement, >0.08). Of the 55 diabetic women who participated in the questionnaire, 47 (86%) were under the care of a physician for their diabetes, 45 (82%) monitored their glucose level at least 3 times per day, 34 (60%) stated that they had been advised to plan a pregnancy, and 29 (53%) stated that they had planned their pregnancies. Women who had not been advised to achieve target hemoglobin A1c levels were more likely to enter pregnancy with suboptimal control of their blood glucose levels (P = .02). Women who experienced prior complications with pregnancy were significantly more likely to enter pregnancy with suboptimal control of their blood glucose levels (P = .02).

CONCLUSIONS

Diabetic women frequently enter pregnancy with suboptimal control of glycemia. Women not advised to achieve target glucose or hemoglobin A1c levels were more likely to enter pregnancy with suboptimal control of glycemia.

Pregnancy after liver transplantation

This article reviews the reported experience with pregnancy after liver transplantation and describes obstetric risks and medical issues that the maternal fetal medicine specialist has a reference for managing these pregnancies and for providing appropriate preconception counseling. Women who undergo liver transplantations have a higher risk of preeclampsia, worsening hypertension, preterm premature rupture of membranes, anemia, small for gestational age, preterm delivery, and cesarean section than the normal obstetric population. Women with preconceptional renal dysfunction appear to be at greatest risk for pregnancy complications. Women who conceived within 6 months of transplant had a high risk of rejection. Reproductive-aged recipients of liver allograft should receive contraception and preconception counseling. In an appropriately timed and planned pregnancy, women who undergo liver transplantations can have successful pregnancies with little risk to their allograft function.

Association of pregnancy complications and choice of immunosuppressant in liver transplant patients

BACKGROUND

The purpose of this study was to identify factors associated with antenatal complications for an ongoing series of pregnant women who have undergone orthotopic liver transplantation.

METHODS

We reviewed Magee-Womens Hospital records from 14 pregnancies in 13 women in whom a liver had been transplanted before pregnancy. We collected and analyzed data regarding the primary liver disease, allograft status, liver function at conception and during pregnancy, immunosuppressive medications, associated medical conditions, time from transplant to conception, cytomegalovirus serostatus, and maternal and fetal outcome.

RESULTS

Seven patients had evidence of renal dysfunction (creatinine, 1.3-2.0 mg/dl), five of whom also were hypertensive at their first prenatal visit. The complications of preeclampsia, worsening hypertension, and small for gestational age occurred only in women with renal dysfunction at conception. Renal dysfunction was more often associated with cyclosporine than tacrolimus use.

CONCLUSIONS

Renal dysfunction is the primary determinant of adverse pregnancy outcome in liver transplant recipients. Immunosuppression with cyclosporine during pregnancy was more often associated with antenatal complications than with the use of tacrolimus.

Hemorrhagic complication of anticoagulation during pregnancy in a woman with lupus anticoagulant

BACKGROUND

Lupus anticoagulant is an acquired antiphospholipid antibody that can increase greatly the risk of thromboembolism during pregnancy. Because a baseline elevated activated partial thromboplastin time (PTT) is associated frequently with this antibody, monitoring anticoagulant effect with activated PTT can be unreliable.

CASE

A pregnant woman with lupus anticoagulant being treated with adjusted dose heparin experienced concurrent severe thrombotic and hemorrhagic complications.

CONCLUSION

This case illustrates the pitfall of activated PTT monitoring when administering anticoagulation therapy to a patient with a baseline elevated activated PTT. We propose that heparin levels be used to monitor anticoagulation in these patients.

Felodipine use in pregnancy. Report of three cases

BACKGROUND

Calcium channel blockers are effective agents for the management of chronic hypertension and are being used with increasing frequency. If their safety and efficacy during pregnancy can be documented, women can be counseled to continue their antihypertensive agent during pregnancy. To our knowledge, the use of felodipine, a calcium channel blocker of the dihydropyridine group, during pregnancy has not been described.

CASES

We report three cases of felodipine use in pregnancy by women with chronic hypertension.

CONCLUSION

In women with severe hypertension (diastolic blood pressure > 100 mm Hg) who require pharmacologic treatment of it during pregnancy, felodipine appears to be an acceptable option.

Successful pregnancy after bilateral hypogastric artery ligation. A case report

BACKGROUND

Selective embolization of the hypogastric arteries is an effective, nonsurgical alternative for the management of obstetric and gynecologic hemorrhage. Successful pregnancy following bilateral hypogastric artery occlusion has been reported, but experience is extremely limited.

CASE

We report a case of successful pregnancy in a patient previously treated with bilateral hypogastric artery embolization. Although a diminution of fetal growth toward term was observed, the fetus tolerated labor and subsequently thrived, without sequelae.

CONCLUSION

This case supports the possibility of normal labor for women who conceive after bilateral hypogastric artery embolization.

Metabolic response to meal eating and extended overnight fast in twin gestation

OBJECTIVE

Our purpose was to compare the metabolic response to normal meal eating and the vulnerability to starvation ketosis in twin versus singleton gestation.

STUDY DESIGN

Data are reported on 10 twin and 10 singleton nondiabetic gestations enrolled in a 40-hour metabolic study. Singletons were age (+/- 5 years) and prepregnancy weight (+/- 10% ideal body weight) matched with twins. The diet (35 kcal/kg ideal body weight for singletons, 40 kcal/kg ideal body weight for twins) was distributed as one fifth at 8 AM, two fifths at 1 PM, and two fifths at 6 PM. An overnight fast was extended until noon the following day. Glucose and beta-hydroxybutyrate measurements were made hourly except at night, when they were made every 2 hours. Insulin values were obtained before and after dinner and on the day when breakfast was delayed.

RESULTS

The glucose, beta-hydroxybutyrate, and insulin excursions in response to meal eating from 8 AM to 12:00 noon on day 1 were similar in twin and singleton pregnancies (analysis of variance for repeated measures, p < 0.05). On day 2, when breakfast was delayed, a progressive decrement in glucose was observed in both twins and singletons (p = 0.4682). Concurrently, there was a progressive rise in beta-hydroxybutyrate in both twins and singletons, which was significantly greater for twins compared with singletons (p = 0.002).

CONCLUSIONS

These data indicate that twin gestations are more vulnerable to the accelerated starvation of late normal pregnancy than singletons are in spite of additional caloric intake. We speculate that the observed difference may be the result of the increased metabolic demands of twin gestation.