The natural history of an umbilical cord hemangioma

Umbilical cord hemangiomas are rare, and the natural history is poorly understood. We present a case where the clinical course was complicated by distal umbilical cord edema, episodes of proximal obstruction of umbilical artery blood flow, transient fetal pleural and pericardial effusions, and position-dependent abnormal fetal heart rate monitoring with periods of sustained fetal tachycardia. Delivery was performed for fetal growth restriction with abnormal fetal surveillance. This case highlights possible mechanisms for fetal decompensation as well as the importance of a multifaceted approach to the management of an umbilical cord mass using multiple tools for fetal assessment. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:455-458, 2016.

A multi-center randomized trial of two different intravenous fluids during labor

OBJECTIVE

To determine if the intrapartum use of a 5% glucose-containing intravenous solution decreases the chance of a cesarean delivery for women presenting in active labor.

METHODS

This was a multi-center, prospective, single (patient) blind, randomized study design implemented at four obstetric residency programs in Pennsylvania. Singleton, term, consenting women presenting in active spontaneous labor with a cervical dilation of <6 cm were randomized to lactated Ringer's with or without 5% glucose (LR versus D5LR) as their maintenance intravenous fluid. The primary outcome was the cesarean birth rate. Secondary outcomes included labor characteristics, as well as maternal or neonatal complications.

RESULTS

There were 309 women analyzed. Demographic variables and admitting cervical dilation were similar among study groups. There was no significant difference in the cesarean delivery rate for the D5LR group (23/153 or 15.0%) versus the LR arm (18/156 or 11.5%), [RR (95% CI) of 1.32 (0.75, 2.35), p = 0.34]. There were no differences in augmentation rates or intrapartum complications.

CONCLUSIONS

The use of intravenous fluid containing 5% dextrose does not lower the chance of cesarean delivery for women admitted in active labor.

Oxytocin discontinuation during active labor in women who undergo labor induction

OBJECTIVE

The purpose of this study was to determine whether there is an increase in the cesarean delivery rate in women who undergo induction when oxytocin is discontinued in the active phase of labor.

STUDY DESIGN

We conducted a prospective randomized controlled trial of women who underwent induction of labor at term; they were assigned randomly to either routine oxytocin use (routine) or oxytocin discontinuation (DC) once in active labor. Analysis was by intention to treat.

RESULTS

Two hundred fifty-two patients were eligible for study analysis: 127 patients were assigned randomly to the routine group and 125 patients were assigned randomly to the DC group. Cesarean delivery rate was similar between the groups (routine, 25.2% [n = 32] vs the DC group, 19.2% [n = 24]; P = .25). There was a higher chorioamnionitis rate and slightly longer active phase in those women who were assigned to the DC group. In adjusted analysis, the rate of chorioamnionitis was not different by randomization group but was explained by the duration of membrane rupture and intrauterine pressure catheter placement.

CONCLUSION

Discontinuation of oxytocin in active labor after labor induction does not increase the cesarean delivery rate significantly.

Determining a threshold for amniotic fluid as a predictor of perinatal outcome at term

OBJECTIVE

To determine a threshold level of amniotic fluid in low-risk term pregnancies predictive of adverse perinatal outcome.

METHODS

Prospective cohort study of low-risk patients at term undergoing amniotic fluid volume measurement. Amniotic fluid index (AFI) remained blinded unless ≤ 1 cm or ≥ 25 cm. Primary outcome was a positive fetal vulnerability index (FVI). The last AFI was evaluated as predictor of a +FVI. We estimated that we needed to perform ultrasounds on 620 women.

RESULTS

Patients were enrolled through 2004-2008. There were 24 (7.8%) patients delivering a neonate with +FVI. An AFI < 8 cm increased the risk of a +FVI (risk ratio 2.70 [95% CI 1.2, 6.0]; p = 0.01); however, the area under the receiver operating characteristics curve was 0.60. Enrollment was stopped at 308 patients due to enrollment challenges.

CONCLUSIONS

An AFI cutoff <8 cm was associated with an increase in FVI outcomes but had a low positive predictive value for a +FVI. Isolated incidentally found low fluid in uncomplicated pregnancies may not be an indication for immediate intervention.

Midtrimester dilation and evacuation versus prostaglandin induction: a comparison of composite outcomes

OBJECTIVE

The objective of the study was to determine the optimal procedure for midtrimester uterine evacuation.

STUDY DESIGN

This was a retrospective cohort study of women undergoing midtrimester uterine evacuation by prostaglandin induction or dilation and evacuation (D&E). Primary outcome was composite complication, defined as any of the following: infection, need for additional surgery, unexpected admission or readmission, serious maternal morbidity, and/or maternal death.

RESULTS

Two hundred twenty patients met inclusion criteria: 94 D&E and 126 induction. D&E was associated with less composite complications (15% vs 28%, P = .02), which persisted in adjusted analysis (adjusted odds ratio, 0.38; 95% confidence interval, 0.15-0.99; P = .05). Women in the induction group had higher rates of retained placenta requiring curettage (22% vs 2%, P = .01), whereas cervical injury was more common in the D&E group (5% vs 0%, P = .01). Median length of stay was significantly shorter in the D&E group (5.7 hours vs 28.4 hours, P < .001).

CONCLUSION

Midtrimester D&E is associated with fewer complications than prostaglandin induction.