Risk Assessment and Treatment Guide for Obstetric Thromboprophylaxis: Comprehensive Review of Current Guidelines

OBJECTIVE

Currently, there are numerous recommendations and often conflicting guidance provided for venous thromboembolism (VTE) prophylaxis in pregnancy. Our objective was to create a one-page risk assessment and treatment guide based on a review of the most recent and evidence-based publications on this subject to simplify the approach and allow all obstetric patients to be properly assessed for risk of VTE and treated if indicated.

STUDY DESIGN

We identified studies by completing a PubMed and MEDLINE search from January of 1980 through March 2017 with articles utilizing a specific combination of the selected general keywords (thrombophilia, pregnancy, VTE, prophylaxis, hypercoagulability, antepartum, postpartum, risk, etc.). We completed the search at the saturation point, meaning that all combinations of the relevant words were directing us to the same articles. After collecting the relevant sources and reviewing them, a total of 10 articles/guidelines were selected for inclusion in the analysis.

RESULTS

We outlined every recommendation in the identified articles and guidelines and included any recommendation that was cited in at least three different sources in the final guide. We used American College of Obstetrics and Gynecology recommendations as the base for screening and dosing guidelines and utilized known and published absolute risk values and odds ratios to stratify risk factors. This stratification was used for both antepartum and postpartum recommendations and a single-page guideline was created.

CONCLUSION

This compilation of guidelines integrates the complicated topic into a simple comprehensive guide where women can be identified early and accurately for appropriate VTE prophylaxis to protect them during and after pregnancy.

Self-Reported Changes in Comfort Level With Basic OB/GYN Procedures After Deployment

OBJECTIVE

To assess the specialty-specific procedures and clinical encounters U.S. Army obstetrician/gynecologist (OB/GYN) providers felt were affected by deployment and identify skills and areas that may benefit from postdeployment training.

METHODS

Active duty Army OB/GYN physicians were invited to participate in an anonymous web-based survey to rate their comfort level and experience performing specialty-specific procedures before and after military deployment. Physicians rated their comfort level on a 5-point Likert scale (1 = very uncomfortable to 5 = completely comfortable). Statistical analysis included Pearson χ(2) and McNemar's χ(2) with a p value of <0.05 considered significant.

RESULTS

Of the 100 physicians eligible to complete the survey, 66 responded (response rate = 66%). Their responses demonstrated a statistically significant perception of decline in their comfort level with nearly every obstetric and gynecologic procedure and clinical encounter evaluated.

CONCLUSION

Time away from regular clinical practice during deployment results in providers feeling less comfortable with many common OB/GYN procedures and clinical situations. Although these results are not a measure of actual performance, this information helps define targets to focus refresher training for providers who leave their normal scope of practice for deployment. These findings apply to civilian providers leaving practice for other reasons as well.

Objective Evaluation of the Effects of Deployment on Laparoscopic Skills: The Simulation and Deployment Laparoscopic Skills Study

OBJECTIVE

To assess the effects of deployment on basic laparoscopic skills of general surgeons and obstetrics/gynecology (OB/GYN) physicians.

METHODS

This was a prospective 10-site study. Active duty Army OB/GYN and general surgery physicians scheduled to deploy were invited to participate. Before deployment, they performed fundamentals of laparoscopic surgery (FLS) tasks and specialty-specific procedures on a virtual reality laparoscopic simulator. Upon returning, physicians repeated the same evaluations. Questions about perceived comfort with laparoscopic procedures were asked before and after deployment. Statistical analysis included paired t tests for continuous variables and nonparametric for ordinal data with a p value of <0.05 considered significant.

RESULTS

121 deploying providers were invited to participate; 35 agreed and 29 completed the predeployment skills assessment. After deployment, 15 providers had postassessment evaluation data collected, and their results were used for analysis. Though physicians reported a decrease in their perception of preparedness for advanced laparoscopic procedures and complications, there was no decrement in their performance of FLS tasks or the basic laparoscopic procedures.

CONCLUSION

Time away from regular clinical practice during deployments did not significantly affect surgeons' performance as measured by a virtual reality laparoscopic simulator. Additional study on effects on advanced procedures should be considered.

Perceived clinical skill degradation of Army family physicians after deployment

BACKGROUND AND OBJECTIVES

Deployment away from regular clinical practice is necessary for Army family physicians, but no current information identifies specific procedures or clinical encounters where they feel less comfortable after deployment. This study identifies specific clinical areas and amount of perceived degradation in skills after deployment to combat zones.

METHODS

Active duty Army family physicians were invited to participate in a web-based and anonymous survey rating comfort level performing clinical encounters or procedures prior to and after military deployment. Participants rated their comfort level using a 5-point Likert scale. The analysis included descriptive statistics about each physician's deployment history. The composite data for each clinical encounter or procedure were analyzed with McNemar's Chi-Square test.

RESULTS

A total of 179 eligible Army family physicians (54% of total) fully completed the instrument, with 39% deploying once and 10% deploying more than five times in their career. Deployments ranged from 1 to >24 months, with 42% having a last deployment of 12 months duration. With statistical significance, providers reported being less comfortable post-deployment with managing first-trimester bleeding, ACLS codes, acute abdominal pain, asthma exacerbations, central line placement, chest pain, COPD exacerbations, CVA/hypertensive emergency, lumbar puncture, neonatal fevers, pediatric codes, sepsis/septic shock, and vaginal delivery. These physicians reported statistically significant increased comfort with the care of major trauma after deployment.

CONCLUSIONS

Family physicians deploying to support combat operations feel less comfortable with critical clinical skills across the spectrum of care. Refresher training could be provided with standardized approach to these needs with a goal of maintaining full scope primary care providers.

Evaluation of force applied during deliveries complicated by shoulder dystocia using simulation

OBJECTIVE

We sought to objectively evaluate the amount of force applied during deliveries complicated by shoulder dystocia among different providers.

STUDY DESIGN

Providers who do deliveries at our institution were approached for participation. The simulation exercise used a childbirth mannequin that measures the amount of force the provider applies to the fetal head during delivery. The amount of force applied and information regarding the provider's level of experience, height, weight, and gender was recorded. This study was approved by the hospital institutional review board.

RESULTS

A total of 47 providers participated. The mean force applied during each situation was not associated with the provider's experience, height, weight, or gender.

CONCLUSION

Provider experience, gender, and body habitus were not associated with the amount of force applied during delivery. We found differences between family medicine and obstetrics/gynecology providers. In addition, a significant number of all providers (19/47, 40%) pulled >100 N.

Effects of deployment on depression screening scores in pregnancy at an army military treatment facility

OBJECTIVE

To estimate the relationship of positive screening for depression during and after pregnancy with deployment status of the spouse.

METHODS

We conducted a retrospective cohort study by reviewing a departmental database of women who completed the Edinburgh Postpartum Depression Scale during pregnancy from 2007 to 2009. Per departmental protocol, screening is offered at the initial obstetric visit, at 28 weeks of gestation, and at 6 weeks postpartum. A score of 14 or higher was considered high risk for having depression, and referral for additional evaluation was recommended. Included in our survey was an additional question that asked if the patient's spouse was currently deployed, returning from deployment, preparing to deploy, or if no deployment was planned. All data were entered into an electronic database and statistical analysis performed comparing Edinburgh Postpartum Depression Scale scores at each time period and deployment status.

RESULTS

A total of 3,956 surveys were complete and available for analysis. The risk of a positive screen was more than doubled compared with the control group (no deployment planned) if the spouse was deployed during the 28-32 week visit (4.3% compared with 13.1%, P=.012) or the postpartum period (8.1% compared with 16.2%, P=.006).

CONCLUSION

Deployment status has a measurable effect on the prevalence of elevated depression screening scores during pregnancy and in the postpartum period. These findings suggest that more intense monitoring, assessment, and treatment may be warranted for this at-risk population.

LEVEL OF EVIDENCE

II.

Female soldiers' gynecologic healthcare in Operation Iraqi Freedom: a survey of camps with echelon three facilities

OBJECTIVE

To describe female soldiers' predeployment gynecologic healthcare screening, common symptoms, and availability of gynecologic care during Operation Iraqi Freedom.

METHODS

A questionnaire distributed to U.S. military females presenting to outpatient facilities in level 3 echelon of care between August 2005 and March 2006.

RESULTS

Three-hundred ninety seven of 401 surveys (99%) were returned. Ten percent of deployed females (40) had no cervical cytology screening 1 year before deployment and 27% of the 399 required additional treatments for abnormal cervical cytology during deployment. Thirty-five percent reported a gynecologic problem and 44% received care at their base. Irregular bleeding was the most common gynecologic problem. Forty-four percent of women used some form of hormonal contraception; however, 43% changed methods because of unavailability. One-third of soldiers received pre-deployment menses regulation counseling, with 48% of those using continuous oral contraceptive pills for cycle control.

CONCLUSION

Gaps remain in predeployment gynecologic screening and counseling. These critical predeployment medical evaluations must remain a priority for all female soldiers to ensure unit readiness.

Use of a postpartum hemorrhage simulator for instruction and evaluation of residents

OBJECTIVE

Postpartum hemorrhage is a common and potentially life-threatening obstetric emergency. We sought to create a realistic simulation and validate a standardized grading form to evaluate competency in the management of postpartum hemorrhage.

METHODS

Residents from 3 programs underwent training with a postpartum hemorrhage simulation using a standard obstetric birthing model equipped with an inflatable uterus to simulate uterine atony. All simulations were graded by staff physicians with a standardized grading sheet constructed from the current literature on the topic. Residents were expected to recognize the hemorrhage and take appropriate steps, including asking the assistant to administer medications, to correct the problem. Objective and subjective performance was measured with standardized grading sheets, and results were analyzed for reliability using Cronbach α and intraclass correlation coefficients. This project was conducted in accordance with the hospital Institutional Review Board policies at each institution.

RESULTS

Forty residents from 3 institutions underwent simulation training. The majority were unable to correct the hemorrhage within 5 minutes and almost half also made at least 1 error, either the dose or route, in the medications they requested. Reliability was evaluated with Cronbach α and demonstrated the grading sheets were valid and had good interrater reliability.

DISCUSSION

A simulated postpartum hemorrhage scenario can identify important deficiencies in resident knowledge and performance, with no risk to patients. The standardized grading form worked well for our purposes and was reliable in our study. Further testing is needed to evaluate whether the training improves performance in real-life hemorrhages.

Improved ultrasonographic estimation of birth weight in macrosomic fetuses by application of a correction factor to the gestation-adjusted projection method

OBJECTIVE

The purpose of this study was to improve estimated birth weight (EBW) determination in macrosomic fetuses (estimated fetal weight >or=4000 g) by application of a correction factor to the gestation-adjusted projection (GAP) method.

METHODS

A review was performed of 411 singleton pregnancies delivered at term. On the basis of ultrasonographic examinations previously performed between 34.0 and 36.9 weeks' gestation, an EBW was calculated for each patient by the GAP method (EBW(GAP)). Using linear regression, a correction factor was developed that minimized the systematic error in the EBW(GAP). The model was then tested retrospectively on a second group of 317 patients.

RESULTS

The GAP method systematically overestimated weights of the heavier fetuses in our population. The model we derived showed improved accuracy compared with the GAP method. When applied to a second group of 317 patients, our correction to the GAP method improved specificity for macrosomia from 94.7% to 98.6% (P = .003). Stated differently, the false-positive rate was reduced from 5.3% to 1.4%. The difference in sensitivity for macrosomia was not significant: 41.2% and 35.3% (P = .68).

CONCLUSIONS

Application of our model to our study population reduced the number of false-positive results for fetal macrosomia.

Post-partum exacerbation of idiopathic pulmonary hemosiderosis

Idiopathic pulmonary hemosiderosis is a disease causing diffuse alveolar hemorrhage and has rarely been reported in pregnancy. We present the first described case of a post-partum exacerbation after an uncomplicated prenatal course.

Maternal glucose levels after dexamethasone for fetal lung development in twin vs singleton pregnancies

OBJECTIVE

Betamethasone administration in singleton pregnancies causes maternal hyperglycemia. With the increased risk of glucose intolerance in twin pregnancies, we sought to determine whether maternal hyperglycemia after dexamethasone administration is different in twin vs singleton pregnancies.

STUDY DESIGN

Patients with singleton or twin pregnancies admitted between 24 and 34 weeks' gestation with diagnoses requiring steroid administration were approached. Exclusion criteria included diabetes, abnormal glucose tolerance test, infection, or medications known to interfere with glucose metabolism. Patients were NPO for 24 hours and received dexamethasone per protocol. Maternal glucose levels were checked at baseline and then at specified intervals after the initial dose; appropriate statistical analysis was performed.

RESULTS

Ten singleton and 9 twin gestations were enrolled. There were no differences in mean maternal or gestational ages. Mean glucose levels were significantly higher in the twin group at 4 hours (114 mg/dL vs 95.6 mg/dL), 8 hours (121.4 mg/dL vs 90.9 mg/dL), and 24 hours (116 mg/dL vs 81 mg/dL) (P < .01 for all).

CONCLUSION

Twin pregnancies had higher mean glucose values than singleton pregnancies in the first 24 hours after dexamethasone administration.

Patients presenting with birth plans: a case-control study of delivery outcomes

OBJECTIVE

To determine if labor management and outcomes, specifically epidural use, cesarean section and episiotomy rates, are different between patients presenting with formal birth plans and matched control patients without plans.

STUDY DESIGN

Patients admitted in labor with birth plans over a 3.5-year period were identified. Patients were excluded if they required a cesarean section prior to labor or if they delivered outside the institution. For each birth plan patient, 2 age- and parity-matched controls were identified. Birth plans and medical records were reviewed for all patients and delivery outcomes recorded. Statistical analysis was performed utilizing chi2 and Fisher's exact test as appropriate. This study was approved by the institutional review board.

RESULTS

Seventy-one patients with birth plans were identified, with complete information available for 68. Sixty-four met the inclusion criteria, and for those 128, matched control patients were identified. There was no difference in the cesarean section rate (17% [11/64] vs. 12% [15/1281, p = 0.30) or episiotomy rate between patients with and without a birth plan (25% [13/53] vs. 23% [26/113], p = 0.83). There was a significant difference in the epidural use rate in patients having a vaginal delivery, with birth plan patients receiving an epidural less often (57% [30/53] vs. 78% [88/1131 p = 0.005).

CONCLUSION

As compared to age- and parity-matched controls, patients in our study with birth plans did not have an increased incidence of episiotomy or cesarean section but were less likely to receive epidural anesthesia during labor.

Fetal growth after preterm premature rupture of membranes: is it related to amniotic fluid volume?

OBJECTIVE

Preterm premature rupture of membranes (PPROM) has been associated with an increased rate of fetal growth restriction (FGR). It is unknown whether impairment of fetal growth is mediated through external compression from decreased amniotic fluid volume or (an)other mechanism(s).

METHODS

Over a three-year period all patients with singleton pregnancies experiencing PPROM at <37 weeks lasting greater than 10 days, and who underwent serial sonograms to assess fetal biometry after PPROM, were included in the study. Patients were excluded for congenital anomalies or other inherent risk factors for abnormal fetal growth. Fetal abdominal circumference (AC) percentiles were compared between the first sonographic exam after PPROM and the last exam before delivery. The median amniotic fluid index between PPROM and delivery was correlated with the change in AC percentiles while controlling for the duration of PPROM. Statistical analysis utilized one-way analysis of variance and correlation; a p value of <0.05 was considered significant.

RESULTS

Twenty-two patients met our inclusion criteria with a mean duration (+/-SD) of PPROM of 58 days (+/-46). The median AFI during the PPROM period was not correlated with the change in AC percentiles after controlling for duration of PPROM (p = 0.49).

CONCLUSIONS

The residual amniotic fluid volume after PPROM does not appear to correlate with fetal growth suggesting that the increased rate of FGR in PPROM is not secondary to oligohydramnios. We hypothesize that the intrauterine pathologic processes responsible for membrane rupture may also interfere with fetal growth.

17-Hydroxyprogesterone caproate reverses induced vasoconstriction of the fetoplacental arteries by the thromboxane mimetic U46619

OBJECTIVE

This study was undertaken to determine whether 17-hydroxyprogesterone caproate (17P) has a vasoactive effect on fetoplacental vasculature.

STUDY DESIGN

Two cotyledons were obtained from each of 5 placentas. Baseline perfusion was established with Hanks-based solution. One cotyledon from each pair was then infused with perfusate to which U46619 a thromboxane sympathomimetic had been added. After 30 minutes, a dose of 17P was then administered to each cotyledon. Finally, a vasoconstricting dose of angiotensin II was administered to each cotyledon. Perfusion pressures were recorded throughout. Statistical analysis of pressure change for a single cotyledon was performed by using a paired t test. Statistical analysis of mean perfusion pressure difference between U46619 exposed and nonexposed cotyledons was analyzed by using a students t test.

RESULTS

17P did not significantly alter the perfusion pressure of the control cotyledon. (30.6 +/- 8.3 mm Hg vs 30.1 +/- 7.8 mm Hg P = .48). 17P administration significantly lowered the perfusion pressure of the U46619 preconstricted vessels in comparison with preadministration. (60.1 +/- 13 mm Hg vs 27.3 +/- 7.1 mm Hg P = .03). Both groups of cotyledons responded with vasoconstriction to angiotension II with no difference in response between groups (38.3 +/- 12 mm Hg vs 45.8 +/- 8.2 mm Hg P = .63).

CONCLUSION

17P reverses induced vasoconstriction by U46619 in fetoplacental arteries.

Antenatal magnesium treatment and neonatal illness severity as measured by the Score for Neonatal Acute Physiology (SNAP)

OBJECTIVE

. To determine if antepartum administration of magnesium sulfate affects the Score for Neonatal Acute Physiology (SNAP).

METHODS

We reviewed a database of consecutive preterm admissions to our neonatal intensive care unit over a 12-month period. Information on delivery indication, magnesium sulfate use, betamethasone administration, neonatal SNAP scores, neonatal serum magnesium levels, and other data was collected. Data was analyzed by Chi-square, Student t-test, and multiple linear regression with P < 0.05 considered significant.

RESULTS

During the study period, 221 cases fulfilled inclusion and exclusion criteria. Multiple regression revealed a significant association between antepartum magnesium use and improved SNAP scores after controlling for gestational age, glucocorticoid use, chorioamnionitis, and birthweight (SNAP score reduction = -2.25 +/- 0.78, P = 0.005).

CONCLUSIONS

Antepartum administration of magnesium sulfate results in a significant improvement in the neonatal SNAP score. These results suggest that antepartum magnesium sulfate may be protective, or at least not detrimental to the newborn infant.

Effect of epidural anaesthesia on clinician-applied force during vaginal delivery

OBJECTIVE

Epidural anesthesia (EA) is used in 80% of vaginal deliveries and is linked to neonatal and maternal trauma. Our objectives were to determine (1) whether EA affected clinician-applied force on the fetus and (2) whether this force influenced perineal trauma.

STUDY DESIGN

After informed consent, multiparas with term, cephalic, singletons were delivered by 1 physician wearing a sensor-equipped glove to record force exerted on the fetal head. Those with EA were compared with those without for delivery force parameters. Regression analysis was used to identify predictors of vaginal laceration.

RESULTS

The force required for delivery was greater in patients with EA (n = 27) than without (n = 5) (P < .01). Clinical parameters, including birth weight (P = .31) were similar between the groups. Clinician force was similar in those with no versus first- versus second-degree laceration (P = .5). Only birth weight was predictive of laceration (P = .02).

CONCLUSION

Epidural use resulted in greater clinician force required for vaginal delivery of the fetus in multiparas, but this force was not associated with perineal trauma.

Management of idiopathic pulmonary haemosiderosis in pregnancy: report of two cases

Idiopathic pulmonary haemosiderosis (IPH) is a rare cause of alveolar haemorrhage. Its management in pregnancy is complicated and little clinical data exist on outcomes or treatment. Two patients with IPH, one with a known diagnosis prior to pregnancy (patient A) and one presenting de novo during pregnancy (patient B) are reported. Both subjects became maximally symptomatic in the third trimester and were treated with corticosteroids. Despite steroid treatment patient A had continued symptoms and was treated with azathioprine. Both patients delivered healthy female infants at 32 weeks and 38 weeks gestation, respectively. Patient B's course was complicated by the development of fatal invasive pulmonary aspergillosis 4 weeks postpartum. With improved care, more patients with IPH survive to childbearing age. Patients become most symptomatic late in pregnancy, underscoring the need for careful third trimester monitoring. These cases demonstrate that steroids are safe and that azathioprine can be used as additional therapy. When considering treatment options it is important to weigh the benefits of these medications against the potential for maternal and foetal harm.

Perineal body length and lacerations at delivery

OBJECTIVE

To define normal perineal body length during labor and determine if a shortened perineal body is associated with perineal lacerations or operative vaginal delivery.

STUDY DESIGN

We reviewed charts of patients admitted for labor over a 4-month period. The perineal body was measured by the admitting physician and delivery outcomes obtained from inpatient records. Patients were excluded for malpresentation, multiple gestation, gestational age < 36 weeks, incomplete records and scheduled cesarean delivery. To determine if differences existed between patients with perineal body measurements available and those without, chi2 analysis was used, with P<.05 considered significant. Multiple logistic regression was used to control for confounding variables and determine if a shortened perineal body affected the incidence of operative vaginal delivery and significant lacerations at vaginal delivery.

RESULTS

A total of 234 patients met our inclusion criteria; perineal body measurements were available for 133 (57%). The average perineal body length was 3.90 cm (+/-0.70). Patients with a perineal body of < or = 2.5 cm had a significantly higher chance of sustaining a third- or fourth-degree laceration (40% vs. 5.6%, P=.004). This risk remained after controlling for both operative vaginal delivery and episiotomy. The incidence of operative vaginal delivery was greater (28.5% vs. 9.2%, P =.006) for patients with a perineal body < or = 3.5 cm.

CONCLUSION

There is an increased risk of significant lacerations and operative vaginal delivery in patients with a shortened perineal body.

Anticonvulsant hypersensitivity reaction in pregnancy

BACKGROUND

Anticonvulsant hypersensitivity reaction is a multisystem disorder that occurs after exposure to aromatic anticonvulsants. It is potentially fatal, with a mortality rate up to 50%. We report a case of an anticonvulsant hypersensitivity reaction that occurred during pregnancy at 10 weeks' gestation.

CASE

A grand multipara was being treated with carbamazapine for a seizure disorder. She developed a maculopapular rash, elevated liver enzymes, and pancytopenia. Withdrawal of aromatic anticonvulsants and supportive therapy resulted in resolution of her illness. The remainder of her pregnancy was uneventful, and she delivered a healthy infant at term.

CONCLUSION

All pregnant women treated with aromatic anticonvulsants are at risk for anticonvulsant hypersensitivity reaction, and a high degree of clinical suspicion is essential for diagnosis.

Intrauterine head entrapment of a second twin by a uterine synechia

BACKGROUND

Fetal head entrapment during delivery is a rare occurrence in modern obstetrics. We present a case of intrauterine head entrapment of a second twin by a uterine synechia diagnosed by ultrasound and subsequent complications that occurred.

CASE

A woman with a twin intrauterine pregnancy presented at 19 weeks for evaluation of a shortened cervix. Ultrasound examination demonstrated fetal head entrapment of twin B by a uterine synechia, as well as intrauterine growth restriction (IUGR). The patient experienced preterm premature rupture of membranes at 24 weeks' gestation and underwent a cesarean delivery for a nonreassuring fetal heart rate tracing of twin B, with findings of a constricting band of fibrous tissue around the neck of twin B.

CONCLUSION

Uterine synechia might cause intrauterine head entrapment and IUGR.

Intrapartum risk factors for permanent brachial plexus injury

OBJECTIVE

The purpose of this study was to compare maternal, neonatal, and second stage of labor characteristics in shoulder dystocia deliveries that result in permanent brachial plexus injury with shoulder dystocia deliveries that result in no injury.

STUDY DESIGN

Our cases were culled from a database of deliveries that resulted in permanent brachial plexus injuries and matched to control cases that were taken from a database of consecutive shoulder dystocia deliveries from one hospital. Deliveries that resulted in injury were excluded from the control cases; those cases with no recorded shoulder dystocia were excluded from the cases. Matching was for birth weight (+/-250 g), parity, and diabetic status. Rates of precipitous and prolonged second stage, operative delivery, neonatal depression, and average number of shoulder dystocia maneuvers used were compared between the two groups with chi(2) test, Fisher exact test, and the Student t test; a probability value of <.05 was considered significant.

RESULTS

There were 80 matched patients, of which 26 patients were nulliparous and 11 patients were diabetic. Mothers of the uninjured group were younger than those of the injured group (23.7+/-6.2 years vs 27.4+/-5.1 years, P<.001). The injured group had a significantly higher rate of 5-minute Apgar scores of <7 (13.9% vs 3.8%, P=.04). Differences in maternal weight, body mass index, height, race, gestational age, average number of maneuvers, head-to-body delivery interval, operative delivery rate, prolonged second stage rate, precipitous second stage rate, and sex were not significant between groups. The rates of precipitous second stage for both groups (28.0% injured and 35.0% uninjured) were more than triple the rates of prolonged second stage (9.5% injured and 11.3% uninjured).

CONCLUSION

No characteristic of second-stage of labor predicts permanent brachial plexus injury. Precipitous second stage is the most prevalent labor abnormality that is associated with shoulder dystocia.

Hypodysfibrinogenemia during pregnancy, labor, and delivery

BACKGROUND

Hypodysfibrinogenemia is an autosomally dominant disorder that can result in excessive bleeding as well as specific pregnancy complications. Increased risks of spontaneous abortion, postpartum hemorrhage, poor wound healing, and placental abruption have been reported.

CASE

A woman with hypodysfibrinogenemia presented for care in the first trimester. Her antepartum course was uncomplicated, and she was administered intermediate-purity factor VIII during labor and did not have excessive bleeding postpartum. The infant's cord fibrinogen was low, at 43 mg/dL (normal 215 +/- 30), showing it was similarly affected.

CONCLUSION

Pregnancy in patients with hypodysfibrinogenemia can be associated with various complications; however, coordination of care and anticipation of specific problems can result in a successful outcome for both mother and infant.