Association between maternal short-term exposure to ambient air pollution and the risk of fetal distress: A matched case-control study.

BACKGROUND: Ambient air pollution has been linked to gestational complications. However, the evidence on the relationship between air pollution and fetal distress is limited. OBJECTIVES: To investigate the relationship between maternal short-term air pollution exposure and fetal distress, and to identify a potential susceptible population. METHODS: This matched case-control study, involving 313 pregnancy women with fetal distress was conducted in Xi'an, the largest city in Northwest China from 2013 to 2016. Each woman with fetal distress was randomly matched with four women without fetal distress of the same age, same gestational week, and registration in the same period (n = 1252). Inverse distance-weighted (IDW) interpolation was applied to estimate maternal air pollution exposure based on the residential addresses. We employed conditional logistic regression model to evaluate the relationship between air pollutants and fetal distress. Distributed lag nonlinear model (DLNM) was performed to examine the exposure-response relationship between air pollutants and fetal distress. RESULTS: Maternal short-term exposure to PM10, PM2.5-10 (PMc), SO2, NO2, and CO was associated with increased risk of fetal distress. Each 10 µg/m3 increment in PM10, PMc, SO2 at lag 014, and NO2 at lag 010, the odds ratio (ORs) of fetal distress were 1.027 (95 % confidence interval (CI): 1.004, 1.050), 1.058 (95 % CI: 1.014, 1.105), 1.140 (95 % CI: 1.029, 1.264), and 1.158 (95 % CI: 1.046, 1.283), respectively. Similarly, with a 0.1 mg/m3 increment in CO at lag 014, the OR of fetal distress was 1.029 (95 % CI: 1.002, 1.058). Stratified analyses showed that the estimate associations of PM10, PM2.5 and CO appeared to be stronger, although not statistically significantly, among women with gestational complications. CONCLUSION: Maternal short-term exposure to ambient air pollution may increase the risk of fetal distress. Understanding the detrimental role of air pollution in fetal distress can help us better develop preventative methods in reducing its' impact on maternal and fetal health.

Duration of Exposure to General Endotracheal Anesthesia during Cesarean Deliveries at Term and Perinatal Complications.

OBJECTIVE: To examine whether the duration of time from initiation of general endotracheal anesthesia (GETA) to delivery for cesarean deliveries (CDs) performed is related to perinatal outcomes. STUDY DESIGN: This is a retrospective study of patients with singleton nonanomalous gestations undergoing CD ≥37 weeks of gestation under GETA with reassuring fetal status at a single tertiary care center from 2000 to 2016. Duration from GETA initiation until delivery was calculated as the time interval from GETA induction to delivery (I-D), categorized into tertiles. Outcomes for those in the tertile with the shortest I-D were compared with those in the other two tertiles. The primary perinatal outcome was a composite of complications (continuous positive airway pressure or high-flow nasal cannula for ≥2 consecutive hours, inspired oxygen ≥30% for ≥4 consecutive hours, mechanical ventilation, stillbirth, or neonatal death ≤72 hours after birth). Secondary outcomes were 5-minute Apgar score <7 and a composite of maternal morbidity (bladder injury, bowel injury, and extension of hysterotomy). Bivariable and multivariable analyses were used to compare outcomes. RESULTS: Two hundred eighteen maternal-perinatal dyads were analyzed. They were dichotomized based on I-D ≤4 minutes (those in the tertile with the shortest duration) or >4 minutes. Women with I-D >4 minutes were more likely to have prior abdominal surgery and less likely to have labored prior to CD. I-D >4 minutes was associated with significantly increased frequency of the primary perinatal outcome. This persisted after multivariable adjustment. In bivariable analysis, 5-minute Apgar <7 was more common in the group with I-D >4 minutes, but this did not persist in multivariable analysis. Frequency of maternal morbidity did not differ. CONCLUSION: When CD is performed at term using GETA without evidence of nonreassuring fetal status prior to delivery, I-D interval >4 minutes is associated with increased frequency of perinatal complications. KEY POINTS: · Cesarean delivery under general anesthesia is associated with increased perinatal complications.. · Perinatal complications are increased with increasing duration of exposure to general anesthetics.. · Maternal complications were not increased with shorter duration of exposure to general anesthesia..

Sodium dichloroacetate stimulates cardiac mitochondrial metabolism and improves cardiac conduction in the ovine fetus during labor.

Previous studies in our laboratory have suggested that the increase in stillbirth in pregnancies complicated by chronic maternal stress or hypercortisolemia is associated with cardiac dysfunction in late stages of labor and delivery. Transcriptomics analysis of the overly represented differentially expressed genes in the fetal heart of hypercortisolemic ewes indicated involvement of mitochondrial function. Sodium dichloroacetate (DCA) has been used to improve mitochondrial function in several disease states. We hypothesized that administration of DCA to laboring ewes would improve both cardiac mitochondrial activity and cardiac function in their fetuses. Four groups of ewes and their fetuses were studied: control, cortisol-infused (1 g/kg/day from 115 to term; CORT), DCA-treated (over 24 h), and DCA + CORT-treated; oxytocin was delivered starting 48 h before the DCA treatment. DCA significantly decreased cardiac lactate, alanine, and glucose/glucose-6-phosphate and increased acetylcarnitine/isobutyryl-carnitine. DCA increased mitochondrial activity, increasing oxidative phosphorylation (PCI, PCI + II) per tissue weight or per unit of citrate synthase. DCA also decreased the duration of the QRS, attenuating the prolongation of the QRS observed in CORT fetuses. The effect to reduce QRS duration with DCA treatment correlated with increased glycerophosphocholine and serine and decreased phosphorylcholine after DCA treatment. There were negative correlations of acetylcarnitine/isobutyryl-carnitine to both heart rate (HR) and mean arterial pressure (MAP). These results suggest that improvements in mitochondrial respiration with DCA produced changes in the cardiac lipid metabolism that favor improved conduction in the heart. DCA may therefore be an effective treatment of fetal cardiac metabolic disturbances in labor that can contribute to impairments of fetal cardiac conduction.

Epidural analgesia during labour and stress markers in the newborn.

Labour and modes of delivery can influence the plasma levels of stress hormones and cytokines involved in pathophysiologic cascade, potentially damaging brain development of the newborn. This prospective observational, single-centre, case-control, non-profit study aimed to detect potential differences in foetal well-being such as stress neuroendocrine responses. Quantitative determinations of the stress markers interleukin (IL)-1ß, IL-8, and ß-endorphin were compared between the control group and the epidural analgesia group. We found higher IL1-ß levels but lower IL-8 and ß-endorphin levels in the epidural analgesia group than in the control group. No significant inter-group differences were observed for any parameters. Our findings demonstrate that epidural analgesia for pain relief during labour does not result in significant differences in blood stress response markers.IMPACT STATEMENTWhat is already known on this subject? We already know that plasma levels of stress hormones and cytokines are influenced by labour and delivery modes. This has a deep impact on the newborn in terms of brain damage, immune system deficits, and altered hypothalamic-pituitary axis responses. We also know that epidural analgesia is a widespread practice that offers pain relief to the woman in labour, but there are few studies on the potentially negative effects of epidural labour analgesia on the unborn child.What do the results of this study add? This study found no significative differences in blood stress response markers between the epidural analgesia group and the control group. Under this study circumstances we found out that epidural analgesia does not significantly influence the newborn's well-being during labour and delivery.What are the implications of these findings for clinical practice and/or further research? These findings must be confirmed by further studies to verify whether epidural analgesia is safe for the newborn's development.

Maternal exposure to fine particulate matter and the risk of fetal distress.

Prenatal life exposure to fine particulate matter (aerodynamic diameter less than or equal to 2.5 µm, PM2.5) has been linked with increased risk of adverse fetal development and birth outcomes in previous studies. However, to our knowledge, no study has investigated the association of maternal PM2.5 with the risk of fetal distress, which is a harmful fetal status and may lead to fetal brain damage, even fetal death. Therefore, we conducted a study to determine the association between maternal PM2.5 and fetal distress among 7835 mother-infant pairs from a birth cohort, in Wuhan, China, 2013-2015. The individual daily PM2.5 level was assessed using land use regression model. We evaluated the association of maternal PM2.5 level over the whole pregnancy with fetal distress by logistic regression model, and estimated the risk between PM2.5 exposure in specific trimester and fetal distress using generalized estimating equations. We observed that per 10 µg/m3 change of maternal PM2.5 level over the whole pregnancy was associated with 25% increased risk of fetal distress (95% confidence interval: 1.09-1.44). Further, we found PM2.5 level in the 2nd trimester, but not in the 1st and 3rd trimesters, was associated with fetal distress. Stratified analyses indicated that the association was only significant among infants who were born in cold seasons. Our study suggested that PM2.5 exposure during the whole pregnancy exhibited significant associations with the risk of fetal distress, and exposure in the 2nd trimester maybe the susceptible window. Further stratified analyses indicated that birth season is a possible modifier in the association.

High-dose versus low-dose of oxytocin for labour augmentation: a randomised controlled trial.

PROBLEM: Delayed labour progress is common in nulliparous women, often leading to caesarean section despite augmentation of labour with synthetic oxytocin. BACKGROUND: High- or low-dose oxytocin can be used for augmentation of delayed labour, but evidence for promoting high-dose is weak. Aim To ascertain the effect on caesarean section rate of high-dose versus low-dose oxytocin for augmentation of delayed labour in nulliparous women. Methods Multicentre parallel double-blind randomised controlled trial (ClinicalTrials.gov: NCT01587625) in six labour wards in Sweden. Healthy nulliparous women at term with singleton cephalic fetal presentation, spontaneous labour onset, confirmed delay in labour and ruptured membranes (n=1351) were randomised to labour augmentation with either high-dose (6.6 mU/minute) or low-dose (3.3 mU/minute) oxytocin infusion. FINDINGS: 1295 women were included in intention-to-treat analysis (high-dose n=647; low-dose n=648). Caesarean section rates did not differ between groups (12.4% and 12.3%, 95% Confidence Interval -3.7 to 3.8). Women with high-dose oxytocin had: shorter labours (-23.4min); more uterine tachysystole (43.2% versus 33.5%); similar rates of instrumental vaginal births, with more due to fetal distress (43.8% versus 22.7%) and fewer due to failure to progress (39.6% versus 58.8%). There were no differences in neonatal outcomes. DISCUSSION: Our study could not confirm results of two systematic reviews indicating, with weak evidence, that use of high-dose oxytocin was associated with lower frequency of caesarean section. CONCLUSION: We found no advantages for routine use of high-dose oxytocin in the management of delay in labour. Low-dose oxytocin regimen is recommended to avoid unnecessary events of tachysystole and fetal distress.

Does Induction with Misoprostol Impact the Small for Gestational Age Neonate?

OBJECTIVE: To compare outcomes in small for gestational age neonates induced with misoprostol to other cervical ripening agents. We hypothesized that misoprostol use will demonstrate no significant difference in outcomes compared with alternative agents. STUDY DESIGN: Small for gestational age neonates (<10th percentile for gestational age) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) sponsored Consortium on Safe Labor database were analyzed. Neonates induced with misoprostol ± oxytocin (n = 451) were compared with neonates induced with prostaglandin E2 ± oxytocin and/or mechanical dilation ± oxytocin (n = 663). Primary outcomes included intrapartum fetal distress, cesarean section for fetal distress, cesarean section for any reason, neonatal intensive care unit admission, low 5-minute Apgar, and composite neonatal morbidity. Multiple logistic regression was used to calculate adjusted odds ratios (aORs). Data were analyzed using SAS. RESULTS: Small for gestational age neonates induced with misoprostol ± oxytocin compared with alternative agents had decreased low 5-minute Apgar scores (aOR 0.27 [0.10-0.71]). No significant differences were demonstrated among very small for gestational age neonates (<5th percentile for gestational age). CONCLUSION: Our results suggest that misoprostol does not increase risk of adverse outcomes in small for gestational age neonates; however, prospective studies are warranted to further assess optimal cervical ripening agents in this population.

[Dinoprostone: slow release vaginal insert (Propess) and intracervical gel (Prepidil) for the induction of labour with unriped cervix]. / Dinoprostone: inserto vaginale a lento rilascio (Propess) e gel intracervicale (Prepidil) nell'induzione del travaglio di parto con Bishop score sfavorevole.

AIM: The purpose of the present study is to compare the effectiveness and safety of a slow release vaginal PGE2 insert (Propess) with intracervical PGE2 gel (Prepidil gel) in the induction of cervical ripening and labour. METHODS: For the induction of labour we selected 103 single pregnancies at term presenting a Bishop score of less than 5. Fifty-one were induced with Propess, and 52 with intracervical Prepidil. RESULTS: The 2 groups were homogeneous as regards indications to induction and obstetric characteristics. The success of induction (achievement of uncomplicated vaginal delivery) was comparable in the 2 groups: Propess 67%, Prepidil 65%. The times needed to induce labour were on average longer with Propess (16 h 59 min) than with Prepidil (12 h 54 min), (p<0.05); nevertheless the time needed to achieve delivery by the vaginal route within 24 hours was comparable (49% vs 48%). The number of patients requiring more than one application of prostaglandin was less in the Propess group (5.9%) than in the Prepidil group (55.8%) (p<0.001). The times relative to dilation and expulsion did not differ significantly. Resort to cesarean section for fetal indication (cardiotocographic changes) was greater in inductions with Prepidil (8 cases) compared to Propess (2 cases), p<0.05. CONCLUSION: The systems proved equally effective, nevertheless Propess seems to be safer thanks to the lower incidence of cardiotocographic changes such as to indicate urgent cesarean section. Propess would seem to be more acceptable on the part of patients thanks to the smaller number of applications necessary.

[Hawaiian baby woodrose: (Psycho-) Pharmacological effects of the seeds of Argyreia nervosa. A case-orientated demonstration]. / Hawaiianische Holzrose: (Psycho-)Pharmakologische Wirkungen der Samen der Argyreia nervosa Eine fallbezogene Darstellung.

The seeds of the Hawaiian baby woodrose ( Argyreia nervosa) are used by adolescents as a supposed hallucinogenic drug. These seeds are legally available and broadly sold. The active components are alkaloids structurally related to lysergic acid diethylamide (LSD). However, the psychic effects are very different from those of LSD and are dominated by rather sedative, uncomfortable autonomic disturbances similar to the effects of scopolamine. The (psycho)pharmacological profile is described on the basis of the active substances lysergacidamide and lysergacidethylamide (and their isomers). It is shown that neither the substances themselves nor the mixture are able to evoke LSD-like perceptual variances. The exposure of Argyreia nervosa is described focusing on potential fetal distress by contained ergometrine and the case history of an intoxication.

Vaginal misoprostol in managing premature rupture of membranes.

We compared the efficacy of misoprostol with that of prostaglandin E2 in cervical ripening and labour induction. Thus 238 women with rupture of membranes beyond 36 weeks gestation without labour were randomized to receive 50 microg misoprostol vaginal gel or 5 mg of prostaglandin E2 gel. Bishop score was evaluated before drug application and 6 hours later. Clinical data and perinatal outcome were recorded. Mean time from induction to delivery and the need for oxytocin were significantly less in the misoprostol group. There were no significant differences in spontaneous labour rate, type of delivery and perinatal outcome. It is concluded that intravaginal misoprostol is safe and more effective than prostaglandin E2 for preinduction cervical ripening in premature rupture of membranes beyond 36 weeks gestation.

A retrospective review of pregnancy outcome after misoprostol (prostaglandin E1) induction of labour.

This retrospective study looked at the outcome of using 50-100 micrograms misoprostol once daily to induce labour compared to the outcome of the overall patient population delivered during the same period (1994-1996). During that period 11,255 patients were delivered and 1037 (9.2%) were induced with misoprostol. Results showed a significantly lower mean Caesarean section rate: 9.3% for the misoprostol group versus 13.3% for the overall population (p = 0.002, Odds Ratio (OR) 0.67, 95% CI 0.53, 0.83). The abruption rates were not significantly different: 0.8% for misoprostol versus 0.4% (p = 0.09, OR 1.86, 95% CI 0.81, 4.09). There was more postpartum haemorrhage in the misoprostol group: 5.6% versus 3.5% (p = 0.0006, OR 1.63, 95% CI 1.22, 2.19); a higher incidence of Apgar scores less than 6 at one minute 10.2% versus 7.9% (p = 0.0093, OR 1.33, CI 1.06, 1.65) but not at five minutes 2.9% versus 2.4% (p = 0.674, OR 1.09, CI 0.73, 1.61) and a higher perinatal mortality rate 55/1000 versus 16.3/1000 (p = 0.00, OR 3.5, 95% CI 2.55, 4.80). The rate remained higher but not significantly so when a correction was made to eliminate the high number of intrauterine deaths induced with misoprostol 18/1000 versus 16.3/1000 (p = 0.69, OR 1.11, 95% CI 0.66, 1.84). There were no cases of uterine rupture in either group. In conclusion, there was a significantly lower Caesarean section rate among patients who had once daily misoprostol induction of labour. Close monitoring of the foetus, in patients with misoprostol induction, is needed to detect foetal distress and prophylaxis against postpartum haemorrhage is still mandatory.

[Comparison of ropivacaine and bupivacaine for epidural analgesia during labor]. / Estudio comparativo entre ropivacaína y bupivacaína en analgesia epidural del parto.

OBJECTIVES: To compare the analgesic efficacy and level of motor block using two local anesthetics, ropivacaine and bupivacaine, during labor. MATERIAL AND METHODS: Sixty nulliparous women were enrolled during labor after full-term pregnancies. They were randomly assigned to receive epidural analgesia with ropivacaine (group R) or bupivacaine (group B). Group R patients received 10 ml of 0.18% ropivacaine with 5 microgram/ml of fentanyl followed by continuous epidural infusion of 0.1% ropivacaine with 2 microgram/ml of fentanyl at a rate of 10 ml/h. Group B patients received 10 ml of 0.15% bupivacaine with 5 microgram/ml of fentanyl followed by continuous epidural perfusion of 0.0625% bupivacaine with 2 microgram/ml of fentanyl at the same rate. Pain intensity was assessed on a visual analog scale, motor blockade on a Bromage scale, and level of sensory block at different moments. We also recorded total doses of local anesthetic employed during continuous epidural infusion, manner of final delivery, Apgar score, degree of maternal satisfaction and side effects. RESULTS: The demographic and delivery characteristics were similar in both groups. We found no statistically significant differences between the two groups for level of motor blockade, which was nil for 29 patients (96.66%) in group R and 28 patients (93.33%) in group B. No differences in degree of pain or level of sensory block (T8-T10 in both groups) were observed. The total doses of local anesthetic used were similar at 23.7 +/- 11.6 mg in group R and 16.5 +/- 7.3 mg in group B (non-significant difference). Nor did we find differences in manner of delivery, neonatal Apgar scores, degree of maternal satisfaction or side effects. CONCLUSION: Ropivacaine and bupivacaine are equally effective for epidural analgesia during labor at the doses used and they do not cause a relevant level of motor blockade.

Use of misoprostol for cervical ripening.

BACKGROUND: Misoprostol, the prostaglandin E1 analog, is increasingly used for cervical ripening and induction of labor. We evaluated our experience with misoprostol in an open-label setting. METHODS: Patients were selected for cervical ripening based on clinical profile. At 3 cm cervical dilation, misoprostol was discontinued and other means of labor augmentation were used. Over 13 months, 470 inductions of labor occurred, and 455 charts were available; 254 patients (56%) received misoprostol for cervical ripening, and 144 (32%) received dinoprostone (prostaglandin E2). RESULTS: With misoprostol, mean time from beginning of contractions until delivery was 7 hours, 30 minutes; vaginal birth occurred in 85% of cases, and spontaneous labor occurred in 38%. Hyperstimulation occurred in 4 cases (1.6%) and precipitate labor in 7 (3%). All infants were discharged in excellent condition; one had a 5-minute Apgar score <7, and 33 (13%) had meconium, none with aspiration. Twenty-three patients who had had a previous cesarean section received misoprostol and delivered vaginally. CONCLUSION: Misoprostol was found to be a safe and effective agent for cervical ripening as part of labor induction.

Acetaminophen poisoning in late pregnancy. A case report.

BACKGROUND: Acetaminophen poisoning is a major cause of hospital admission and has been extensively reviewed. Its occurrence in pregnant women has been reported seldom, and the prognosis has been good except for one case, in which the fetus died. We report on a case of acetaminophen poisoning that resulted in the death of both the mother and the infant. CASE: A 38-year-old woman whose pregnancy was at 31 weeks' gestational age was evaluated for treatment of an acetaminophen overdose. She was admitted more than 26 hours after taking 35 g of acetaminophen. An emergency cesarean section was performed one hour after admission because of acute fetal distress. A grossly normal, 1,620-g, female infant was delivered and had Apgar scores at 1, 5 and 10 minutes of 0, 0 and 1, respectively, despite the initiation of resuscitation immediately following delivery. Acidosis was noted in the mother during the operation; it was followed by acute hepatorenal failure 16 hours after admission. That resulted in the mother's death 40 hours after admission. The infant also died 34 hours after delivery. CONCLUSION: Delays in administering the antidote treatment, N-acetylcysteine, after acetaminophen intoxication significantly increase the risk of mortality in both the mother and infant. The development of acidosis carries a poor prognosis in such patients and may necessitate liver transplantation to save the life of the mother.

Uterine rupture during induction of labor at term with intravaginal misoprostol.

BACKGROUND: Misoprostol (prostaglandin E1) compares favorably with dinoprostone (prostaglandin E2) and oxytocin for labor induction at term. Excessive uterine activity has been reported using high-dose regimens, but no negative effect on outcomes has been observed. CASE: Labor was induced in a 34-year-old multipara at 39 weeks' gestation using intravaginal misoprostol tablets. Five hours after administration of the second 25-microgram dose, fetal bradycardia prompted emergency cesarean delivery. Hysterectomy and left salpingo-oophorectomy were necessary to control bleeding from a 15-cm posterior uterine wall rupture. CONCLUSION: Misoprostol can cause excessive uterine activity and uterine rupture.