Predictors of maternal mortality and near-miss maternal morbidity.

OBJECTIVE: To identify risk factors for life-threatening maternal outcomes. STUDY DESIGN: Hospital charts were reviewed for cases of maternal mortality or near-miss and for controls overmatched 1:3. Significant risk factors were identified through simple and best subsets multiple logistic regression. RESULT: Eight cases of mortality and 69 near-miss cases were found. Significant risk factors with their odds ratios and 95% confidence intervals are: age 35 to 39 years (2.3, 1.2 to 4.4) and >39 years (5.1, 1.8 to 14.4); African-American race (7.4, 2.5 to 22.0) and Hispanic ethnicity (4.2, 1.3 to 13.2); chronic medical condition (2.7, 1.5 to 4.8); obesity (3.0, 1.7 to 5.3); prior cesarean (5.2, 2.8 to 9.8) and gravidity (1.2, 1.1 to 1.5 per pregnancy). In multivariable logistic regression, race remained significant while controlling for other significant factors and markers of socioeconomic status. CONCLUSION: Some risk factors can be modified through medical care, education or social support systems. Racial disparity in outcome is confirmed and is unexplained by traditional risk factors.

Defective annexin A5 crystallization: a mechanism for pregnancy losses in the antiphospholipid syndrome.

We have accumulated a significant body of evidence that support the hypothesis that aPL antibody-mediated disruption of annexin A5 crystallization is a mechanism for RSPL in the APS. Further investigation of the functions of the annexins in placental physiology and disease are likely to be productive areas for future research.

Heart rate patterns in fetuses exposed to cocaine.

Heart rate patterns of 42 fetuses exposed to cocaine near the time of delivery were compared with patterns in 42 controls. Decreased long-term variability and an increased frequency of contractions were observed more often in the cocaine group (P = .046 and P = .0306, respectively). There were no significant differences in the frequency of fetal tachycardia or decelerations. Although accelerations were less frequent in cocaine-exposed fetuses, the difference compared with controls was not statistically significant. We found no characteristic heart rate pattern in fetuses exposed to cocaine near delivery. The heart rate patterns likely represent the underlying state of fetal oxygenation. Frequent contractions in an unstimulated labor should raise suspicions of maternal cocaine use.

Short labor: characteristics and outcome.

OBJECTIVE: To determine the characteristics and consequences of short labor. METHODS: Ninety-nine term pregnancies with singleton vertex presentation and labor lasting 3 hours or less were compared with controls with longer labor, matched to the index cases by maternal age, parity, and birth weight. RESULTS: Short labor occurred mostly in multiparas. Both the first and second stages of labor were found to be shortened in these cases. There was significantly more placental abruption, uterine tachysystole, and maternal cocaine use among short-labor cases. Major perineal lacerations, postpartum hemorrhage, birth trauma, and low Apgar scores were distributed approximately equally between cases and controls. A preponderance of the bad outcomes in the short labors occurred in the subgroup of those with rates of dilatation and descent that exceeded established 95th percentile limits. CONCLUSIONS: Labors of 3 hours or less in duration were strongly associated with placental abruption, but were otherwise not major contributors to maternal and fetal morbidity.

Labor patterns in women with previous cesareans.

Little information exists to help determine the presence or significance of labor abnormalities in women attempting vaginal birth after previous cesarean. A case-control study was performed to obtain information on patterns of labor progress and the incidence of dysfunctional labor in patients having a trial of labor after previous cesarean delivery. Sixty-eight such women were matched to nulliparous and multiparous controls. Labor-curve characteristics for the group of women with previous cesarean differed significantly from those of both the nulliparas and multiparas. When stratified by history of previous vaginal birth, however, those with no previous vaginal birth were indistinguishable from nulliparous controls and those with a previous vaginal birth were indistinguishable from multiparous controls. Parity-specific criteria for the diagnosis of dysfunctional labor were thus indicated. Labor disorders were present most frequently in the previous-cesarean group with no previous vaginal birth (41.9%). This incidence did not differ significantly from that in the control nulliparas (27.1%) (P = .15), but did differ from that in the multiparas (15.8%) (P less than .01). Previous-cesarean patients with a previous vaginal birth had a frequency of labor disorders (14.3%) not significantly different from that of multiparous controls. We conclude that trial of labor in women with a previous cesarean should be evaluated by standard criteria for nulliparas if there has been no previous vaginal birth, and by criteria for multiparous women if there has been any previous infant born vaginally.

Cocaine using during pregnancy and low birth weight: the impact of prenatal care and drug treatment.

Cocaine use in pregnancy has been associated with low birth weight. Large population-based studies suggest that 5 to 7% of pregnant women have used cocaine, with much higher rates in low income inner-city women. Among 140 births at our institution of cocaine-using women, we found a lower rate of low birth weight in those who received prenatal care compared with those without prenatal care: 33 of 96 (34.3%) versus 23 of 44 (52.3%), P < .05. A review of the literature shows that comprehensive care, which includes both prenatal care and drug treatment, seems to be associated with better birth weight outcomes, particularly in women who stop their use in the first trimester. Prenatal care alone, however, is also associated with improved outcomes even if not specialized or linked to drug treatment.

Vaginal progesterone is associated with a decrease in risk for early preterm birth and improved neonatal outcome in women with a short cervix: a secondary analysis from a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To investigate the efficacy of vaginal progesterone to prevent early preterm birth in women with sonographic evidence of a short cervical length in the midtrimester. METHODS: This was a planned, but modified, secondary analysis of our multinational, multicenter, randomized, placebo-controlled trial, in which women were randomized between 18 + 0 and 22 + 6 weeks of gestation to receive daily treatment with 90 mg of vaginal progesterone gel or placebo. Cervical length was measured with transvaginal ultrasound at enrollment and at 28 weeks of gestation. Treatment continued until either delivery, 37 weeks of gestation or development of preterm rupture of membranes. Maternal and neonatal outcomes were evaluated for the subset of all randomized women with cervical length < 28 mm at enrollment. The primary outcome was preterm birth at

Progesterone vaginal gel for the reduction of recurrent preterm birth: primary results from a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: Preterm birth is the leading cause of perinatal morbidity and mortality worldwide. Treatment of preterm labor with tocolysis has not been successful in improving infant outcome. The administration of progesterone and related compounds has been proposed as a strategy to prevent preterm birth. The objective of this trial was to determine whether prophylactic administration of vaginal progesterone reduces the risk of preterm birth in women with a history of spontaneous preterm birth. METHODS: This randomized, double-blind, placebo- controlled, multinational trial enrolled and randomized 659 pregnant women with a history of spontaneous preterm birth. Between 18 + 0 and 22 + 6 weeks of gestation, patients were assigned randomly to once-daily treatment with either progesterone vaginal gel or placebo until either delivery, 37 weeks' gestation or development of preterm rupture of membranes. The primary outcome was preterm birth at

Asthma in pregnancy: a review.

Asthma complicates 1% to 4% of pregnancies and has been associated with an increased incidence of preeclampsia, gestational diabetes, preterm delivery, and intrauterine growth retardation. Asthma must be treated promptly and aggressively to prevent maternal and fetal morbidity and mortality. New approaches to therapy emphasize treating the underlying inflammation that is associated with airway hyperreactivity as well as treating the bronchospasm directly.

Successful pregnancy in a separated conjoined twin.

A case of successful pregnancy in a separated conjoined twin is described. The patient underwent cesarean delivery because of the reconstructed pelvis and extensive perineal reconstruction, which resulted in dense fibrosis. Surgical records and communication with the patient's pediatric surgeons were helpful in planning for delivery.

Catastrophic complications of previous cesarean section.

Of 711 patients who were delivered after one or more previous cesarean sections, 17 (2.4%) had an extremely serious complication. Uterine rupture and placenta previa or placenta accreta with accompanying hemorrhage were the major contributors to mortality and major morbidity. Nine uterine ruptures occurred, including five associated with labor with a low transverse uterine scar and one with an unknown scar (1.4% of trials of labor). There were two cases of placenta previa and five with varying degrees of placenta accreta. The nature and frequency of the observed complications emphasize the potentially serious remote consequences of cesarean section.

Disseminated herpes simplex infection in an immunocompromised pregnancy: treatment with intravenous acyclovir.

In this article, we report a case of third-trimester disseminated herpes simplex virus (HSV) infection in an immunocompromised gravida who was treated with parenteral acyclovir. Rapid resolution of lesions occurred, and the fetus was delivered at term without evident abnormalities. Of the four previous reports on this therapy, there has been one maternal death and survival of all neonates. Acyclovir should be considered in the treatment of disseminated HSV infection in pregnancy.

Perinatal screening for drugs of abuse: reassessment of current practice in a high-risk area.

Anonymous urine toxicology screening among parturient women during 1 month in 1990 and selective newborn testing during this and the subsequent 4-month period was done to assess prevalence of drug use among parturients in a municipal hospital in the Bronx and to assess impact of infant urine toxicology screening on discharge placement. Infant testing was performed for maternal history of drug use, poor prenatal care (5 or fewer visits), or infant symptoms. Urine was screened for cocaine, opiates, methadone, barbiturates, amphetamines, and benzodiazepines. Of 204 women screened, 9.3% were positive. Of these, 74% were positive for cocaine and 21% revealed polysubstance use. Only 28.6% of cocaine-positive mothers gave a history of use. Selective testing of 1196 newborns during this 5-month period revealed an apparent prevalence of cocaine exposure of 4.9%. Selective infant testing failed to identify 42.1% of newborns of cocaine-positive women. Social work evaluation was performed on all families and was the basis for reporting to state agencies for protective services. Only 6 of 83 drug-positive infants entered foster care, none because of positive toxicology per se. Selective infant toxicology studies miss many cocaine-exposed infants and has little impact on placement. Universal social work evaluation of families may be as effective and freer of bias than selective urine screening.

Heart rate patterns and fetal sepsis.

Fetal heart rate patterns from 15 cases of in utero bacterial fetal sepsis were reviewed. All patterns contained some abnormality, the most common being persistent tachycardia. Ninety-three percent of fetuses had periodic decelerations, which were either late or variable in nature. Neither maternal fever nor fetal tachycardia was invariably present during fetal infection. Although fetal sepsis was associated frequently with fetal heart rate pattern aberrations, no specific pattern was identified that was consistently or uniquely related to infection.

Spontaneous infarction of placental chorioangioma and associated regression of hydrops fetalis.

We report a case of a large chorioangioma diagnosed prenatally with concomitant meconium peritonitis and hydrops fetalis in the second trimester. Spontaneous regression of the tumor occurred, associated with some resolution of the fetal hydrops and delivery near term with good neonatal outcome.

Impact of an inner-city, hospital-based preterm prevention program on preterm births in twin gestation.

The objective of this study was to determine the impact of an inner-city, hospital-based preterm-birth prevention program on the outcome of twin pregnancies. A retrospective study of delivery outcomes from 1985 to 1992 of eligible consecutive twin deliveries that were > or = 20 weeks' gestation compared two inner-city hospitals in the Bronx, New York: one with a preterm prevention program for twin births and a comparable site offering conventional prenatal care. A group of patients receiving no prenatal care was also included. Outcomes were evaluated by prenatal-care site, except for those who received no prenatal care and delivered at either site. Data were analyzed by chi-square analysis and analysis of variance. Of the 377 twin pregnancies, 330 pregnancies were eligible deliveries. One hundred thirty-four women received prenatal care from the preterm prevention program, 161 received conventional prenatal care at a comparable site, and 35 received no prenatal care. Maternal age, parity, and mode of delivery were similar in the two delivery sites. There was an increased incidence of complications in the no-prenatal-care group compared with the groups who received the preterm prevention or conventional prenatal care. The percentage of low-birth-weight (< 2500 g) and very-low-birth-weight (< 1000 g) infants was similar in the preterm prevention and the conventional care groups. The percentage of extremely low-birth-weight (< 1000 g) infants was significantly lower in twin births of the preterm prevention site (9.7%) and the conventional site (11.3%) compared with the no-prenatal-care group (28.6%) (P < .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Beta-human chorionic gonadotropin in cervicovaginal secretions as a predictor of preterm delivery.

OBJECTIVE: This study's objective was to determine whether the concentrations of beta-human chorionic gonadotropin in the secretions of the cervix and vagina could be used to predict preterm delivery in a group of women at high risk for this complication. STUDY DESIGN: Women attending a prematurity prevention clinic at an inner-city hospital July 1, 1996-October 1, 1997, were invited to participate. From those who consented, secretions from the cervix and posterior vaginal fornix were sampled every 2 weeks until delivery, beginning at 24 weeks' gestation. Concentrations of beta-human chorionic gonadotropin were measured with a commercially available enzyme-linked immunosorbent assay. Providers of obstetric care were blinded to the results. Levels of beta-human chorionic gonadotropin in those who were delivered before 34 weeks' gestation and those who were delivered at term were compared. A value >50 mIU/mL was considered elevated. This cutoff value was determined according to beta-human chorionic gonadotropin values obtained during pregnancies that were delivered at term. RESULTS: Of the 146 women asked to participate, 77 consented. There was no difference between participants and nonparticipants with respect to age, race, indication for enrollment in the clinic, gestational age at delivery, or parity. Of the 77 participants, 24 (31%) were delivered before 37 weeks' gestation and 12 (16%) were delivered before 34 weeks' gestation. A single beta-human chorionic gonadotropin value >50 mIU/mL obtained between 24 and 28 weeks' gestation was associated with a significant increase in the incidence of delivery before 34 weeks' gestation (P = .03). This cutoff value had sensitivity, specificity, and positive and negative predictive values for predicting delivery before 34 weeks' gestation of 50%, 87%, 33%, and 93%, respectively. CONCLUSION: These data suggest that the concentration of beta-human chorionic gonadotropin in cervicovaginal secretions may be a useful predictor of preterm delivery.

Methods to encourage the use of antenatal corticosteroid therapy for fetal maturation: a randomized controlled trial.

CONTEXT: Antenatal corticosteroids for fetal maturation have been underused, despite evidence for their benefits in cases of preterm birth. OBJECTIVE: To evaluate dissemination strategies aimed at increasing appropriate use of this therapy. DESIGN AND SETTING: Twenty-seven tertiary care institutions were randomly assigned to either usual dissemination of practice recommendations (n = 14) or usual dissemination plus an active, focused dissemination effort (n = 13). SUBJECTS: Obstetricians and their preterm delivery cases at participating hospitals. INTERVENTION: Recommendations by a National Institutes of Health (NIH) Consensus Conference held in late February-early March 1994 were disseminated in early May 1994. Usual dissemination was publication of the recommendations and endorsement by the American College of Obstetricians and Gynecologists. Active dissemination was a year-long educational effort led by an influential physician and a nurse coordinator at each facility, consisting of grand rounds, a chart reminder system, group discussion of case scenarios, monitoring, and feedback. MAIN OUTCOME MEASURE: Use or nonuse of antenatal corticosteroids was abstracted from medical records of eligible women delivering at the participating hospitals in the 12 months immediately prior to release of the NIH recommendations (average number of records abstracted, 130) and in the 12 months following their release (average number of records abstracted, 122). RESULTS: Active dissemination significantly increased the odds of corticosteroid use after the conference. Use increased from 33.0% of eligible patients receiving corticosteroids to 57.6%, or by 75% over baseline, in usual dissemination hospitals. Use increased from 32.9% to 68.3%, oran 108% increase, in active dissemination hospitals. Gestational age and maternal diagnosis affected use of the therapy in complex ways. CONCLUSION: An active, focused dissemination effort increased the effectiveness of usual dissemination methods when combined with key principles to change physician practices.