Pregnancy outcome following recurrent spontaneous abortions.

OBJECTIVE: The purpose of the present study was to examine the association between spontaneous consecutive recurrent abortions and pregnancy complications such as hypertensive disorders, abruptio placenta, intrauterine growth restriction and cesarean section (CS) in the subsequent pregnancy. METHODS: A population-based study comparing all singleton pregnancies in women with and without two or more consecutive recurrent abortions was conducted. Deliveries occurred during the years 1988-2002. Stratified analysis, using a multiple logistic regression model was performed to control for confounders. RESULTS: During the study period 154,294 singleton deliveries occurred, with 4.9% in patients with history of recurrent consecutive abortions. Using a multivariate analysis, with backward elimination, the following complications were significantly associated with recurrent abortions-advanced maternal age, cervical incompetence, previous CS, diabetes mellitus, hypertensive disorders, placenta previa and abruptio placenta, mal-presentations and PROM. A higher rate of CS was found among patients with previous spontaneous consecutive recurrent abortions (15.9% versus 10.9%; OR = 1.6; 95% CI, 1.5-1.7; P < 0.001). Another multivariate analysis was performed, with CS as the outcome variable, controlling for confounders such as placenta previa, abruptio placenta, diabetes mellitus, hypertensive disorders, previous CS, mal-presentations, fertility treatments and PROM. A history of recurrent abortion was found as an independent risk factor for CS (OR = 1.2; 95% CI, 1.1-1.3; P < 0.001). About 58 cases of inherited thrombophilia were found between the years 2000-2002. These cases were significantly more common in the recurrent abortion as compared to the comparison group (1.2% versus 0.1%; OR = 11.1; 95% CI, 6.5-18.9; P < 0.001). CONCLUSION: A significant association exists between consecutive recurrent abortions and pregnancy complications such as placental abruption, hypertensive disorders and CS. This association persists after controlling for variables considered to coexist with recurrent abortions. Careful surveillance is required in pregnancies following recurrent abortions, for early detection of possible complications.

Can asphyxiated infants at risk for neonatal seizures be rapidly identified by current high-risk markers?

OBJECTIVE: Markers currently used to identify infants at highest risk for perinatal hypoxic-ischemic cerebral injury are insensitive in predicting the subsequent occurrence of neonatal seizures and/or neurodevelopmental sequelae, ie, cerebral palsy. To facilitate therapeutic strategies, early identification of the infant at highest risk for developing seizures secondary to hypoxia ischemia or asphyxia is critical, particularly if novel but potentially toxic therapies currently under experimental investigation become available for clinical use. METHODS: Ninety-six inborn term infants considered at high risk for having neonatal seizures secondary to hypoxia ischemia or asphyxia and admitted to the neonatal intensive care unit directly after labor and delivery were prospectively evaluated. Markers of high risk included the presence of moderate to thick meconium-stained amniotic fluid (MSAF), fetal heart rate (FHRT) abnormalities abruptio placentae, intubation and positive pressure ventilation in the delivery room (DR), chest compressions and epinephrine administration as part of resuscitation, a 5-minute Apgar score of 5 or less, umbilical cord arterial pH of 7.00 or less, and/or a base deficit of -14 mEq/L or more negative. RESULTS: Seizures developed in 5 (5.2%) of the 96 infants. High-risk markers included FHRT abnormalities only (n=36), FHRT abnormalities and MSAF (n=20), MSAF only (n=23), abruptio placentae (n=6), intubation in the DR (n=44), intubation in the neonatal intensive care unit (n=22), chest compressions (n=2), 5-minute Apgar scores of 5 or less (n=21), umbilical cord arterial pH of 7.00 or less (n=21), and base deficits of -14 mEq/L or more negative (n=19). By univariate analysis, significant relationships with seizures were found with Apgar scores, the need for intubation in the DR, umbilical cord arterial pH, and base deficit. Combinations of the identified risk markers showed a strong relationship with seizures with the following odds rations (ORs), 95% confidence limits, sensitivity, specificity, and positive predictive values (PPVs): (1) low cord pH and intubation, OR, 163 (confidence limits, 7.9 and 3343.7); sensitivity, 100%; specificity 94%; and PPV, 50%; (2) low cord pH and low 5-minute Apgar score, OR, 39 (confidence limits, 3.9 and 392.5); sensitivity, 80%; specificity, 91%; and PPV, 33.3%; and (3) low pH, intubation, and low 5-minute Apgar score, OR, 340 (confidence limits, 17.8 and 6480.6); sensitivity, 80%; specificity, 98.8%; and PPV, 80%. CONCLUSIONS: A combination of high-risk postnatal markers, specifically, a low 5-minute Apgar score and intubation in the DR in association with severe fetal acidemia, facilitates the identification within the first hour of life of term infants at highest risk for developing seizures secondary to perinatal asphyxia.

Reproductive risk factors of fetal asphyxia at delivery: a population based analysis.

To investigate reproductive maternal risk factors of intrapartum fetal asphyxia, we analyzed 556 women with singleton pregnancies complicated by intrapartum fetal asphyxia who gave birth at Kuopio University Hospital from January 1990 to December 1998. The general obstetric population (N=21746) was selected as the reference group and logistic regression analysis was used to identify independent reproductive risk factors. The incidence of intrapartum fetal asphyxia was 2.5%. Placental abruption, primiparity, alcohol use during pregnancy, low birth weight, preeclampsia, male fetuses, and small-for-gestational age births were independent risk factors of intrapartum asphyxia, with adjusted relative risks of 3.74, 3.10, 1.75, 1.57, 1.49, 1.48 and 1.33, respectively. Most cases of intrapartum fetal asphyxia occur in low-risk pregnancies and, therefore, risk screening in antenatal care cannot accurately predict which women will eventually need emergency care for fetal asphyxia.

Preliminary experience with magnetic resonance imaging in patients with third-trimester bleeding.

Fifteen patients with third-trimester bleeding, in whom transabdominal ultrasound had failed to identify a definitive source of bleeding, underwent magnetic resonance imaging (MRI). Magnetic resonance imaging correctly identified three cases of placenta previa. In four patients, intrauterine blood was identified in hematomas. One hematoma was associated with a previa, two progressed to acute abruptions, and one was associated with a clot at the marginal cord insertion. Blood was seen leading away from the placenta in a case that progressed to an acute abruption. It was also seen in the region of the cervix in two patients with placenta previa. One patient had a normal MRI but had a fresh clot at delivery, which presumably formed after the imaging. In the remaining seven patients, MRI scans were negative and the placentas were normal at delivery. Our preliminary results suggest that MRI is helpful in evaluating patients with unexplained third-trimester bleeding.

Successful term pregnancy after bilateral uterine artery embolization for postpartum hemorrhage.

BACKGROUND: Selective bilateral uterine artery embolization has been used since the 1970s for the conservative treatment of postpartum hemorrhage. The fertility rate after the embolization procedure is yet to be determined. CASE: A 30-year-old woman presented with placental abruption and subsequently delivered preterm at 29 weeks' gestation. Her delivery was complicated by postpartum hemorrhage, for which selective bilateral uterine artery embolization was performed with successful cessation of the hemorrhage. Three months later, the patient presented with a spontaneous pregnancy. Her pregnancy resulted in an appropriately grown fetus delivered at 39 weeks' gestation. CONCLUSION: This is one of the earliest reported successful pregnancies after a bilateral uterine artery embolization procedure performed for postpartum hemorrhage. This case adds to a growing literature demonstrating that pregnancy after embolization is possible, and can occur soon after the procedure.

Rupture of the pregnant uterus.

Ninety-three incidents of uterine rupture are reviewed. There is a distinct difference in both the fetal and maternal outcome between the group with a previously scarred uterus and the group with no previous scarring. Rupture of the unscarred uterus is a more dramatic event. The most common etiologic factors appear to be oxytocin, cephalopelvic disproportion, grand multiparity, and abruptio placentae. Abruptio placentae was diagnosed in almost half the maternal deaths. When the uterine tear is longitudinal, the maternal and fetal prognosis is relatively poor. Fetal mortality is much higher in patients with an unscarred uterus. Hysterectomy was more commonly performed in this group. Rupture of a previously scarred uterus is usually incomplete and the tear is transverse. Maternal and fetal prognosis is much better and repair of the uterus with sterilization is more often feasible in this situation.

Relationship of hypertensive disease to abruptio placentae.

The purpose of the present retrospective study was to examine the relationship between hypertension and abruptio placentae. Two hundred sixty-five consecutive cases of abruption were reviewed, with an emphasis on the occurrence and severity of hypertensive disease. The results confirm a close relationship between abruptio placentae and hypertension. The incidence of abruption was highest with eclampsia (23.6%), followed by chronic hypertension (10.0%) and preeclampsia (2.3%). In addition, those with eclampsia and chronic hypertension had a significantly higher perinatal mortality than those without these conditions. These data demonstrate that hypertension is associated with an increased risk of abruption. Furthermore, the degree of this increased risk is clearly dependent upon the specific type of hypertensive disorder.

Successful pregnancy outcome following mid-gestational uterine rupture and repair using Gore-Tex soft tissue patch.

The first reported gestational use of the Gore-Tex soft tissue patch (expanded polytetrafluoroethylene) for uterine repair and support is presented in a pregnant woman whose partially dehisced, congenitally abnormal uterus was operated upon at 19 weeks' gestation. Use of the expanded polytetrafluoroethylene Gore-Tex soft tissue patch for assisted uterine integrity in combination with a program of uterine tocolysis and close maternal/fetal surveillance averted a pregnancy loss.

Placental infarction leading to fetal or neonatal death. A prospective study.

The pathogenesis of perinatal death due to placental infarction was analyzed in a large prospective study that included more than 1000 medical, demographic, hereditary, and postmortem variables. The disorder was the fifth most frequent cause of death in the study with a perinatal mortality of 2.26/1000 births. Its frequency was directly correlated with the gravidas' blood pressures, an effect augmented by albuminuria and work during pregnancy. Fatal infarcts were increased 20-fold with glomerulonephritis, fivefold with abruptio placentae, and twofold when the gravidas' hemoglobins were over 12 g/100 ml. Maternal weight gains were suboptimal and the involved neonates had a pattern of growth retardation characteristic of undernutrition. The disorder was more frequent when the gravida had made few prenatal visits for medical care and had had prior unsuccessful pregnancies.

Abruptio placentae. An assessment of the time and method of delivery.

Abruptio placentae occurs once per 120 deliveries, but accounts for 15--25% of all perinatal mortality. Several series in the literature suggest that an abnormal fetal-maternal relationship exists in patients with abruptio placentae weeks prior to the actual placental separation and that the separation is only the terminal event. A review of the literature and an analysis of 388 cases of abruptio placentae from the US Navy Coding System were undertaken. It was found that approximately 75% of fetal deaths occurred more than 90 minutes after admission to the hospital and almost 70% of all perinatal mortality occurred in infants who were delivered more than 2 hours from the time of diagnosis. Delivery by cesarean section improved survival in those infants weighing 1500 g or greater and reduced perinatal mortality as much as fourfold in some reports. A prospective study is proposed which would compare two methods of management of this condition.

Peripheral placental separation: a possible relationship to premature labor.

This investigation was undertaken to determine the relationship, if any, between peripheral placental separation and idiopathic premature labor. Ninety placentas from prematurely delivered patients (who had had no antepartum bleeding) were examined grossly and microscopically. Criteria for antepartum peripheral placental separation included adherent clot, with fibrin deposition and lamination, as well as polymorphonuclear infiltration and marginal decidual necrosis. Forty-nine placentas showed unequivocal evidence of previous peripheral separation. Another three placentas showed presumptive evidence of previous peripheral separation. It is suggested that this separation is of venous origin, and that it may play a role in the process of premature labor. This is not necessarily a cause and effect relationship.

Predictability of pregnancy outcome in preterm delivery.

Multivariate models have great potential value in enhancing the understanding of why some pregnancies have poor outcomes. Recently, such models have been advocated as a basis for predictive scoring systems that attempt to classify patients into high-risk and low-risk groups. In this report the usefulness of such an approach was assessed by studying the predictability of preterm delivery at The Johns Hopkins Hospital during 1980, using a multiple logistic model. Choosing a cutoff point (or probability of preterm delivery) of 10%, 697 of 2865 patients were placed in the high-risk group. The sensitivity, specificity, and positive predictive value of the model, as applied to this select population, were 62.2, 79.4, and 22.7%, respectively. Thus, only 23% of patients predicted to have preterm deliveries in fact delivered preterm. The predictive value could have been improved by increasing the cutoff point, but only at the expense of markedly reducing the sensitivity of the model. It was concluded that the potential value of multivariate analyses of pregnancy outcome as a predictive, risk-classification technique is limited. Nevertheless, such studies may aid the clinical evaluation of each individual patient by providing a better understanding of the etiologies of poor outcome.

Vasopressin concentration in cord blood: correlation with method of delivery and cord pH.

Cord plasma vasopressin concentration, determined by radioimmunoassay, was higher in arterial than in venous blood in 122 (84%) infants; the highest vasopressin values were recorded in 21 acidotic infants (mean cord pH, 7.13) delivered per vaginam and the lowest values in 50 infants delivered by cesarean section. Cord vasopressin levels were not elevated in infants delivered by cesarean section because of obstructed labor. There was a lack of correlation between vasopressin levels and the length of labor or cervical dilatation; a significant correlation was found between cord arterial vasopressin values and pH. Low vasopressin values were recorded in a group of 22 healthy infants (mean cord pH, 7.29) delivered by low forceps operation.

Eclampsia. I. Observations from 67 recent cases.

Sixty-seven cases of eclampsia were managed from 1977 to 1980, for an incidence of 1 in 310 deliveries. Eighty-four percent of patients were nulliparous and 82% had received some prenatal care. Prior to convulsion, 14 patients (21%) had a diastolic blood pressure below 90 mmHg, 39% had no edema, and 21% had no proteinuria. Thirty-seven patients (55%) had their first convulsion in the hospital. Eight patients had convulsions while receiving magnesium sulfate therapy. Convulsions occurred post partum in 25 patients (37%). In 11 patients the onset of eclampsia occurrred 3 to 11 days after delivery. The total perinatal mortality was 8.6% for all cases of eclampsia. Excluding postpartum cases, perinatal mortality was 13.3%, but was only 5% for those fetuses alive on admission to the perinatal center. Abruptio placentae was present in 9 cases and accounted for 4 of the 6 perinatal deaths. The high incidence of eclampsia at the authors' center has not decreased over the past 20 years, but maternal mortality has been reduced from 2.1 to 0%. It was disturbing to find that management error played some role in the development of eclampsia in 50% of the cases. Significant errors--including ineffective magnesium sulfate therapy, failure to treat adequately prior to transport, and lack of communication with a perinatal center--are discussed.

Influence of chorioamnionitis on long-term prognosis in low birth weight infants.

The contribution of obstetric management to quality of life of surviving low birth weight infants is unclear. A possible association between maternal chorioamnionitis and development outcome was evaluated. One hundred twenty-seven mother/infant pairs with infant birth weight less than 2000 g were studied. The antenatal course was complicated by chorioamnionitis, premature rupture of membranes without chorioamnionitis, premature labor, or abruptio placenta. Analysis of variance was performed using these four diagnosis groups. After potentially confounding variables were taken into account, the overall difference in the four groups in Mental Development Index (Bayley Scales) was borderline (P = .138). However, significant differences remained between the group with chorioamnionitis and the group with premature rupture of membranes without chorioamnionitis (P = .017). The potential advantage of leaving infants in utero after premature rupture of membranes may be offset by disadvantage of chorioamnionitis with respect to future development in surviving infants.

Tetany following resuscitation after abruptio placentae.

BACKGROUND: Serum ionized calcium and magnesium are normally decreased during later stages of pregnancy. A further rapid decline may be caused by the rapid infusion of blood bank products in which citrate is used as an anticoagulant/preservative. Tetany, as reported here, may be precipitated by such infusions. CASE: A gravid woman presented in hemorrhagic shock due to abruptio placentae. Rapid infusion of packed red blood cells and fresh frozen plasma precipitated signs of tetany, muscle rigidity, posturing, high airway pressure during mechanical ventilation, etc. Ionized calcium and magnesium blood levels were very low (0.58 mmol/L and 1.0 mg/dL, respectively), but responded to rapid electrolyte administration. CONCLUSION: Binding of calcium and magnesium by citrate may lead to hypo-ionized calcemic and hypomagnesemic tetany after rapid replacement of blood products in the pregnant patient. This consequence is worsened when extreme alkalemia due to respiratory or metabolic causes is also present.

Placental abruption and its association with hypertension and prolonged rupture of membranes: a methodologic review and meta-analysis.

OBJECTIVE: To conduct a meta-analysis of published studies on placental abruption to examine its incidence, recurrence, and association with hypertensive disorders (chronic hypertension and preeclampsia) and prolonged rupture of membranes (PROM) in pregnancy. DATA SOURCES: We reviewed studies on placental abruption published since 1950, based on a comprehensive literature search using MEDLINE, and by identifying studies cited in the references of published reports. METHODS OF STUDY SELECTION: We identified 54 studies, excluding case reports on placental abruption and studies relating to placenta previa and vaginal bleeding of unknown origin. We also restricted the search to articles published in English. TABULATION, INTEGRATION, AND RESULTS: Studies chosen for the meta-analysis were categorized based on their study design (case-control or cohort), where they were conducted (United States or other countries), source of the data (vital records versus other sources), and magnitude of risk (risk of abruption greater or less than 1.0%). We used both fixed- and random-effects analysis to identify sources of heterogeneity in results among studies. There were striking differences in the incidence of placental abruption between cohort (0.69%) and case-control (0.35%) studies. United States-based studies found a somewhat higher incidence both for cohort (0.81%) and case-control (0.37%) studies compared with studies conducted outside the U.S. (0.60% and 0.26%, respectively). Abruption was more than ten times more common in pregnancies preceded by a pregnancy with abruption. Chronically hypertensive patients were more than three times as likely to develop placental abruption (odds ratio [OR] 3.13, 95% confidence interval [CI] 2.04-4.80) as normotensive patients. The OR for placental abruption was 1.73 (95% CI 1.47-2.04) for patients with preeclampsia. Similarly, women with pregnancies complicated by PROM were more than three times as likely to develop placental abruption (OR 3.05, 95% CI 2.16-4.32). United States-based studies, case-control studies, and studies with an incidence of abruption greater than 1% demonstrated stronger associations between abruption and hypertension and PROM. CONCLUSION: Risk of abruption is strongly associated with chronic hypertension, PROM, and especially abruption in a prior pregnancy, and somewhat more modestly with preeclampsia. The criteria for the diagnosis of placental abruption, hypertensive disorders, and PROM may have introduced variability among the results of these studies. More standardized definitions of these pregnancy complications would improve the comparability of the study results.

Analysis of variables affecting perinatal mortality: St. Louis City Hospital, 1969-1975.

A marked drop in perinatal mortality at St. Louis City Hospital No. 1 (SLCH) from 1974 to 1975 (39.7 vs 20.6 per 1000 births) prompted a detailed analysis of various factors which might have effected the change. Comparisons were also made between SLCH and St. Mary's Health Center (SMHC), a private hospital affiliated with St. Louis University. The significant drop in perinatal mortality at SLCH in 1975 seems to be due to a combination of various factors: 1) improvement in antepartum care, 2) increase use of cesarean sections, and 3) the influence of intrapartum fetal monitoring.

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.

Management of obstetric hemorrhage.

A reluctance to proceed with hysterectomy for obstetric hemorrhage may be a more likely cause of preventable death in obstetrics than a lack of surgical or medical skills. Every obstetric unit should have protocols available to deal with hemorrhage and, in addition, have specific guidelines for patients who object to blood transfusions for various reasons. Risk factors for hemorrhage should be identified antenatally, using all possible imaging modalities available, and utilizing multidisciplinary resources whenever possible. Novel strategies for prenatal diagnosis of abnormal placentation include advanced sonography and magnetic resonance imaging. Placement and utilization of arterial catheters for uterine artery embolization is becoming more widespread and new surgical technology such as the argon beam coagulator seems promising. When intra or postpartum hemorrhage is encountered, a familiar protocol for dealing with blood loss should be triggered. Timely hysterectomy should be performed for signs of refractory bleeding. Application of medical and surgical principles combined with recent technologic advances will help the obstetrician avoid disastrous outcomes for both mother and fetus.