Perinatal mortality: a sporadic event or a recurrent catastrophe?

OBJECTIVE: The purpose of this study was to determine whether women who experienced perinatal mortality in their first delivery had, in their subsequent birth, a higher risk for adverse perinatal outcome. METHODS: A population-based study was undertaken to compare all second deliveries of women with previous perinatal mortality in their first delivery to those with no such history. Deliveries occurred from 1988 to 2004 in a tertiary medical center. Patients lacking prenatal care, multiple gestations, and congenital malformations were excluded from the analysis. A multivariable logistic regression model and the Mantel-Haenszel procedure were carried out to control for confounders. RESULTS: During the study period, out of 25,876 singleton second deliveries, 230 (0.9%) cases were of patients with previous perinatal mortality. Multivariable analysis with backward elimination showed a significant association between previous perinatal mortality and the following conditions: hypertensive disorders (OR=2.6, 95% CI 1.7-3.9, P<0.001), diabetes mellitus (OR=2.4, 95% CI 1.5-3.7, P<0.001), fertility treatment (OR=2.7, 95% CI 1.6-4.7, P=0.001), and younger maternal age (OR=0.9, 95% CI 0.92-0.98, P<0.001). Controlling for preterm delivery, using the Mantel-Haenszel procedure, the association between previous and subsequent perinatal mortality remained significant (weighted OR=2.2, 95% CI 1.2-3.9, P=0.010). CONCLUSION: Previous perinatal loss poses an independent risk for subsequent perinatal mortality. Prospective studies are warranted in order to establish the appropriate means of surveillance and/or interventions needed to decrease future adverse perinatal outcomes.

Trial of labor and vaginal birth after cesarean section in patients with uterine Müllerian anomalies: a population-based study.

OBJECTIVE: The aim of our study was to determine the success rate of vaginal birth after cesarean section among patients with Müllerian anomalies in comparison to the success rate of vaginal birth after cesarean section in patients with normal uterus with emphasis on the rate of uterine rupture. STUDY DESIGN: A retrospective population-based study was designed, including all patients with a previous cesarean section that attempted vaginal birth after cesarean section during the study period. Women with known Müllerian anomalies were included in the study group. The control group consisted of women with normal uterus. The rates of vaginal birth after cesarean section, uterine rupture, maternal morbidity, and perinatal outcome were compared between the groups. RESULTS: Of 5571 eligible patients, 165 (2.96%) had Müllerian anomalies. The rate of vaginal birth after cesarean section was significantly lower among patients with Müllerian anomalies than in patients with normal uterus, 37.6% (62/165) vs 50.7% (2740/5406), respectively (P = .0009). During the study period, there were 10 cases of uterine rupture, all in patients with normal uterus. The major indication for repeated cesarean delivery among Müllerian anomalies patients was malpresentation, 58.3% (60/103) vs 14.4% (385/2666) in patients with normal uterus (P < .001). CONCLUSION: A trial of vaginal birth after cesarean section in patients with uterine Müllerian malformations and cephalic presentation is not associated with a higher rate of maternal morbidity and uterine rupture.

Abnormal fetal heart rate tracings and congenital fetal hypothyroidism.

BACKGROUND: Fetal heart rate (FHR) monitoring is commonly used for fetal surveillance. Despite its widespread usage, there is still a disagreement about its value in predicting fetal distress. CASE: A 29-year-old woman in her first pregnancy was admitted for routine follow-up at 38 weeks gestation. The FHR tracing demonstrated severely reduced baseline variability. Due to non-reassuring FHR patterns accompanied by abnormal biophysical profile, the patient was scheduled for urgent Cesarean section. A newborn with congenital absence of the thyroid gland was delivered. CONCLUSION: Severe reduced baseline variability might be an early sign for fetal hypothyroidism. Future research in this area may examine large populations of neonates with thyroid abnormalities in order to determine if abnormal FHR tracing can better predict congenital hypothyroidism.

The effect of epidural analgesia on labor progress and outcome in nulliparous women.

OBJECTIVE: The present study was designed to investigate the influence of epidural analgesia on labor progress and outcome in nulliparous women. METHODS: A population-based study comparing women with and without epidural analgesia was conducted. Deliveries occurred during 1988-2006 at the Soroka University Medical Center. A multivariable logistic regression model with backward elimination was constructed to control for confounders. RESULTS: During the study period there were 39 498 deliveries; epidural analgesia was given in 9960 (25.2%) of these. Using a multivariable analysis with backward elimination, the following conditions were significantly associated with the use of epidural analgesia: advanced maternal age, oligohydramnios, premature rupture of membranes, induction of labor, and Jewish (vs. Bedouin) ethnicity. These patients were more likely to deliver by cesarean delivery (CD; OR = 1.4, 95% CI 1.3-1.5; p < 0.001) and vacuum extraction (OR = 1.5, 95% CI 1.4-1.7; p < 0.001). After controlling for possible confounders such as macrosomia, failed induction, hypertensive disorders, gestational diabetes, maternal age, labor dystocia, and ethnicity, epidural analgesia was not found to be an independent risk factor for CD but rather a protective factor (OR = 0.9, 95% CI 0.8-0.9; p = 0.038). When vacuum extraction was the outcome variable, epidural analgesia was documented as an independent risk factor (OR = 1.1, 95% CI 1.01-1.3; p = 0.04). CONCLUSIONS: Epidural analgesia in nulliparous parturients increases the risk for labor dystocia and accordingly is an independent risk factor for vacuum extraction. Nevertheless, it does not pose an independent risk for cesarean delivery.