Indications for caesarean sections at ≥34 weeks among nulliparous women and differential composite maternal and neonatal morbidity.

OBJECTIVE: To compare composite maternal and neonatal morbidities (CMM, CNM) among nulliparous women with primary indications for caesarean section (CS) as acute clinical emergency (group I; ACE), non-reassuring fetal heart rate (group II) and arrest disorder (group III). DESIGN: A multicentre prospective study. SETTING: Nineteen academic centres in the USA, with deliveries in 1999-2002. POPULATION: Nulliparous women (n = 9829) that had CS. METHODS: Nulliparous women undergoing CS for three categories of indications were compared using logistic regression model, adjusted for five variables. MAIN OUTCOME MEASURES: CMM was defined as the presence of any of the following: intrapartum or postpartum transfusion, uterine rupture, hysterectomy, cystotomy, ureteral or bowel injury or death; CNM was defined as the presence of any of the following: umbilical arterial pH <7.00, neonatal seizure, cardiac, hepatic, renal dysfunction, hypoxic ischaemic encephalopathy or neonatal death. RESULTS: The primary reasons for CS were ACE in 1% (group I, n = 114) non-reassuring FHR in 29% (group II; n = 2822) and failed induction/dystocia in the remaining 70% (group III; n = 6893). The overall risks of CMM and CNM were 2.5% (95% confidence intervals, CI, 2.2-2.8%) and 1.9% (95% CI 1.7-2.2), respectively. The risk of CMM was higher in group I than in group II (RR 4.1, 95% CI 3.1, 5.3), and group III (RR 3.2, 95% CI 2.7, 3.7). The risk of CNM was also higher in group I than in group II (RR 2.8, 95% CI 2.3, 3.4) and group III (RR 14.1, 95% CI 10.7, 18.7). CONCLUSIONS: Nulliparous women who have acute clinically emergent caesarean sections are at the highest risks of both composite maternal and neonatal morbidity and mortality.

Human tail with spina bifida.

A true human tail is a rare occurrence and is defined as a caudal, vestigial, midline protrusion with skin covering connective tissue, muscle, vessels and nerves. We report a case of true human tail in a child, which is a very rare happening in humans.

Giant benign schwannoma on scalp causing 'double-head'.

Abstract- Schwannomas are tumors derived from Schwann cells. They are usually small and comparatively rare on scalp. A 25-year old woman presented with huge mass on posterior side of the scalp that gave the appearance of 'double-head'. The mass was excised and reconstruction was achieved by primary closure. Histology proved to be a benign schwannoma. The patient is well at 6-months of follow up. Giant benign schwannoma on scalp is extremely rare. Clinicians that came across the giant tumors of the scalp should suspect this possibility as these tumors have favorable prognosis.

The theaflavin fraction is responsible for the facilitatory effect of black tea at the skeletal myoneural junction.

The effect of various fractions of black tea [(Camellia Sinensis) (L) O. Kuntze (Theaceae)] on the function of mammalian skeletomotor apparatus was studied. The theaflavin fraction (Tfs) produced a concentration- dependent facilitation of indirect twitch responses of the rat phrenic nerve diaphragm preparation and the facilitation was dependent on the amount of calcium present in the bathing fluid. Nifedipine reduced the facilitatory effect of Tfs as a function of its concentration. Tfs failed to produce facilitation when the twitch height was reduced to about 50% of the control value in presence of magnesium chloride. Tfs completely antagonized the submaximal paralytic effect of d- tubocurarine and decamethonium bromide. Tfs did not have any effect on direct twitch responses or on acetylcholine (Ach) and potassium chloride (KCl) induced contractures of denervated diaphragm. The results revealed that the site of action of Tfs is on the contractile mechanism of the voluntary muscle and point to a critical role of calcium in the mechanism of action of Tfs. N omega-nitro-L-arginine-methyl ester (L-NAME), a nitric oxide synthase (NOS) inhibitor, antagonized both the facilitatory and inhibitory effects on indirect twitch responses of rat diaphragm induced by L-arginine and Tfs when the phrenic nerve was stimulated at 5 Hz and 50 Hz respectively. The thearubigin (Trs) fraction of black tea and the aqueous part which is completely devoid of Tfs, did not potentiate the twitch responses. The findings suggest that Tfs have a potentiating effect on the contractile mechanism of skeletal muscle and that calcium and nitric oxide may modulate this action of Tfs.

Estimators of birth weight in pregnant women requiring insulin: a comparison of seven sonographic models.

OBJECTIVE: To determine if the relative accuracy of the sonographic estimate of birth weight among diabetic gravidas requiring insulin improves significantly as more fetal measurements are used. METHODS: We studied 172 diabetic women requiring insulin who had sonographic measurements of fetal parts within 7 days of delivery. Friedman nonparametric analysis of variance followed by Dunn multiple comparison and chi 2 were used to assess the relative accuracy of the seven models. Prediction limits were calculated to determine the estimate of fetal weight that would ensure (with 90% accuracy) that the newborn was macrosomic (at least 4 kg). RESULTS: The mean (+/- standard deviation [SD]) birth weight was 3388 +/- 727 g, and the frequency of macrosomia at term gestation was 19.4% (29 of 149). The mean standardized absolute error (g/kg) based on abdominal circumference (AC) and femur length (FL) (86 +/- 72 g/kg) was not significantly different from the other models (range 84 +/- 72 to 116 +/- 99 g/kg, P > .05). The percent of estimate within 10% of actual birth weight using AC and FL (65%) was similar to the other models (53.4-66.2%). Regardless of the White classification, the estimation of fetal weight using AC and FL had an accuracy similar to the other six regression equations. To ensure that the birth weight is at most 3999 g, the estimated fetal weight should be 3200 g, and, conversely, if the predicted weight is 4700 g, then the newborn is macrosomic. CONCLUSION: Among patients requiring insulin, estimation of birth weight using AC and FL is as accurate as more complicated models. The ability to detect macrosomia by ultrasound is limited.

Intrapartum clinical, sonographic, and parous patients' estimates of newborn birth weight.

The accuracy of estimating birth weight clinically, sonographically (using femur length and abdominal circumference), and by maternal prediction was studied prospectively in 106 term parous women who were in active labor. Estimates of birth weight by these women had lower standardized error (86.8 +/- 78.0 g/kg) than either clinical estimates (90.2 +/- 84.8 g/kg) or sonographically derived estimates (155.8 +/- 118.0 g/kg) of birth weight (P = not significant). Maternal estimates of birth weight were within +/- 10% of the actual weight in 69.8%, compared with 66.1% for clinical estimates and 42.4% for sonography. A term parous woman in labor can predict the birth weight with accuracy comparable to a clinical estimation by a physician or a sonographic estimate based on infant measurements.

Amniotic fluid index and single deepest pocket: weak indicators of abnormal amniotic volumes.

OBJECTIVE: To compare amniotic fluid index (AFI) with the single deepest pocket in the identification of actual abnormal amniotic fluid (AF) volumes. METHODS: One hundred seventy-nine women with singleton pregnancies at the University of Mississippi between March 1994 and June 1999 had ultrasound estimations of AF volume sequentially using the AFI and single deepest pocket techniques. Each woman subsequently had ultrasound-directed amniocentesis with dye-dilution and spectrophotometric calculation of actual AF volume. RESULTS: Actual AF volumes were low (under 5% by volume for gestational age) in 62 women, normal (5-95%) in 100 women, and high (more than 95%) in 17 women. An AFI up to 5 cm (sensitivity 10%, specificity 96%) and a single deepest pocket up to 2 cm (sensitivity 5%, specificity 98%) were similarly inadequate in identifying dye-determined low AF volumes. Likewise, AFI above 20 (sensitivity 29%, specificity 97%) and a single-deepest pocket above 8 cm (sensitivity 29%, specificity 94%) were poor in identifying dye-determined abnormally high volumes. CONCLUSION: There was no difference between AFI and single deepest pocket techniques for identifying truly abnormal AF volumes. Both techniques were unreliable for identifying true AF volumes.

Amniotic fluid volume estimation and the biophysical profile: a confusion of criteria.

The biophysical profile (BPP) can be used as an initial test of fetal health and as a secondary back-up assessment of fetuses at risk of adverse outcomes when preliminary evaluations are not reassuring. The BPP evaluates five characteristics: fetal movement, tone, breathing, heart reactivity, and amniotic fluid (AF) volume estimation. Three of the most frequently used obstetric textbooks define adequate AF volume differently. In two of the three, the stated method of evaluating AF volume differs from that actually used by the referenced authors. We reviewed articles by Manning and found that his methodology changed from a 1-cm pocket in one plane to a 1-cm pocket in two perpendicular planes, and finally to a 2-cm vertical pocket with a 1-cm horizontal measurement. The 2 x 2-cm pocket is a fourth methodology that has been introduced recently. It is not known how often and in which groups each of the four methods has been used to evaluate abnormal AF volumes. The relevance and importance of determining precisely the ultrasound measurement actually used for investigations are emphasized by looking at women with AF indices < or = 5. Fifty-three percent of those women had a 2 x 2 pocket, 72% had a 2 x 1 pocket, and 95% had a 1 x 1 pocket. The diagnosis of low fluid can lead to additional testing, hydration, and intervention, so the importance of a universal definition linked with pregnancy outcomes cannot be overemphasized.

Intrapartum prediction of birth weight: clinical versus sonographic estimation based on femur length alone.

OBJECTIVE: To determine the relative accuracy of predicting birth weight by clinical estimate versus sonographic mensuration of femur length (FL) alone. METHODS: Two hundred pregnant women at term and in early labor had the weight of their fetuses estimated by clinical and sonographic methods. RESULTS: Clinical assessment of birth weight had a significantly lower mean standardized absolute error (90.6 g/kg) than sonographic estimate based on FL alone (106.7 g/kg) (P < .05). Clinical estimates were significantly more often within 5% (35%) of actual birth weight than were those derived sonographically (29%) (P = .005). CONCLUSION: Using FL alone to predict birth weight has no advantage over a clinical estimate among term patients in labor.

Amniotic fluid volume in normal singleton pregnancies.

OBJECTIVE: To evaluate the amniotic fluid (AF) volume in normal singleton pregnancies from 15 to 40 weeks. METHODS: This prospective study evaluated the AF volume in singleton pregnancies undergoing amniocentesis for genetic assessment of fetal karyotype, preterm labor, or fetal lung maturity. Amniotic fluid volume was determined using a dye dilution technique. To assess the relationship between AF volume and estimated gestational age, a nonlinear regression model was applied. RESULTS: One hundred forty-four normal singleton pregnancies had AF volume evaluated. There was wide variability in the measured AF volumes with a significant (P < .01) increase in AF volume as a function of gestational age. Growth curve modeling estimated that AF volume continued to increase until 40 weeks' gestation. Analyses of the observed AF volume indicated that AF volume nearly doubled after 30 weeks' gestation. CONCLUSION: In contrast to other reports indicating that maximal AF volume in singleton gestations is expected early in the third trimester, we observed the attainment of maximal AF volume near term.

Sonographic examination does not predict twin growth discordance accurately.

OBJECTIVE: To assess the accuracy of estimating birth weight among twins with discordancy (intra-pair difference in actual birth weight of more than 25%) and to determine the relative accuracy of an intra-pair difference in abdominal circumference (delta AC) of 20 mm or more or in estimated fetal weight (delta EFW) of 25% or more for the identification of discordant growth in twins. METHODS: Over a 6-year period, we identified all non-anomalous twin pairs with gestational ages greater than 23 weeks and sonographic examinations within 3 weeks of birth. Ultrasonographic biometry of both twins included AC, head circumference, and femur length; these indices were used to estimate fetal weight by Hadlock's formula. Likelihood ratios, receiver-operating characteristic curves, and prediction limits were applied to assess the accuracy of the two diagnostic methods to predict an abnormal outcome. RESULTS: A total of 242 twin pairs were studied. The mean gestational age among the 21 twins with abnormal growth (30.6 +/- 4.6 weeks) was significantly less than among the 221 twins with normal growth (33.2 +/- 4.0 weeks) (P < .005). The biometric measurements of fetal parts, sonographic estimate of fetal weight, and actual birth weight for both fetuses were significantly less for discordant twin pairs (P < .05). The accuracy of predicting birth weight, as determined by mean error and percentage of the estimate within 10% of the actual weight, was similar between the groups. Receiver-operating characteristic curves showed that both diagnostic tests yielded areas under the two curves not significantly different from the area under the nondiagnostic line (P > .05). Most important, prediction limit calculations indicated that a 90% certainty that the actual birth weight discordance was at least 25% was achievable only if delta AC was 172 mm or greater or delta EFW was 112% or more. CONCLUSION: The most popular current methods (difference in AC or EFW) for predicting discordant growth in twin gestations have limited accuracy when held to a standard for discordance that requires a birth weight difference of at least 25%.

Prediction of hemorrhage at cesarean delivery.

OBJECTIVE: To identify and quantitate the risk factors that might be predictive of hemorrhage during abdominal delivery. METHODS: Over a 2-year period, 1610 women underwent cesarean delivery and 127 (7.9%) had hemorrhage, defined as a decrease in hematocrit of 10% or greater, estimated blood loss greater than 1500 mL, or packed red blood cell administration. These women were compared through a case-control study design with the next abdominal birth without hemorrhage that could be matched for age, parity, indication for cesarean delivery, type of anesthesia, type of skin incision, and antepartum hematocrit. RESULTS: Preeclampsia (odds ratio 3.6, 95% confidence interval [CI] 1.8-7.4), disorders of active labor (odds ratio 4.4, 95% CI 1.4-13.7), Native American ethnicity (odds ratio 6.4, 95% CI 1.8-22.4), previous postpartum hemorrhage (odds ratio 8.4, 95% CI 1.9-37.4), and obesity of greater than 250 lb (odds ratio 13.1, 95% CI 1.7-102.7) were all statistically associated with significant bleeding during abdominal delivery. Combinations of two or more of these factors were associated with a markedly increased risk for hemorrhage, with odds ratios of 18.4 or greater. CONCLUSIONS: Patients undergoing cesarean delivery who have factors exposing them to increased risk of hemorrhage can be identified prospectively. These women will benefit greatly from extended preoperative counseling when possible, effective utilization of blood bank technology through type and cross-match requests, and preventive measures during abdominal delivery to minimize blood loss.

Intrapartum amniotic fluid index: a poor predictor of abnormal fetal size.

OBJECTIVE: Using receiver-operating characteristic (ROC) curves, we tried to determine the diagnostic threshold of amniotic fluid index (AFI) that will identify abnormal fetal size (birth weights under 2500 g or at least 4000 g) at 37 weeks or beyond. METHODS: We analyzed prospectively over 2 years all parturients with intact membranes and known AFI in early labor. Patients with the following conditions were excluded: pregestational or gestational diabetes, known anomalies, and preterm labor. Two ROC curves were constructed, and the areas (+/- standard error of the mean [SE]) under the curves were calculated. P < .05 was considered significant. RESULTS: Of the 1038 subjects meeting study criteria, 3.6% and 11.5% gave birth to infants who were small for gestational age (SGA) or macrosomic, respectively. Overall, 28.7% had oligohydramnios (AFI at most 5.0 cm) and 3.6% had hydramnios (AFI at least 24.0 cm). Small for gestational age was more common in patients with AFI at most 5.0 cm (6.4%) than in those with adequate fluid (AFI 5.1-23.9; 2.5%), or hydramnios (2.7%; P = .012). Macrosomic newborns were less likely to be born to women with oligohydramnios (7.7%) than to those with adequate amniotic fluid (13.1%) or hydramnios (13.5%). Areas under ROC curves are not significantly different from the area under the nondiagnostic line, indicating that AFI (0-34 cm) cannot differentiate between newborns under 2500 g and at or over 2500 g or under 4000 and at or more 4000 g. CONCLUSION: Intraparterium AFI appears to be a poor screening test to identify risk for delivery of SGA or macrosomic fetus.

Ultrasound estimate of amniotic fluid volume: color Doppler overdiagnosis of oligohydramnios.

OBJECTIVE: To determine if concurrent use of color Doppler affects ultrasound estimates of amniotic fluid (AF) volume. METHODS: Study gravidas underwent ultrasound estimations of AF volume subjectively (visualization without measurements) and objectively (using amniotic fluid index [AFI]) and single-deepest pocket techniques, without and with concurrent color Doppler. Amniocentesis with the dye-dilution technique to measure actual AF volume was utilized for comparison. RESULTS: Sixty-seven women at a mean gestational age of 37.1 +/- 2.5 weeks were entered into this investigation between June 1999 and March 2000. Dye-determined AF volume was classified as low in 18 patients and as high in seven, with the remaining 42 within normal range. Using either ultrasound technique with color Doppler produced significantly lower estimates of AF volume (9.3 +/- 4.9) compared to those without color ([11.6 +/- 5], P <.001) for the AFI and (3.7 +/- 1.5) with color compared to those without color ([4.5 +/- 1.5], P <.003) for the single-deepest pocket. Using AFI without color identified two of 67 (3%) of the pregnancies as having low fluid compared to 14 of 67 ([21%] P =.002) using color. The increased classification of oligohydramnios with color did not accurately identify a greater number of dye-determined low volumes; instead, the AFI with color mislabeled nine pregnancies with normal fluid as low. The diagnosis of dye-determined low and high fluid volumes was not significantly different with or without color. CONCLUSION: Concurrent use of color Doppler with AFI measurements leads to the overdiagnosis of oligohydramnios.

Intrapartum assessment by house staff of birth weight among twins.

OBJECTIVE: To determine among twins in labor: 1) the relative accuracy of an intrapartum sonographic estimate of the birth weight for both fetuses using biparietal diameter and abdominal circumference, 2) the accuracy of detecting discordant growth (difference in actual birth weights greater than or equal to 15%), and 3) the estimate of fetal weight for nonvertex twin B that would reliably avoid breech extraction of infants less than 1500 g. METHODS: Retrospectively, we identified and analyzed parturients with twins who had an intrapartum sonogram performed by a house officer assigned to the labor and delivery suite. RESULTS: The mean birth weight (+/- standard deviation) for the twin A group was 1910 +/- 628 g and for twin B was 1869 +/- 668 g. The mean standardized absolute errors for the twin A group (121 +/- 118 g/kg) and the twin B group (92 +/- 67 g/kg) were not significantly different (P = .06). Analysis of variance revealed that regardless of the presentation of the fetuses, the mean standardized absolute error was not significantly different (P = .10). Using a difference in the estimates of birth weight of 15% or greater, the positive and negative predictive values of detecting discordant growth within a twin pair were 53 and 83%, respectively. Among 30 vertex-nonvertex twin pairs, 12 of the second fetuses had actual birth weights of 1500 g or less, and all were estimated to weigh less than 1700 g. CONCLUSIONS: The intrapartum sonographic estimate of fetal weight in twin pregnancy by house staff appears reliable, and the accuracy of prediction is similar regardless of presentation, discordance, or actual birth weight greater or less than 1500 g. To avoid vaginal delivery of a persistent nonvertex twin B with a birth weight of 1500 g or less, a sonographic estimate of 1700 g for the second fetus may be adequate.