Intrapartum measurement of cervical dilatation using translabial 3-dimensional ultrasonography: correlation with digital examination and interobserver and intraobserver agreement assessment.

OBJECTIVE: The purpose of this study was to determine the accuracy and reproducibility of intrapartum translabial 3-dimensional (3D) ultrasonographic measurements of cervical dilatation during labor. METHODS: A prospective observational study was conducted. Three-dimensional ultrasonographic volume data sets from 52 patients were collected during labor and stored. Later, all volumes were randomly reviewed twice offline by 2 examiners blinded to previous clinical and ultrasonographic measurements. The correlation with delivery room personnel digital vaginal examinations and interobserver and intraobserver agreement were determined. RESULTS: Twenty-four patients were examined during the latent phase (0- to 4-cm cervical dilatation), and 28 patients were examined during the active phase (5- to 10-cm cervical dilatation). Translabial 3D ultrasonographic measurements of the cervical mean and maximal diameters and inner cervical area showed a positive correlation with digital vaginal examinations (r(2) = 0.609, 0.587, and 0.469, respectively; all P < .001). The interobserver mean differences +/- SD between paired measurements for the mean and maximal cervical dilatation and inner cervical area were 0.11 +/- 0.49 cm, 0.12 +/- 0.48 cm, and -0.22 +/- 5.69 cm(2), and the intraclass correlation coefficients (ICCs) were 0.82, 0.85, and 0.87. The intraobserver mean differences between paired measurements of the mean and maximal cervical dilatation and inner cervical area were 0.002 +/- 1.15 cm, 0.02 +/- 1.4 cm, and -0.41 +/- 1.15 cm(2), and the ICCs were 0.85, 0.79, and 0.75. CONCLUSIONS: Assessment of cervical dilatation using 3D ultrasonography during labor is feasible and reproducible.

Clinical significance of uterine scar dehiscence in women with previous cesarean delivery: prevalence and independent risk factors.

OBJECTIVE: To determine the prevalence and risk factors for uterine scar dehiscence in women following cesarean delivery (CD). STUDY DESIGN: Our computerized database was used to identify patients with recurrent CDs in the index pregnancy (1988-2002). Women with uterine dehiscence were compared to those without dehiscence. Multiple logistic regression analysis was used to determine independent risk factors for dehiscence. RESULTS: Of 7,833 women with at least 1 previous CD and a CD in the index pregnancy, 81 (1.03%) had uterine scar dehiscence. This finding was associated with nonprogress of labor during the first stage, number of previous CDs, parity, preterm delivery and low Apgar scores at 5 minutes. For patients with only 1 previous CD, failure to progress during the first stage of labor and lower parity were associated with uterine scar dehiscence. The numbers of previous CDs, gravidity and placenta previa rate were significantly higher in the group with dehiscence who delivered preterm. CONCLUSION: Preterm delivery, nonprogress of labor during the first stage and number of previous CDs were found to be independent risk factors for uterine scar dehiscence. In contrast, parity had a protective effect against dehiscence.

Maternal and neonatal outcome following cerebrovascular accidents during pregnancy.

OBJECTIVE: To assess the clinical characteristics of maternal and neonatal outcome among women with cerebrovascular accidents (CVA) during pregnancy. METHODS: Our computerized database was used to identify patients with CVA during pregnancy and puerperium from January 1988 to March 2004. Their medical records were identified and reviewed. RESULTS: There were 16 cases of CVA among 173,803 deliveries, giving a risk of almost one case per 10,000 pregnant women. Out of 16 patients, 14 (88%) had a stroke and the remaining two cases were diagnosed with venous thrombosis. Of those 14 cases, nine (64%) had ischemic strokes and five (36%) had hemorrhagic strokes. Ten of the CVAs occurred antepartum, two intrapartum and four postpartum. Hypertensive disorders were diagnosed in 75% (12/16) of the patients. Out of these 12 patients with hypertension, 9 (75%) suffered from preeclampsia. One woman had a history of chronic hypertension. Smoking was associated with 63% (10/16) of the cases. There were two maternal deaths, both in women who had hemorrhagic strokes, and both in the first half of the study (1994 and 1996). Nine out of 16 women (56%), were delivered within 48 hours of the CVA including 7 (78%) antepartum, and two (22%) intrapartum. Cesarean deliveries were performed in 11/16 women (69%) including 8/10 with CVAs occurring antepartum, 1/2 intrapartum and 2/4 postpartum. One case of neonatal mortality was identified in a patient who was delivered at 24 gestational weeks. CONCLUSIONS: (1) Hypertensive disorders and smoking were the most important factors associated with CVA during pregnancy. (2) Maternal mortality was high among patients with CVA during pregnancy. (3) Neonatal outcome was considered generally good in cases of CVA.

Increased maternal serum human chorionic gonadotropin concentrations are an independent risk factor for SGA in dichorionic twin gestations.

OBJECTIVE: To determine maternal and neonatal complications among dichorionic and monochorionic twins with isolated midtrimester elevated maternal serum human chorionic gonadotropin (MShCG). MATERIAL AND METHODS: MShCG was determined in 247 women with dichorionic twins and 32 women with monochorionic twins between 16-18 weeks gestation. Among the dichorionic twins 219 patients had MShCG < 2.5 MoM, 14 between 2.5-3.0 MoM and 14 above 3.0 MoM. Of the patients with monochorionic twins 15 had MShCG < 2.5 MoM, nine between 2.5-3.0 MoM and 8 above 3.0 MoM. All patients had maternal serum alpha fetoprotein < 2.5 MoM. Karyotype was normal among all neonates. Statistical analysis was performed with SPSS package. RESULTS: Patients with monochorionic twins had higher rates of cesarean section when MShCG was > 3.0 MoM (100% vs. 44%; p = 0.03) and of preterm delivery when MShCG was > 2.5 MoM (87.5% vs. 46.7%; p = 0.04). A non significant higher rate of small for gestational age (SGA) neonates was found when MShCG was > 2.5 MoM among first twin (37.5% vs. 13.3%; p = 0.08). In contrast, patients with dichorionic twins had higher rates of SGA neonates and low 1 minute Apgar scores in the second twin when MShCG was > 2.5 MoM (23.1% vs. 10%; p = 0.04, 15.4% vs. 11.9%; p < 0.01). A multivariate logistic regression model with forward stepwise selection was performed with SGA as outcome variable. The model included the following variables: MShCG, hypertensive disorders, gestational age at delivery, chorionicity, twin order, cesarean section (CS) and preterm delivery. MShCG levels were the only significant factor predicting SGA among bichorionic twins (OR 1.76, 95% CI 1.2-2.5). CONCLUSIONS: (1) Increased concentrations of MShCG are an independent risk factor for SGA among dichorionic twins. (2) MShCG > 2.5 MoM are associated with adverse maternal outcome among monochorionic twins.

Increasing amniotic fluid magnesium concentrations with stable maternal serum levels: a prospective clinical trial.

OBJECTIVE: To compare the effect of prolonged maternal intravenous MgSO4 administration on amniotic fluid and serum concentrations of magnesium over time in preterm labor patients. STUDY DESIGN: Patients at 24-34 weeks of singleton gestation who presented with contractions (> 8 in 60 minutes) underwent amniocentesis to rule out intrauterine infection after signing an informed consent form. Some of these women who were clinically judged to have preterm labor received intravenous MgSO4: a 4-g loading dose followed by a 2 g/h maintenance dose. For technical reasons some patients had amniocentesis performed before initiation of MgSO4 (controls), while others had the procedure during tocolytic therapy (study subjects). Duration of treatment until amniocentesis was recorded, and blood samples were drawn at the time of amniocentesis. Maternal serum and amniotic fluid magnesium levels were measured using a colorimetric end point method. Data were evaluated using the Student t test and linear regression analysis. RESULTS: Mean magnesium levels in maternal serum rose from 1.74 +/- 0.2 mg/dL in controls to 4.01 +/- 0.4 mg/dL in the study group. Mean magnesium levels in Mean magnesium levels in amniotic fluid were 1.41 +/- 0.18 mg/dL in the controls versus 2.28 +/- 0.53 mg/dL in the treatment group. Duration of MgSO4 treatment ranged from 3 to 22 hours. Amniotic fluid magnesium concentrations increased significantly during therapy (correlation coefficient = 0.89; p < 0.001), while maternal serum levels remained stable over time (correlation coefficient between maternal serum levels and time = -0.39; p=0.34). CONCLUSION: Although maternal serum magnesium levels remained stable with intravenous MgSO4 therapy, concentrations continued to rise in amniotic fluid over time. However, amniotic fluid magnesium levels never exceeded maternal serum concentrations during the study period.

Risk factors for recurrent preterm delivery.

OBJECTIVE: To identify risk factors for recurrent preterm delivery among primiparous women with previous preterm delivery. STUDY DESIGN: A retrospective case-control study was designed: 152 primiparous women who delivered preterm (22-36 weeks) were divided into two groups: 81 had a second preterm delivery (study group) and 71 had a second-term delivery (control group). Exclusion criteria were induced preterm delivery, hydramnions and multiple gestations. RESULTS: Comparing second preterm delivery before 34 weeks (n = 36) to the second delivery of the control group, higher rates of hospitalization due to preterm labor were noted in the study versus the control group (52.8% versus 16.9%,P = 0.001). The interval between pregnancies was shorter in the study subgroup, before 34 weeks gestational age, versus the controls (20.1 +/-15.7 months versus 28.9 +/- 18.7 months, P = 0.011). Multiple regression analyses, adjusted for confounding variables, found the occurrence of preterm labor and short interval between pregnancies, especially up to 12 months, as independent risk factors for the recurrence of preterm delivery (OR = 4.98; P , 0.001; OR = 5.13; P = 0.007, respectively). CONCLUSION: When adjusted for confounding variables, short interval between pregnancies is an independent risk factor for recurrent preterm delivery.

Intravenous magnesium sulphate effect on maternal serum and amniotic fluid cytokines levels in preterm labour patients.

Our objective was to evaluate the effect of intravenous magnesium sulphate administration to patients with preterm labour on maternal serum and amniotic fluid IL-1beta, IL-6, IL-10 and TNFalpha concentrations. Thirty-six patients at 24-34 weeks of singleton gestation, who presented with contractions (> or = 8 in 60 min) had amniocentesis to rule out intrauterine infection. The patients received intravenous MgSO4 for tocolysis. Twenty-six patients had amniocentesis performed before initiation of MgSO4 (controls) while 10 others had the procedure during tocolytic therapy (study patients). Magnesium, IL-1beta, IL-6, TNFalpha and IL-10 concentrations were measured. Study and control groups were statistically compared using Student t test. Mean magnesium levels were significantly higher in the study group (P < 0.01). There were no significant differences between the cytokines levels in maternal serum and in amniotic fluid between the groups. Our results suggest that the mechanism of magnesium as a tocolytic agent may not be mediated via the examined cytokines.

Independent risk factors for cesarean section among women with thrombophilia.

UNLABELLED: OBJECTIVE To determine the prevalence of cesarean section (CS) in pregnant women with a diagnosis of thrombophilia and to identify risk factors for CS. STUDY DESIGN: The women were recognized by an ICD-9 code from a computerized database. Maternal records were reviewed between the years 2000 and 2005. Pregnancy characteristics of 86 women with thrombophilia were compared according to the mode of delivery: CS (n = 18) versus vaginal delivery (n = 68). RESULTS: The prevalence of CS in the study population was 21% (18/86). Women with CS had a lower gestational age at delivery (P = 0.019), lower birth weight (P = 0.048), higher incidence of the following: preterm delivery (P < 0.001), gestational hypertension (P = 0.028), intrauterine growth retardation/antepartum death/placental abruption (P = 0.065) and non-reassuring fetal heart rate (NRFHR) monitoring (P < 0.001) compared to those with vaginal delivery. In a multiple logistic regression analysis only NRFHR monitoring, birth weight and malpresentation remained statistically significant. CONCLUSION: CS in women with thrombophilia are associated with common obstetrical causes rather than specific thrombophilia dependent factors.