The patient with asymptomatic shortened cervix at 23 to 28 weeks: is delivery imminent?

We investigated whether the presence of symptoms predicts the timing of subsequent spontaneous preterm birth in a cohort of women with cervical length (CL) <1.5 cm. A retrospective cohort study was conducted that included patients from 23 to 28 weeks' gestation with a CL <1.5 cm on routine ultrasound. Two groups were defined on the basis of presenting symptoms at the time of the ultrasound examination: asymptomatic patients and those with symptoms of preterm labor. The incidence of delivery within 2 weeks was determined for both groups. A total of 88 patients with CL <1.5 cm were identified from an ultrasound database. There were 52 patients with CL <1.5 cm and no symptoms. Of these, 1 (1.9%) delivered within 2 weeks. The remaining 36 patients had a CL <1.5 cm and symptoms of preterm labor. Of these, 11 (30.6%) delivered within 2 weeks (relative risk 15.9, 95% confidence interval 2.1 to 118). Premature cervical shortening at 23 to 28 weeks, in the absence of symptoms of preterm labor, is rarely associated with preterm delivery within 2 weeks. Following those patients clinically may prevent prolonged hospitalization and allow steroid administration closer to the date of delivery.

Time of delivery and neonatal morbidity and mortality.

OBJECTIVE: The objective of the study was to examine the association between time of delivery and neonatal outcomes in term deliveries. STUDY DESIGN: We conducted a retrospective cohort study of all term pregnancies delivered at an academic institution with 24-hour in-house obstetric and anesthesia coverage. Time of delivery was categorized as day (7 am to 6 pm), evening (6 pm to 12 midnight), and late night (12 midnight to 7 am). Outcomes included 5-minute Apgar less than 7, umbilical artery pH less than 7.0, base excess less than -12, admission to the neonatal intensive care unit (NICU), and neonatal death. We excluded patients delivered via cesarean delivery not in labor. We had greater than 80% power to detect a 25% difference in Apgar score, base excess, and admission to the NICU and 80% power to detect a 50% difference in umbilical artery pH less than 7.0. RESULTS: Among the 34,424 deliveries meeting inclusion criteria, 15,664 were during the day, 8495 were during the evening, and 10,265 were during the night. In univariate comparisons, there were no statistically significant differences in neonatal outcomes. For example, the rate of pH less than 7.0 was 0.7% during the day, 1.0% in the evening, and 0.6% at night (P = .12). Admissions to the NICU were 3.6% during the day, 3.7% in the evening, and 3.5% at night (P = .81). When we controlled for obstetric history, demographic factors, and labor characteristics, there were still no differences in rates of either neonatal morbidity or mortality by time of delivery. CONCLUSION: At our institution, we could not demonstrate any significant differences in neonatal morbidity or mortality by time of day among neonates delivered at term. These data can be used to counsel patients and families concerned about differences in time of delivery and potential impact on their infant's health. Future research should include time of delivery in relation to maternal and neonatal outcomes in various types of inpatient settings.

The association between time of birth and fetal injury resulting in death.

OBJECTIVE: In obstetrics, the care of patients in labor or with emergencies takes place day and night. Birth-related injury is among the worst of obstetric outcomes. This study sought to examine the relationship between time of birth and fetal injury resulting in death. STUDY DESIGN: The Birth-Related Neurologic Injury Compensation Association (NICA) is a Florida organization that pays for the care of infants >2500 g with birth-related brain or spinal cord injury resulting in permanent impairment. We conducted a case-control study using all deaths from the NICA database from 1989 to 2002. Data were collected on the antepartum, intrapartum, and postpartum care of the mother and fetus/child. Time of birth was identified for all cases and compared with a randomly selected control group of 1000 births in 1996 from Florida. RESULTS: Eighty deaths were identified in the NICA database of 447 total cases. Of the 80 cases, 36/80 (45%) were born from 11 pm to 8 am. Of the 999 controls (1 certificate sealed for adoption) 281 (28.1%) were born from 11 pm to 8 am. This yields an odds ratio of 2.09 (95% CI 1.29-3.40) for the association of nighttime birth with fetal injury resulting in death. CONCLUSION: Fetuses sustaining injuries resulting in death were more than twice as likely as controls to have been born from 11 pm to 8 am. Further studies are needed to determine the factors that affect this association and what changes might need to be made to optimize care regardless of time of day or night.

Are the SSRI antidepressants safe in pregnancy? Understanding the debate.

BACKGROUND: Rates of antidepressant use during pregnancy are rising worldwide. It is, therefore, essential to determine the effects of these medications in pregnancy and on the developing fetus. OBJECTIVE: To review the two main explanatory models for understanding the effects of antidepressant use during pregnancy and compare the evidence to support them. METHODS: Review, synthesis, and discussion of the available literature. RESULTS: The preponderance of the basic science, animal data, and human studies supports the view that the Harmful Chemical Model is the best explanatory framework for understanding the effects of the SSRI antidepressants during pregnancy. They do not appear to be helpful medications that produce better outcomes for moms and babies. They are not like using insulin in pregnant diabetics. Their profile fits more with a harmful chemical exposure. CONCLUSIONS: The totality of the scientific evidence convincingly suggests that the SSRI antidepressants are chemicals that do cause fetal harm and that the FDA should strongly consider changing the FDA Category from C to D for the entire class. This move would provide appropriate warning to the public while still allowing for use in selected cases.

Preterm birth and antidepressant medication use during pregnancy: a systematic review and meta-analysis.

INTRODUCTION: Preterm birth is a major contributor to neonatal morbidity and mortality and its rate has been increasing over the past two decades. Antidepressant medication use during pregnancy has also been rising, with rates up to 7.5% in the US. The objective was to systematically review the literature to determine the strength of the available evidence relating to a possible association between antidepressant use during pregnancy and preterm birth. METHODS: We conducted a computerized search in PUBMED, MEDLINE and PsycINFO through September 2012, supplemented with a manual search of reference lists, to identify original published research on preterm birth rates in women taking antidepressants during pregnancy. Data were independently extracted by two reviewers, and absolute and relative risks abstracted or calculated. Our a priori design was to group studies by level of confounding adjustment and by timing of antidepressant use during pregnancy; we used random-effects models to calculate summary measures of effect. RESULTS: Forty-one studies met inclusion criteria. Pooled adjusted odds ratios (95% CI) were 1.53 (1.40-1.66) for antidepressant use at any time and 1.96 (1.62-2.38) for 3rd trimester use. Controlling for a diagnosis of depression did not eliminate the effect. There was no increased risk [1.16 (0.92-1.45)] in studies that identified patients based on 1st trimester exposure. Sensitivity analyses demonstrated unmeasured confounding would have to be strong to account for the observed association. DISCUSSION: Published evidence is consistent with an increased risk of preterm birth in women taking antidepressants during the 2nd and 3rd trimesters, although the possibility of residual confounding cannot be completely ruled out.

Chorioamnionitis and sternoclavicular septic arthritis after drainage of Bartholin gland abscess.

BACKGROUND: Complications after drainage of Bartholin gland abscesses in pregnancy are rare. CASE: A 29-year-old primigravid at 35 weeks of gestation with dichorionic-diamniotic twins underwent Bartholin gland abscess drainage. Afterward, she reported shoulder pain and became febrile. Examination revealed maternal and fetal tachycardia with abdominal tenderness consistent with chorioamnionitis, and she underwent delivery. Blood cultures grew Escherichia coli, and antibiotics were begun. Her shoulder pain worsened, and examination demonstrated inflammation over the sternoclavicular joint. Fluid aspirate of this joint grew E coli. She experienced improvement after aspiration and was discharged home on antibiotics. CONCLUSION: Although rare, severe consequences can result from Bartholin gland abscesses in pregnant patients, including sepsis and septic arthritis. Close clinical follow-up should be considered in pregnant patients undergoing abscess drainage.