Precarity and pregnancy in Paris.

OBJECTIVE: Our purpose was to assess to what extent the absence of health insurance (Social Security) contributes to poor pregnancy outcome. STUDY DESIGN: A prospective, population-based study compared the perinatal outcome of women without Social Security (n=243) to a contemporaneous control group (n=243) and to a group of women (n=32) with Social Security but presenting another risk factor for precarity (a judicial child-mother separation sentence). RESULTS: Prenatal consultations were less frequent and initiated later for women without Social Security than for controls. There was no difference between these two groups concerning maternal morbidity (premature labour, hypertension, gestational diabetes, post-partum complications) or maternal mortality, no difference for the mode of delivery and the rate of low birth-weight, foetal death, and neonatal morbidity (hypoglycaemia, hypocalcemia, anaemia, jaundice, infection and transfer to intensive care unit). The rate of prematurity was not significantly higher in the group without Social Security compared to the control group (11.1% versus 6.2%, P=0.08). However, in the group with Social Security and a court sentence of child mother separation, the rate of fetal growth retardation, prematurity, home delivery, caesarean section, neonatal drug deprivation syndrome and transfer to an intensive care unit was significantly higher compared to the two other groups (P<0.01). CONCLUSION: In our study, absence of Social Security during pregnancy is not a major determinant of poor pregnancy outcome, whereas other factors of precarity seem to be more influential.

Two different regimens of preinduction ripening of the uterine cervix with prostaglandin E2: a randomized clinical study.

A randomized clinical study was designed to test the relative efficacy of preinduction cervical ripening with 0.25 mg prostaglandin E2 (PGE2), repeated if necessary (group 1) compared to a single maturation with 0.50 mg PGE2 (group 2). In group 1 (n = 42), the ripening process was repeated every day until spontaneous onset of labor occurred or induction with oxytocin was decided (for improved Bishop score above 5, or maternal or fetal distress). In group 2 (n = 42) the patients who had not labored 12 h after the maturation procedure had labor induced with oxytocin, irrespective of their cervical status. In group 1, 28 patients experienced repeated maturations (from 2 to 9). Thirty patients had an induction of labor with oxytocin in group 2 and only 12 in group 1 (P < 0.0001). There were four failures of induction of labor in group 2 and none in group 1 (P < 0.05). Three episodes of myometrial hyperstimulation requiring an emergency cesarean section for acute fetal distress occurred in group 2 and none in group 1. There were 13 cesarean sections in group 2 and eight in group 1. The outcome of pregnancy was otherwise similar in both groups. In order to avoid failure of induction of labor, pre-induction cervical ripening with 0.25 mg PGE2, repeated daily if necessary, is therefore recommended in high risk pregnancy unless a severe maternal or a fetal distress call for a prompt delivery irrespective of the cervical status.

Pharmacokinetics of salbutamol in the pregnant woman after subcutaneous administration with a portable pump.

OBJECTIVE: We sought to determine whether subcutaneous administration of salbutamol resulted in plasma levels comparable to those achieved after intravenous or oral administration. METHODS: Twenty-nine women with preterm labor received subcutaneous infusion of salbutamol through a portable pump. We used three different rates of continuous infusion: a low rate of 3.33 micrograms/minute (20 subjects), an intermediate rate of 6.66 micrograms/minute (four subjects), and a high rate of 9.99 micrograms/minute (five subjects). Plasma salbutamol concentrations were assayed by high-performance liquid chromatography after 48 hours of continuous infusion in the subcutaneous tissue and after bolus injections (184 micrograms in the low-rate group and 368 micrograms in the intermediate- and high-rate groups). RESULTS: Plasma salbutamol concentrations after 48 hours of subcutaneous infusion increased almost linearly with the rate of infusion: 6.29 +/- 1.58, 15.5 +/- 1.0, and 21.7 +/- 4.26 ng/mL in the low-, intermediate-, and high-rate groups, respectively (P less than .001 between the three groups). After bolus injection, maximum plasma concentrations were significantly different between the three groups (P less than .001) and from their respective baseline values (P less than .001): 8.33 +/- 1.9, 18.85 +/- 2.0, and 25.86 +/- 4.8 ng/mL in the low-, intermediate-, and high-rate groups, respectively. CONCLUSION: Subcutaneous tocolysis can provide plasma salbutamol levels similar to the levels obtained orally or intravenously.

Maturation of the uterine cervix by repeated intracervical instillation of prostaglandin E2.

An attempt was made to ripen the uterine cervix in 100 high-risk pregnancy patients (pregnancy between 34 to 41 weeks' gestation), with the use of intracervical instillations of 0.25 mg of prostaglandin E2 mixed with a tylose gel. The maturation process was repeated every 48 hours. Forty-nine patients were delivered of infants after the first maturation and 51 patients required between two and nine instillations. In patients requiring multiple instillations, the mean delay between the first procedure and delivery was 9 +/- 4 days (range, 2.4 to 16 days). Among the 59 nulliparous women, only 23 were delivered of infants after a single maturation and 36 required multiple maturations (p less than 0.02). When the group of patients who were delivered of infants after a single maturation process was compared with the group requiring multiple maturations, no difference could be seen with regard to age, term of pregnancy, or Bishop cervical score at the time of inclusion in the study. The myometrial activity and the onset labor induced by prostaglandin E2, were similar in both groups. Fetal heart rate decelerations occurred in 16.3% (8/49) of the patients with single maturations and in 17.6% (9/51) of the patients who required multiple maturations. The outcome of the pregnancy and the rate of cesarean sections (24% and 27%) were similar in both groups. No patients required cesarean sections because of failed induction of labor. Cervical ripening after repeated applications of 0.25 mg of prostaglandin E2 seems to be safe for the fetus, providing that the patient is closely supervised.

Relationship of fetal bradycardia to maternal administration of lidocaine in sheep.

The casual relationship between the use of lidocaine and fetal bradycardia and the effect of the drug on maternal and fetal hemodynamics were studied on 13 chronically instrumented pregnant sheep. Lidocaine was infused intravenously to the mother for 60 minutes during arterial lidocaine concentrations were maintained at 2 to 5 microgram per milliliter in the mother and at less than 2 microgram per milliliter in the fetus. A decrease in uterine blood flow and an increase in uterine vascular resistance and uterine activity occurred immediately following the administration of lidocaine to the ewe. These changes were followed by a transient fetal bradycardia in 12 out of 17 experiments, accompanied by a decrease in fetal PaO2 values. These phenomena were seen in the absence of such predisposing conditions as maternal hypotension and fetal acidosis. It would appear that the mechanism responsible for a transient fetal bradycardia following regional obstetric anesthesia, particularly paracervical block anesthesia, in the initially nonasphyxiated fetus may in part be related to a brief decrease in perfusion of intervillous spaces. The bradycardia can occur at low lidocaine concentrations in both the maternal and fetal blood in a range similar to that observed in clinical practice.