ST depression at caesarean section and the relation to oxytocin dose. A randomised controlled trial.

OBJECTIVE: To investigate whether there is a difference in occurrence of electrocardiogram changes suggestive of myocardial ischaemia between two different doses of oxytocin. DESIGN: Double-blind randomised controlled trial. SETTING: University hospital in Sweden. POPULATION: A total of 103 healthy women undergoing elective caesarean section under spinal anaesthesia. METHODS: The participants were randomised to 5 or 10 units of oxytocin, given as an intravenous bolus. A Holter monitor was used to record electrocardiograms and non invasive blood pressure and heart rate (HR) was monitored. A blood sample was obtained 12-hour postoperatively. MAIN OUTCOME MEASURES: Depression of the ST segment. SECONDARY OUTCOMES: symptoms, Troponon I levels, mean arterial pressure (MAP), HR and blood loss. RESULTS: There was a significant difference in occurrence of ST depressions associated with oxytocin administration, 4 (7.7%) with 5 and 11 (21.6%) with 10 units, P < 0.05. The absolute risk reduction was 13.9% (95% confidence interval, 0.5-27.3). Decrease of mean MAP from baseline to 2 minutes differed, being 9 mmHg in the 5 unit group and 17 mmHg in the 10 unit group (P < 0.01). The increase in mean HR did not differ. Troponin I levels were increased in four subjects (3.9%). There were no differences in occurrence of symptoms, Troponin I levels, or estimated blood loss. CONCLUSION: ST depressions were associated with oxytocin administration significantly more often in subjects receiving 10 units compared with 5 units. Interventions to prevent hypotension during caesarean section may reduce the occurrence of ST depressions on electrocardiograms.

Metabolic acidosis at birth and suboptimal care--illustration of the gap between knowledge and clinical practice.

OBJECTIVE: To evaluate the occurrence and nature of suboptimal intrapartum care in cases with metabolic acidosis in the newborn, and to estimate the degree to which this may be prevented. DESIGN: Case-control study. Clinical audit. Setting Delivery units at two university hospitals in Sweden. POPULATION: Out of 28 486 deliveries, 161 neonates > or =34 weeks of gestational age were born with metabolic acidosis. METHODS: Cases (n = 161): umbilical artery pH < 7.05 and base deficit > or =12 mmol/l. Controls (n = 322): pH > or = 7.05 and Apgar score > or =7 at 5 minutes. Obstetric characteristics and oxytocin administration were recorded. The last 2 hours of electronic fetal monitoring before delivery were evaluated blinded to outcome. Intrapartum management was analysed for suboptimal care by using predefined criteria. MAIN OUTCOME MEASURE: Suboptimal intrapartum care. RESULTS: Case and control comparisons displayed an occurrence of suboptimal care in 49.1% versus 13.0% (P < 0.001), oxytocin misuse in 46.6% versus 13.0% (P < 0.001), a failure to respond to a pathological cardiotocographic pattern in 19.9% versus 1.2% (P < 0.001) and suboptimal care related to vacuum deliveries in 3.1% versus 0.3% (P < 0.01) respectively. CONCLUSION: Metabolic acidosis at birth is often associated with suboptimal intrapartum care. The high rate of suboptimal care with regard to oxytocin use and fetal surveillance illustrate a gap between guidelines and clinical practice. Metabolic acidosis and related neonatal morbidity could potentially be prevented in 40-50% of cases. The adherence to guidelines must be checked.

Decreased maternal lipolysis in intrauterine growth restriction in the third trimester.

OBJECTIVE: Intrauterine growth restriction (IUGR) is a common complication of pregnancy. There are many possible aetiologic factors of maternal, placental and/or fetal origin. Often there is no known explanation. The aim of this study was to investigate whether a reduction in maternal energy substrate production could be one of the factors involved in IUGR. DESIGN: Measurement of maternal energy substrate production and glucoregulatory hormones in women with growth-restricted fetuses. SETTINGS: University Hospital, Uppsala, Sweden. POPULATION: Ten healthy pregnant women with IUGR were compared with eight recently reported healthy women with normal pregnancies. The women were studied at 35.4+/-1.6 weeks of gestation after an overnight fast. METHODS: Rates of glycerol and glucose production were analysed by gas chromatography/mass spectrometry following constant-rate infusion of [1,1,2,3,3-(2)H5]glycerol and [6,6-(2)H2]glucose. MAIN OUTCOME MEASURE: Third trimester glycerol and glucose production. RESULTS: Glycerol production, reflecting lipolysis, was lower in the women with IUGR than in those with normal pregnancies, 2.36+/-0.58 versus 3.06+/-0.66 micromol kg-1 minute-1 (P=0.033), whereas there was no difference in rate of glucose production (glucose production rate [GPR]), 12.1+/-1.5 versus 13.2+/-1.5 micromol kg-1 minute-1 (P=0.23). Plasma glycerol levels were increased in the women with IUGR (P=0.008). CONCLUSIONS: Lipolysis is lower in pregnancies complicated by IUGR as compared with normal pregnancies. Increased lipolysis during pregnancy provides substrate for maternal energy metabolism, which spares glucose for the fetus. A reduced maternal production of energy substrate could be one of several factors underlying IUGR. A lack of relationship between insulin levels and either lipolysis or GPR suggests defective regulation of energy substrate production in this group of pregnant women.

Hypertension and factors associated with metabolic syndrome at follow-up at 15 years in women with hypertensive disease during first pregnancy.

OBJECTIVES: To study the possibility of identifiable factors at or close to pregnancy that could predict hypertension later in life. To evaluate if women with hypertensive disease in their first pregnancy and who later develop hypertension also have characteristics of the metabolic syndrome. METHODS: Case control study of a cohort of women with hypertension diagnosed in first pregnancy (n = 46) and controls without hypertension in pregnancy (n = 47), studied 15 years after the index pregnancy. Blood pressure, antihypertensive drug treatment, body parameters, blood glucose, serum insulin, and serum lipids were analyzed. RESULTS: In the study group, 43% had hypertension compared to 4% in the control group. Among the women in the study group with more than one pregnancy, there was a significantly higher prevalence of hypertension if pregnancy-induced hypertension was repeated in a later pregnancy. There were also significantly higher waist/hip ratios and fasting plasma levels of insulin in the study group. CONCLUSION: Hypertension in pregnancy is a strong predictor of hypertension later in life. Other factors related to hypertension and present at pregnancy are not useful in selecting a high-risk group. In a proportion of cases, the metabolic syndrome might be related to the hypertensive disease in pregnancy.

Perinatal mortality and route of delivery in term breech presentations.

OBJECTIVE: To compare intrapartum related infant mortality in term (> 34 weeks) breech presentations in relation to vaginal delivery or delivery by caesarean section. DESIGN: Register based nationwide study. SETTING: Sweden from 1991 to 1992. PARTICIPANTS: 6542 singleton fetuses born in the breech presentation. MAIN OUTCOME MEASURES: Intrapartum and early neonatal deaths, stillbirths and congenital malformations, low Apgar score < 7 at 5 min, mode of delivery. RESULTS: After exclusion of antepartum stillbirths and congenital malformation, the intrapartum and early neonatal mortality rate was 2/2248 (0.09%) in the group delivered vaginally and 2/4029 (0.05%) in the group delivered by caesarean section. The relative risk was 1.81 (95% CI 0.26-12.84). Thus the difference was not statistically significant. This result was further supported after reviewing individual cases. CONCLUSIONS: The intrapartum related mortality in the group delivered vaginally was low and the result could not verify an increased mortality in term breech presentations delivered vaginally compared with those delivered by caesarean section.