Does cesarean section decrease the incidence of major birth trauma?

OBJECTIVE: To determine whether the increase in frequency of cesarean section is associated with a decreased incidence of major birth trauma. STUDY DESIGN: A retrospective cohort study was performed evaluating all neonatal cases of major birth trauma from January 1989 to December 1994. Major birth trauma was defined as peripheral plexus or nerve injuries, fractures, or lacerations. The data were grouped into two mutually exclusive periods (January 1989 to December 1990 vs January 1991 to December 1994) in which a significant difference in the cesarean section rate was known. RESULTS: Of 17,957 deliveries during the period, 141 cases of birth trauma occurred. One hundred thirty-seven of the 141 medical records were available for review, and 116 were classified as having had major birth trauma and were included in the study. The overall incidence of major birth trauma was 6.5/1000 deliveries. During the two-year period (January 1989 to December 1990), 18.3% of deliveries were by cesarean section and the major birth trauma rate was 8.4/1000 deliveries. During the following 4 years, the cesarean section rate was 22.3% and the major birth trauma rate was 5.3/1000 deliveries. Significant differences in the birth trauma chi(2) = 6.12, p = 0.013) and cesarean section (chi(2) = 40.80, p < 0.001) rates were observed. Controlling for the mode of delivery lessened the association between time period and birth trauma incidence (chi(2)MH = 3.28, p = 0.07). A significant decrease in the occurrence of major birth trauma in neonates delivered by cesarean section in the later period was discovered (relative risk = 0.46, 95% confidence interval 0.22 to 0.97). This decrease appeared to be mediated by a decrease in total lacerations between the periods (chi(2) = 11.76, p < 0.001), because the rates of other types of major birth trauma did not differ in neonates delivered by cesarean section or the vaginal route. CONCLUSIONS: With a 4% increase in rate of cesarean section at our institution, a significant decrease in the occurrence of major birth trauma was observed. This finding cannot be explained by a decreased risk of neonatal trauma in patients delivering vaginally, but rather by a decreased risk of neonatal trauma at cesarean section during the latter period.

Chronic relapsing thrombotic thrombocytopenic purpura in pregnancy: a case report.

Thrombotic thrombocytopenic purpura (TTP) is a disorder of unknown etiology affecting the microcirculation of multiple organ systems. Plasma therapy has significantly reduced the mortality rate; thus, an increased incidence of recurrence has been noted. Since corticosteroids, antiplatelet agents, and splenectomy do not prevent recurrences, monthly plasma infusion have been instituted to decrease the risk of recurrence. However, in pregnancy, increase in frequency of plasma infusions to weekly or biweekly intervals has been associated with avoidance of placental infarcts. This is the first report of a successful pregnancy in which bimonthly prophylactic single plasma-exchange plasmapheresis was the treatment regimen with no obvious maternal-fetal morbidity.

Utilization of routine ophthalmologic examinations in pregnant diabetic patients.

OBJECTIVE: To determine the appropriate frequency of ophthalmologic examinations for retinopathy during gestation in diabetics categorized according to White's classification. STUDY DESIGN: Retrospective review was performed over the period of 1989-1994. Inclusion criterion for gestational diabetics was a late second or early third trimester ophthalmologic examination. Inclusion criteria for classes B-R were a first trimester and third trimester or early postpartum examinations. RESULTS: Of 300 charts reviewed, 100 met inclusion criteria. None of the gestational diabetics had retinopathy. Of class B patients (n = 21), 19% had retinopathy, with 11% progression in background retinopathy; none developed severe background or proliferative disease. In class C patients (n = 9), 56% had retinopathy, 33% with progression; none developed severe background or proliferative disease. Thirteen patients were class D; 92% had background retinopathy, in whom 45% showed progression, 31% with severe background retinopathy; none developed proliferative disease. Combined classes F, R, RF represented 13 patients; 100% demonstrated retinopathy; 46% progressed, 77% with proliferative disease; 15% required laser treatment during the pregnancy. CONCLUSIONS: Routine ophthalmologic examinations in gestational (class A) diabetics have little utility. Results suggest that the need for subsequent ophthalmologic examinations can be based upon White's classification and initial examination results. Classes B and C do not require every trimester eye examinations. Rigorous follow-up is warranted in classes D-R.