Misoprostol induction of labor among women with a history of cesarean delivery.

OBJECTIVE: Several reports have appeared of uterine rupture among women with a history of cesarean delivery who received misoprostol for induction of labor. A recent review suggested a uterine rupture rate of almost 6%, but the experience at our institution did not seem to reflect this high complication rate. This study was undertaken to compare complications of labor induction with misoprostol between women with a history of cesarean delivery and women without uterine scarring. STUDY DESIGN: A computerized database was used to select women with a viable fetus who underwent induction of labor with misoprostol during the period from January 1996 through December 1998. Patients were given 50 microg misoprostol every 4 hours. Women with a history of cesarean delivery were retrospectively compared with those without uterine scarring. RESULTS: A total of 425 women were given misoprostol for induction of labor: 48 had a history of cesarean delivery and 377 did not. Women with a history of cesarean delivery were more likely to be delivered abdominally (56% vs 28%; P <.04). Among women with a history of cesarean delivery, women who had a history of vaginal birth after cesarean were more likely to be delivered vaginally (92% vs 42%; P =.003). There was no difference in the overall rate of complications (2% with scarring vs 3% without scarring). There were no uterine ruptures. However, the previous cesarean group was more likely than the unscarred group to have blood loss >500 mL (38% vs 22%; P <.03). Although the incidences of fetal distress were similar, neonates born to women in the previous cesarean group were more likely to have an Apgar score <7 at 5 minutes (13% vs 5%; P <.04). CONCLUSION: Misoprostol induction of labor in women with a history of cesarean resulted in a higher rate of cesarean delivery than was seen among women without uterine scarring but was not associated with a higher incidence of complications. There were no uterine ruptures in either group.

Sickle cell disease in pregnancy: twenty years of experience at Grady Memorial Hospital, Atlanta, Georgia.

OBJECTIVE: We compared pregnancy outcomes among women with sickle cell disease with outcomes for African American women without the disease. STUDY DESIGN: We selected 127 deliveries in women with sickle cell disease (hemoglobin SS or hemoglobin SC) that occurred between 1980 and 1999. A control group of 129 deliveries by African American women with normal hemoglobin (hemoglobin AA) was also selected. Evaluated pregnancy outcomes included low birth weight, prematurity, intrauterine growth restriction, antepartum hospital admission, preterm labor or preterm premature rupture of membranes, postpartum infection, preeclampsia, pyelonephritis, intrauterine fetal death, perinatal mortality, and maternal mortality. RESULTS: Compared with deliveries among women with hemoglobin AA, deliveries among women with hemoglobin SS or hemoglobin SC were at increased risk for intrauterine growth restriction, antepartum hospital admission, and postpartum infection. In addition, deliveries among women with Hb SS were more likely to be complicated by low birth weight, prematurity, and preterm labor or preterm premature rupture of membranes when compared with deliveries among women with hemoglobin AA. There were no significant differences among the groups (hemoglobin SS, hemoglobin SC, and hemoglobin AA) in terms of perinatal deaths; there were no maternal deaths in the study population. CONCLUSION: Those caring for women with sickle cell disease should be aware that they are at increased risk for pregnancy complications, although overall pregnancy outcome is favorable.

Transvaginal ultrasonographic cervical measurement as a predictor of successful labor induction.

OBJECTIVE: Our purpose was to compare transvaginal cervical measurement and the Bishop score as indicators of duration of labor and successful induction of labor at term. STUDY DESIGN: This prospective observational study recruited women with singleton gestations scheduled for induction of labor at > or =37 weeks. Transvaginal ultrasonographic measurement of cervical length was performed and the Bishop score was determined, each by operators masked to the other measurement. Data were collected on parity, gestational age, mode of delivery, induction agent, induction-to-delivery interval, Bishop score, and cervical length measurement. RESULTS: A total of 77 women were analyzed. Vaginal delivery occurred in 69%. Both Bishop score and cervical length showed linear correlation with duration of labor (R(2) = 0.43, P <. 001; R(2) = 0.48, P <.001; respectively). Women with cervical length <3.0 cm had shorter labors (P <.001) and were more likely to be delivered vaginally (P <.001). Women with a Bishop score >4 also had shorter labors and were more likely to be delivered vaginally, with similar P values. A logistic regression model identified cervical length and parity as the only independent predictors of vaginal delivery. CONCLUSIONS: Both ultrasonographically measured cervical length and Bishop score predict duration of labor and likelihood of vaginal delivery. However, only cervical length and parity were independent predictors of mode of delivery.

Postoperative morbidity in the morbidly obese parturient woman: supraumbilical and low transverse abdominal approaches.

OBJECTIVE: Our purpose was to determine the differences in postoperative morbidity in obese women who had a supraumbilical or a Pfannenstiel incision at cesarean delivery. STUDY DESIGN: A case-control retrospective review was conducted of all patients who were at >150% ideal body weight when undergoing cesarean delivery between 1989 and 1995 by means of either a supraumbilical or a Pfannenstiel incision. Patients were excluded if medical records were unavailable. A total of 15 women who had a supraumbilical incision and 54 who had a low transverse incision were included in the analysis. Antenatal complications were examined, as were age, weight, and training level of the surgeon. Postoperative complications were then compared. RESULTS: The groups were similar in age and antepartum complications. However, mean weight and percentage of ideal body weight in the supraumbilical group were both higher (P <.00001 and P <.0001, respectively), with the supraumbilical group 83 lb heavier on average. No significant differences were seen in any postoperative complication. CONCLUSION: Postoperative morbidity in morbidly obese women undergoing cesarean delivery does not differ between a supraumbilical approach and the low transverse abdominal incision.

Umbilical cord vascular cell adhesion molecule concentration following labor.

OBJECTIVE: This study was designed to determine if VCAM concentrations are increased in serum from neonates delivered vaginally compared to those delivered by cesarean in the absence of labor at term. METHODS: Serum was collected from umbilical cords immediately after delivery of term uncomplicated pregnancies either prior to onset of labor by scheduled cesarean or following labor. VCAM concentration was determined by commercial ELISA. RESULTS: Mean VCAM concentration was significantly higher in the laboring (1,106.2 +/- 279 ng/ml) than the nonlaboring group (906.9 +/- 217 ng/ml, P = 0.01). CONCLUSIONS: Increases in neonatal serum VCAM concentrations may represent a response to enhanced lipid peroxidation and oxidative stress during labor as well as a component of the normal fetal immune response.

Maternal serum vascular cell adhesion molecule concentration during pregnancy.

OBJECTIVE: Vascular cell adhesion molecule (VCAM-1), a transmembrane glycoprotein known primarily as a mediator of white blood cell adhesion and extravasation from the intravascular space, is synthesized by vascular endothelial cells, macrophages, epithelial cells, and placental trophoblasts. Vascular cell adhesion molecule has also been identified as an angiogenic agent, and it appears to play an important role in early placental development. The expression of VCAM-1 is stimulated by cytokines, such as tumor necrosis factor, interleukin-1, and interferon gamma, as well as by oxidatively modified lipoproteins. Our objective was to determine the concentration of soluble VCAM-1 normally present throughout gestation. METHODS: Maternal serum soluble VCAM-1 concentrations were measured by enzyme-linked immunosorbent assay in healthy pregnant women. RESULTS: In 78 patients, soluble VCAM concentrations ranged from 128.02 to 728.6 ng/mL between 5 and 39 weeks of gestation. Maternal soluble VCAM concentrations showed a negative correlation with gestational age. The mean concentration (+/-standard deviation) was significantly higher before 20 weeks (406.76 +/- 134.41 ng/mL) than at or after 20 weeks (346.04 +/- 111.20 ng/mL). CONCLUSION: These findings are consistent with the hypothesis that VCAM-1 may play an important role in the normal process of placentation during early pregnancy.

Growth retardation in fetuses with gastroschisis.

This study was designed to determine the prevalence of intrauterine growth restriction in neonates with gastroschisis and to evaluate the accuracy of the ultrasonographic diagnosis of intrauterine growth restriction. Birth weight and gestational age were determined for 46 infants diagnosed prenatally as having gastroschisis. Biometric data were analysed for the 30 pregnancies in which an examination was conducted within 1 week of delivery. Fetal growth parameters were compared with norms for gestational age. The prevalence of intrauterine growth restriction in the entire study group was 24% with a mean birth weight of 2401 +/- 508 g. Ultrasonographic estimated fetal weight was significantly less than birth weight (mean, 2079 +/- 508 g versus 2331 +/- 512 g, respectively; P < 0.0001). Intrauterine growth restriction was predicted in 43% of infants but was present in only 23%. The percentage difference between measured abdominal circumference and gestational age norm was significantly more than for biparietal diameter and for femur length (P < 0.001). Of the three biometric measures, only the difference between measured abdominal circumference and gestational age norms and the difference between estimated fetal weight and birth weight showed a significant correlation. Both abdominal circumference and femur length correlated with the difference between estimated fetal weight and birth weight. We conclude that the prevalence of intrauterine growth restriction is increased in infants with gastroschisis but is overestimated with prenatal ultrasonography, primarily because of smaller than average abdominal circumference measurements.

Prenatal diagnosis of fetal disseminated intravascular coagulation associated with umbilical cord arteriovenous malformation.

BACKGROUND: Congenital disseminated intravascular coagulation (DIC) has been reported in a variety of clinical settings, but to our knowledge, it has never been documented before birth. We describe prenatal identification of an umbilical cord vascular tumor and echogenic foci in the fetal liver leading to the diagnosis of fetal DIC by funipuncture. CASE: A large vascular tumor of the umbilical cord was identified using prenatal sonography. At 31 weeks' gestation, echogenic areas, which were thought to represent infarcts or thrombi, were seen in the liver. When funipuncture revealed florid fetal DIC, delivery was accomplished by cesarean to prevent intracranial bleeding. Pathologic examination of the umbilical cord tumor showed it to be a large arteriovenous malformation. CONCLUSION: Arteriovenous malformations may cause fetal coagulopathy. This case illustrates that funipuncture may be used to diagnose this condition and that timely cesarean delivery may contribute to a favorable outcome.

Granulocyte colony-stimulating factor in amniotic fluid.

OBJECTIVE: The purpose of this study was to determine if granulocyte colony-stimulating factor (G-CSF) is normally present in amniotic fluid and then to determine if amniotic-fluid G-CSF levels are affected by labor and intrauterine infection. METHODS: Amniotic fluid was collected from 35 patients in 4 groups: no labor, early labor, late labor, and labor plus chorioamnionitis. G-CSF levels were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: The mean amniotic-fluid G-CSF concentrations prior to labor were lower than during labor (0.49 +/- 0.25 ng/ml for prior to labor vs. 1.83 +/- 1.0 ng/ml for labor, P < 0.001). With chorioamnionitis, the mean levels were elevated compared with normal labor (25.0 +/- 4.8 ng/ml for chorioamnionitis vs. 1.83 +/- 1.0 ng/ml for normal labor, P < 0.0001). In early and late labor, G-CSF was higher than prior to labor (0.49 +/- 0.25 ng/ml for no labor vs. 1.48 +/- 1.0 ng/ml for early labor, P < 0.02, vs. 2.2 +/- 0.8 ng/ml for late labor, P < 0.0005). The mean concentrations in early and late labor were not different. CONCLUSIONS: G-CSF is present in amniotic fluid and increased with labor. When labor is complicated by chorioamnionitis, G-CSF is significantly elevated.

Cytomegalovirus infection in pregnancy.

CMV is the most common cause of intrauterine infection in this country, affecting approximately 1% of newborns. As such, CMV infection is a leading cause of deafness and an important contributor to learning disabilities. The virus is transmitted through close contact with infected secretions as well as transplacentally, through sexual contact, and through blood transfusion and organ transplantation. CMV has a high prevalence in the population; antibody to the virus can be detected in 50% to 85% of individuals. Like herpes simplex, the virus can be reactivated and cause recurrent infection. Congenital disease occurs in about 30% to 40% of women with primary infection. Ten percent of infants with congenital infection will have clinical disease at birth. Of these, as many as 30% die. Ninety percent of survivors have sequelae such has deafness, mental retardation, chorioretinitis, and motor deficits. The other 90% of infants with congenital infection are asymptomatic at birth, but 5% to 17% develop long-term sequelae. Congenital disease also occurs with recurrent maternal infection in about 0.2% to 1% of immune women. Congenital infection due to recurrent disease is far less severe, and less than 10% of affected infants have long-term sequelae (Fig 3). The diagnosis of congenital infection can be established using a combination of ultrasound, amniocentesis, and cordocentesis. Viral culture of neonatal urine can confirm the diagnosis after birth. Routine screening of the pregnant population is not currently recommended because present laboratory methods limit the ability to differentiate primary from recurrent infection. Preventive efforts at this time must focus on good hygiene, limited intimate contact with infected children, and responsible sexual practices.

The experience with vaginal birth after cesarean delivery in a small rural community practice.

OBJECTIVE: The purpose of this study was to determine if the success and safety of vaginal birth after cesarean delivery in a small, isolated, rural hospital compare with those seen in larger centers. STUDY DESIGN: As part of a continuing study, the prenatal and hospital records of all patients with previous cesarean delivered by the Rural Health Group between October 1988 and January 1991 were reviewed. Patients were allowed a trial of labor with one or more previous cesarean sections, unknown scar, and breech presentation but not for other malpresentation or a vertical scar. RESULTS: A total of 67 patients were studied; 76.1% of these had a trial of labor, and 60.8% of them were delivered vaginally, whereas 39.2% underwent repeat cesarean delivery. Of the 67 patients 11.9% were not candidates for vaginal birth after cesarean delivery, and the same percentage refused. Forty-nine percent received oxytocin; of these, 56% were delivered vaginally. Overall, maternal complications were similar between the groups. Two uterine ruptures occurred; neither was associated with labor. The major maternal complications occurred in the vaginal birth after cesarean delivery group, but all were associated with antepartum conditions and not related to labor and delivery. There were no maternal deaths. The only neonatal death resulted from a congenital anomaly. CONCLUSION: We concluded that vaginal birth after cesarean delivery can be performed safely in an isolated small community hospital with success rates similar to those of larger centers and with no increased maternal or neonatal morbidity or mortality.

Effects of sheep digoxin-specific antibodies and their Fab fragments on digoxin pharmacokinetics in dogs.

Intact sheep antidigoxin antibodies and their Fab fragments have both been found to exert profound effects on digoxin pharmacokinetics in [3H] digoxin-treated dogs. Both classes of molecule remove digoxin from the extravascular space and sequester it in the circulation in protein-bound form, a form in which the digoxin is presumably inactive. These two classes of molecule differ, however, in that the intact antibody molecules interfere with digoxin excretion, thereby promoting the retention of the glycoside; this retained digoxin is eventually released in free, active form when the administered antibody is metabolically degraded. In contrast, urinary excretion of digoxin continues in Fab-treated dogs, with significant quantities of digoxin being excreted promptly in the urine in complex with Fab fragments. These differences in urinary excretion, together with the probable decreased immunogenicity of sheep antidigoxin Fab fragments, suggest that such fragments possess potential advantages over intact antibody molecules for use in the therapy of life-threatening digoxin intoxication in man.

Antigenic differences in (Na+, K+)-ATPase preparations isolated from various organs and species.

Antisera to purified (Na+, K+)-ATPase raised in rabbits and in sheep were purified by an absorption procedure employing purified canine kidney (Na+, K+)-ATPase. The antibodies were fractionated into two components, one which inhibited catalytic activity, and a second which inhibited ouabain binding. Under certain conditions, the fraction that inhibited ouabain binding also inhibited catalytic activity, and the effectiveness of both was dependent to some extent on the ligands present in the incubation medium. Thus, both antibody fractions appeared to detect conformations of the enzyme that depended upon ligand-induced perturbations. When the antibody raised against catalytic activity was incubated with erythrocyte membrane fragments, an inhibition of the (Na+, K+)-ATPase occurred, but only minimal or no effect on potassium influx or on digoxin-induced inhibition of potassium flux in intact erythrocytes was noted. In a similar experiment, however, the antibody against ouabain binding significantly inhibited potassium influx, suggesting specificity in terms of the macromolecular surfaces of the pump which were exposed to the external medium. We concluded that there may be organ and species differences among (Na+, K+)-ATPase preparations. Antibodies prepared in rabbits and sheep were fractionated by absorption to dog brain enzyme. Both the antibody fraction which bound to the brain enzyme and that which did not bind inhibited the dog kidney (Na+, K+)-ATPase, but only the former inhibited dog brain (Na+, K+)-ATPase. When the two fractions were recombined, inhibition was restored to the extent of the unfractionated antibody.