How does uterine contractile activity affect the success of trial of labour after caesarean section, and the risk of uterine rupture? An exploratory, blinded analysis of a cohort from a randomised controlled trial.

OBJECTIVE: To investigate the impact of uterine contractile activity on the outcome of trial of labour after caesarean section (TOLAC). DESIGN: Secondary, blinded analyses of a prospective TOLAC cohort. SETTING: Two labour wards, one in a university tertiary hospital and the other in a central hospital. POPULATION: A total of 194 TOLAC parturients with intrauterine tocodynamometry during labour. METHODS: Analysis of intrauterine pressure, frequency of contractions and baseline tonus of uterine muscle in 30-minute periods for 4 hours before birth. MAIN OUTCOME MEASURES: Primary outcome: uterine contractile activity during TOLAC. Secondary aims: contributors associated with failed TOLAC and uterine rupture. RESULTS: TOLAC succeeded in 74% of cases. Uterine contractile activity, expressed as intrauterine pressure, was significantly higher in successful TOLAC compared with failed TOLAC (210 versus 170 Montevideo units). The statistically significant risk factors of failed TOLAC, after multivariate regression analysis, were prolonged gestational age, reduced cervical dilatation at admission and lower mean intrauterine pressure. In cases of uterine rupture, contractile activity did not differ from that in failed TOLAC. Cervical ripening with a Foley catheter appeared to be a risk factor for uterine rupture, as well as cervical dilatation <3 cm at admission. The incidence of total uterine rupture was 2.6% (n = 5). CONCLUSIONS: Women with successful vaginal birth had higher uterine contractile activity than those experiencing failed TOLAC or uterine rupture despite similar use of oxytocin. Induction of labour with a Foley catheter turned out to be a risk factor for uterine rupture during TOLAC among parturients with no previous vaginal delivery. TWEETABLE ABSTRACT: During VBAC the response to oxytocin, assessed as intrauterine pressure, is greater and adequate, in contrast to failed TOLAC.

Maternal and neonatal characteristics in obstetric intensive care unit admissions.

BACKGROUND: The objective of this study was to evaluate the course of pregnancy and delivery of obstetric patients admitted for intensive care, and determine the health status of their infants. METHODS: This was a retrospective register-based study. Four university hospitals in Finland participated. Obstetric patients admitted to the intensive care unit in any trimester of pregnancy, during delivery or up to 42 days post partum were identified from clinical information systems over a five-year study period. Parturient and infant data were collected from the Medical Birth Register. RESULTS: During the study period (2007-2011), 283 obstetric patients were identified from the clinical information system. The most common reason for admission was hypertensive complications (58%), followed by obstetric haemorrhage (25.1%). Advanced maternal age, nulliparity and multiple pregnancies were associated with obstetric intensive care unit admissions. Of patients admitted to intensive care, 68.9% delivered by unscheduled caesarean section. Nearly 60% of neonates were born preterm, 56.1% needed treatment in a neonatal intensive care unit or an observation unit and 4.6% died within one week. CONCLUSION: Advanced maternal age, nulliparity and multiple pregnancy were more common among intensive care unit-admitted women than in the general obstetric population. The main causes for admission were hypertensive complications and obstetric haemorrhage. Compared with the general obstetric population, neonates of intensive care unit-admitted mothers were eight times more likely to require treatment on a neonatal ward and their risk of neonatal death was also eight times greater.

Evaluation of a rapid strip test for insulin-like growth factor binding protein-1 in the diagnosis of ruptured fetal membranes.

We evaluated the clinical usefulness of a new bedside test (PROM TEST) for insulin-like growth factor binding protein-1 (IGFBP-1) in the detection of ruptured fetal membranes (ROM). Cervicovaginal secretion was sampled between 15 and 37 weeks of gestation from asymptomatic women with apparently intact membranes and from women with clinically confirmed ROM, as well as from symptomatic women with suspected ROM based on history. IGFBP-1 in samples was detected with a dipstick based on immunochromatography. The test result was positive in 100% of cases with unequivocal ROM and in 5.3% of cases with apparently intact membranes. Furthermore, the PROM TEST was positive in 64 of 181 patients evaluated for suspected ROM based on history, but in whom the diagnosis could not be clinically confirmed at the initial evaluation. Fifty of the 64 women (78.1%) were delivered prematurely (< 37 weeks). Five of the 117 PROM-negative patients had elective cesarean section for reasons unrelated to ROM before 37 weeks and 10 of the remaining 112 patients (8.9%) had preterm delivery. Women with equivocal ROM and a positive test result had a 6.9-fold increased relative risk (95% confidence interval 4.2-11.4) of preterm delivery compared with women who had a negative result at the time of evaluation. Multiple logistic regression including PROM TEST result, contractions, vaginal bleeding and cervical changes indicated that a positive PROM TEST result was an independent predictor of preterm delivery (P = 0.0001). In summary, a positive PROM TEST result identifies ROM with high sensitivity and a negative result effectively excludes those with intact membranes. In patients with suspected but clinically unconfirmed ROM, the positive test result is associated with increased risk of preterm delivery, suggesting that microruptures of fetal membranes can also be detected by the PROM TEST.

The total peroxyl radical-trapping ability of plasma and cerebrospinal fluid in normal and preeclamptic parturients.

Plasma and cerebrospinal fluid total peroxyl radical-trapping antioxidative parameter (TRAP) and the main antioxidant components of TRAP (vitamin E, ascorbic acid, uric acid, protein sulfhydryl groups, and the unidentified antioxidant proportion) were analyzed in 11 preeclamptic parturients, 9 healthy parturients with an uncomplicated pregnancy, and 10 healthy nonpregnant women. In addition, the possible effects of ongoing labor were studied in 10 healthy parturients. The samples of plasma and cerebrospinal fluid (CSF) were collected at cesarean section (pregnant women) or minor surgical procedure (nonpregnant women). Normal pregnancy or ongoing labor induced no significant changes in total TRAP, as compared with nonpregnant women, but significant changes in the percentage contributions of individual antioxidants were noted in plasma and CSF. In preeclampsia, a significant increase in TRAP was noted in both plasma and CSF. This increase was mainly due to an increased proportion of uric acid and unidentified antioxidants in plasma samples, and an increased proportion of unidentified antioxidants in CSF. The concentration of CSF ascorbic acid was decreased in preeclampsia, and a negative correlation between CSF ascorbic acid and blood pressure was observed.

Findings on lipid peroxidation and antioxidant function in hypertensive complications of pregnancy.

OBJECTIVE: To assess lipid peroxidation and antioxidant function in hypertensive complications of pregnancy. DESIGN: Cross sectional study comparing pre-eclamptic and control patients. SETTING: Tampere University Hospital, Finland. SUBJECTS: Twenty healthy women with normal, uncomplicated pregnancy; 23 women with severe pre-eclampsia; 20 women with mild pre-eclampsia; and 13 women with pregnancy-induced hypertension. MAIN OUTCOME MEASURES: Conjugated dienes; thiobarbituric acid--reactive material or malondialdehyde (MDA); fluorescent chromolipids (FCL); glutathione peroxidase (GSHPx); selenium; uric acid; and vitamin E. RESULTS: Lipid peroxidation assessed by the appearance of conjugated dienes and malondialdehyde was significantly increased in the hypertensive patients as compared with control patients. Lipid peroxidation products also showed high correlation to the level of blood pressure, but failed to show significant relation to the outcome of the fetus. The activities of erythrocyte and plasma glutathione peroxidase were increased in severe pre-eclampsia, and high levels of plasma or platelet glutathione peroxidase were found to have some association with fetal growth retardation or asphyxia. CONCLUSIONS: Our findings give support to those few studies considering lipid peroxidation as an important factor in the pathogenesis of pre-eclampsia. The rise in antioxidants is probably of compensatory nature responding to the increased peroxide load in pre-eclampsia and may reflect the severity of the disease.