Indications for caesarean sections at ≥34 weeks among nulliparous women and differential composite maternal and neonatal morbidity.

OBJECTIVE: To compare composite maternal and neonatal morbidities (CMM, CNM) among nulliparous women with primary indications for caesarean section (CS) as acute clinical emergency (group I; ACE), non-reassuring fetal heart rate (group II) and arrest disorder (group III). DESIGN: A multicentre prospective study. SETTING: Nineteen academic centres in the USA, with deliveries in 1999-2002. POPULATION: Nulliparous women (n = 9829) that had CS. METHODS: Nulliparous women undergoing CS for three categories of indications were compared using logistic regression model, adjusted for five variables. MAIN OUTCOME MEASURES: CMM was defined as the presence of any of the following: intrapartum or postpartum transfusion, uterine rupture, hysterectomy, cystotomy, ureteral or bowel injury or death; CNM was defined as the presence of any of the following: umbilical arterial pH <7.00, neonatal seizure, cardiac, hepatic, renal dysfunction, hypoxic ischaemic encephalopathy or neonatal death. RESULTS: The primary reasons for CS were ACE in 1% (group I, n = 114) non-reassuring FHR in 29% (group II; n = 2822) and failed induction/dystocia in the remaining 70% (group III; n = 6893). The overall risks of CMM and CNM were 2.5% (95% confidence intervals, CI, 2.2-2.8%) and 1.9% (95% CI 1.7-2.2), respectively. The risk of CMM was higher in group I than in group II (RR 4.1, 95% CI 3.1, 5.3), and group III (RR 3.2, 95% CI 2.7, 3.7). The risk of CNM was also higher in group I than in group II (RR 2.8, 95% CI 2.3, 3.4) and group III (RR 14.1, 95% CI 10.7, 18.7). CONCLUSIONS: Nulliparous women who have acute clinically emergent caesarean sections are at the highest risks of both composite maternal and neonatal morbidity and mortality.

Antenatal assessment for the detection of fetal asphyxia. An evidence-based approach using indication-specific testing.

One of the most important advances in perinatal health care is the use of antepartum fetal testing. Antepartum fetal testing methods may include inexpensive tests such as fetal kick counts or tests that can be quite expensive such as non-stress tests, fetal biophysical profiles, and Doppler assessments as well as invasive tests such as amniocentesis or cordocentesis. Clinical experience, combined with recent literature, suggest that there is no ideal test for all high-risk fetuses and that some antepartum fetal tests may be more appropriate than others, depending on the underlying pathophysiology or the indication for testing. Because many different pathophysiological processes lead to fetal acidemia and in-utero death, indication-specific testing may be not only logical, but also cost-effective. In this article, specific guidelines of antepartum fetal testing are presented. These indication-specific guidelines are based on the underlying pathophysiological processes that place the fetus at risk and also on the need to use the fewest number of tests without compromising safety.

Glycohemoglobin determinations in normal pregnancy and in insulin-dependent diabetics.

Minor components of adult hemoglobin (A1a,b, and c) are known to increase in the presence of sustained elevations of maternal blood glucose. This study demonstrates the correlation between glycosylated hemoglobin components and the usual shorter term indices of diabetic control. In addition, a correlation was noted between glycosylated hemoglobin values and birth weight and placental weight. Glycohemoglobin values serve as an accurate index of long-term control of blood sugar and are helpful in assessing the efficacy of the treatment plan.

Relationship among placenta previa, fetal growth restriction, and preterm delivery: a population-based study.

OBJECTIVE: To examine the independent contributions of prematurity and fetal growth restriction to low birth weight among women with placenta previa. METHODS: A population-based, retrospective cohort study of singleton live births in New Jersey (1989-93) was performed. Mother-infant pairs (n = 544,734) were identified from linked birth certificate and maternal and infant hospital discharge summary data. Women diagnosed with previa were included only if they were delivered by cesarean. Fetal growth, defined as gestational age-specific observed-to-expected mean birth weight, and preterm delivery (before 37 completed weeks) were examined in relation to previa. Severe and moderate categories of fetal smallness and large for gestational age were defined as observed-to-expected birth weight ratios below 0.75, 0.75-0.85, and over 1.15, respectively, all of which were compared with appropriately grown infants (observed-to-expected birth weight ratio 0.86-1.15). RESULTS: Placenta previa was recorded in 5.0 per 1000 pregnancies (n = 2744). After controlling for maternal age, education, parity, smoking, alcohol and illicit drug use, adequacy of prenatal care, maternal race, as well as obstetric complications, previa was associated with severe (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.25, 1.50) and moderate fetal smallness (OR 1.24, 95% CI 1.17, 1.32) births. Preterm delivery was also more common among women with previa. Adjusted OR of delivery between 20-23 weeks was 1.81 (95% CI 1.24, 2.63), and 2.90 (95% CI 2.46, 3.42) for delivery between 24-27 weeks. OR for delivery by each week between 28 and 36 weeks ranged between 2.7 and 4.0. Approximately 12% of preterm delivery and 3.7% of growth restriction were attributable to placenta previa. CONCLUSION: The association between low birth weight and placenta previa is chiefly due to preterm delivery and to a lesser extent with fetal growth restriction. The risk of fetal smallness is increased slightly among women with previa, but this association may be of little clinical significance.

Congenital hydrocephalus: a review and protocol for perinatal management.

A review of the literature on congenital hydrocephalus was used to develop a protocol for management. Specific emphasis is given to early diagnosis, evaluation of associated anomalies, and prognosis based on etiology.

Incidence of placental abruption in relation to cigarette smoking and hypertensive disorders during pregnancy: a meta-analysis of observational studies.

OBJECTIVE: To systematically review the literature and summarize the relationship between cigarette smoking and placental abruption, and to evaluate the joint influences of smoking and hypertensive disorders (chronic hypertension and preeclampsia) on the subsequent development of abruption. DATA SOURCES: We reviewed studies identified through a MEDLINE literature search between 1966 and 1997 and through studies cited in the references of published reports. METHODS OF STUDY SELECTION: A total of 13 observational (seven case-control and six cohort) studies were identified which included a total of 1,358,083 pregnancies. We excluded case reports on placental abruption, and restricted the literature search to studies published in English. A meta-analysis was performed by computing pooled odds ratios based on random-effects models describing the association between placental abruption, smoking, and hypertensive disorders. Potential sources of heterogeneity among these studies were explored in detail. TABULATION, INTEGRATION, AND RESULTS: The overall incidence of placental abruption was 0.64% (8724 of 1,358,623). Smoking was associated with a 90% increase in the risk of placental abruption (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.8, 2.0). This pattern was consistent by study design (case-control compared with cohort studies) and smoking prevalence (low compared with high prevalence, defined as less than 30% compared with 30% or more, respectively). However, the association was significantly (p < .001) stronger among the seven studies conducted outside the United States (OR 2.1, 95% CI 2.0, 2.2), compared with the six studies conducted in the United States (OR 1.6, 95% CI 1.5, 1.8). Pooled population attributable risk percentage for each stratum ranged between 15% and 25%, implying that 15-25% of placental abruption episodes are attributable to cigarette smoking. Data on the dose-response relationship between number of cigarettes smoked per day and the risk of abruption indicate that the OR increased with increasing number of cigarettes smoked. Furthermore, a meta-analysis of the joint effects of smoking and hypertension during pregnancy on the development of abruption identified two published studies, including 102,609 pregnancies. In the presence of smoking, the risk of abruption was further increased due to chronic hypertension, mild or severe preeclampsia, or chronic hypertension with superimposed preeclampsia. CONCLUSION: Our meta-analyses showed an increased risk for placental abruption in relation to both cigarette smoking and hypertensive disorders during pregnancy. Because cigarette smoking is a modifiable risk factor, and hypertensive disorders are potentially treatable if diagnosed early in pregnancy, patient education, smoking cessation programs, and early prenatal care may be important factors in the prevention of placental abruption.

Spontaneous resolution of fetal cystic hygroma in Down's syndrome.

We describe a case of spontaneous resolution of a cystic hygroma between 14-16 weeks' gestation in a fetus with trisomy 21 who, at termination at 19 weeks, revealed only mild webbing of the neck. Redundant nuchal skin folds are among the most common features of trisomy 21. Our case supports the hypothesis that this redundant skin of the fetal neck represents early cystic hygromas, which resolve in utero before 16 weeks' gestation.

Ultrasonic diagnosis of discordant fetal growth in twin gestations.

Forty-three consecutive twin pregnancies were evaluated by ultrasound to establish criteria for antenatal detection of discordant fetal growth. For each fetus an attempt was made to measure the biparietal diameter (BPD), abdominal circumference, and femur length; the estimated fetal weight was also calculated based on published formulas. The intrapair differences in BPD, abdominal circumference, femur length, and estimated fetal weight were evaluated as predictors of discordant fetal growth. Although the intrapair difference in BPD measurement was not a statistically significant predictor, an intrapair difference in abdominal circumference of 20 mm or more was found to have sensitivity 80%, specificity 85%, positive predictive value 62%, and negative predictive value 93%. Intrapair difference in the estimated fetal weight was found to be the best predictor of discordant fetal growth (sensitivity 80%, specificity 93%, positive predictive value 80%, and negative predictive value 93%). These data suggest that the intrapair difference in abdominal circumference measurement could be effectively used as a screening test for the diagnosis of discordant fetal growth. If the intrapair difference in abdominal circumference is 20 mm or greater, further evaluation, by determining the intrapair difference in estimated fetal weight, is indicated.

Antenatal evaluation and management of ultrasonically detected fetal anomalies.

With the advent of improved ultrasound imaging, it is now possible to make an intrauterine diagnosis of many fetal anomalies. The key to an accurate antenatal diagnosis is careful scanning of the fetus and knowledge of the abnormalities that may be associated with a particular anomaly. In the presence of fetal anomalies known to be associated with increased frequency of chromosome abnormalities, fetal karyotyping is indicated, using either amniocentesis or fetal blood sampling, depending upon the urgency of the diagnosis. Fetal echocardiography is mandatory when the ultrasonically detected fetal anomaly is one that is known to be associated frequently with cardiac disease. Based on the antenatal findings, the parents should receive appropriate genetic and perinatal counseling. The management plan should always take into consideration the parents' wishes. Management plans for the most common ultrasonically detected fetal anomalies are presented, based upon review of the literature and authors' experience.

The relationship between fetal biophysical profile and cord pH in patients undergoing cesarean section before the onset of labor.

In a prospective study of 124 patients undergoing cesarean section before the onset of labor, the fetal biophysical profile was found to have a significant relationship with umbilical cord blood pH (artery and vein). Using cord arterial pH less than 7.20 as a standard for the diagnosis of fetal acidosis, the sensitivity, specificity, and positive and negative predictive values of the fetal biophysical profile score were 90, 96, 82, and 98%, respectively. When the combination of nonreactive nonstress test and absent fetal breathing was used as the "abnormal test," the sensitivity, specificity, and positive and negative predictive values were 100, 92, 71, and 100%, respectively. The first manifestations of fetal acidosis are nonreactive nonstress testing and loss of fetal breathing; in advanced acidemia, fetal movements and fetal tone are compromised. A protocol of antepartum fetal evaluation is suggested based upon the individual biophysical components rather than the score alone.

Perinatal management and outcome of fetal ventriculomegaly.

In 20 consecutive cases of fetal ventriculomegaly, diagnosed by antenatal ultrasound examination, hydrocephalus was isolated in six patients (30%) and was associated with other anomalies in 14 (70%). There were no false positive diagnoses of fetal ventriculomegaly in this series. Fetal structural and/or chromosome abnormalities were diagnosed antenatally in 11 of the 14 patients (78.5%) with postnatally documented anomalies. In ten patients (50%), isolated fetal ventriculomegaly or ventriculomegaly associated with spina bifida was diagnosed antenatally, and the perinatal management consisted of frequent ultrasound examinations, weekly fetal biophysical profiles, and delivery by cesarean section after documenting fetal lung maturity. Ventriculo-amniotic shunt placement was not part of the management. The outcomes were induced abortion, four patients (20%); intrapartum death, two patients (10%); postnatal death, five patients (25%); and currently alive, nine patients (45%).

Intrauterine growth and ultrasound findings in fetuses with Beckwith-Wiedemann syndrome.

OBJECTIVE: To assess intrauterine growth in a series of nine fetuses diagnosed with Beckwith-Wiedemann syndrome. METHODS: Infants confirmed postnatally to have Beckwith-Wiedemann syndrome were identified from records maintained in the Division of Clinical Genetics. Antenatal ultrasound and birth records were evaluated. Head circumference (HC), abdominal circumference (AC), and estimated fetal weight (EFW) were assigned percentiles based on gestational age. Newborn HC and birth weight were also assigned percentiles. Polyhydramnios was diagnosed using either amniotic fluid index or documented subjective assessment. RESULTS: Nine infants with Beckwith-Wiedemann syndrome had antenatal ultrasound examinations. Seven of these had more than one examination. Two infants were suspected to have Beckwith-Wiedemann syndrome in utero. Important ultrasound findings included omphalocele (four), enlarged liver and kidneys (one), and enlarged liver (one). Fetal tongue protrusion on ultrasound was not identified in any fetus. Six of nine fetuses (66%) with ultrasound examinations after 25 weeks' gestation had polyhydramnios. Evaluation of the fetal HC, AC, and EFW percentiles demonstrated that fetuses with Beckwith-Wiedemann syndrome may exhibit accelerated growth as early as 25-30 weeks' gestation, but may exceed the 90th percentile only after 36 weeks' gestation. CONCLUSIONS: Fetuses with omphalocele, polyhydramnios, and an AC less than the 90th percentile may have Beckwith-Wiedemann syndrome. Polyhydramnios and accelerated growth beginning between 25 and 36 weeks' gestation, even without omphalocele, should alert the physician to the possibility of Beckwith-Wiedemann syndrome.

The ultrasound femur length as a predictor of fetal length.

A linear relationship between the ultrasound fetal femur length and the crown-heel length of the fetus is described. The formula for calculating the fetal length in centimeters was found to be 6.18 + 0.59 x femur length in millimeters. The value and potential uses of the calculated length of the fetus are discussed.

Fetal atrial flutter and X-linked dominant vitamin D-resistant rickets.

A pregnancy, complicated by hypophosphatemic familial rickets (vitamin D-resistant rickets) of a female fetus, associated with atrial flutter and congestive heart failure is presented. Upon review of the literature, only 22 cases of fetal atrial flutter have been reported. The association between hypophosphatemic familial rickets and atrial flutter has not yet been described.

Degree of oligohydramnios and pregnancy outcome in patients with premature rupture of the membranes.

Amniotic fluid volume was serially assessed by real-time ultrasound in 90 patients who presented with premature rupture of the membranes (PROM) and not in labor. The degree of oligohydramnios was correlated to the outcome of pregnancy, as reflected by pregnancy prolongation, intrapartum fetal heart rate patterns consistent with umbilical cord compression, cesarean section rate, fetal distress, infection, and perinatal mortality rate. These data suggest that in patients with PROM the degree of oligohydramnios is positively correlated with unfavorable pregnancy outcome.

A comparison of pre-discharge survival and morbidity in singleton and twin very low birth weight infants.

The perinatal mortality rate of twins is four to 11 times higher than that of singletons, and twins are widely reported to have more morbidity than singletons, mainly because of a higher preterm birth rate. However, it is not clear that live-born preterm birth rate. However, it is not clear that live-born preterm twins suffer greater morbidity than comparable singletons. In fact, twins have been reported to develop pulmonary maturity earlier than singletons, which might result in decreased morbidity relative to comparable preterm singletons. We conducted this retrospective review of 496 consecutive singleton and 104 twin infants weighing 500-1499 g and born alive at 24-31 weeks' gestation to determine whether pre-discharge survival and morbidity in very low birth weight (VLBW) twin infants were greater than those of comparable singletons. The mean (+/- standard deviation) gestational age of the singletons was 27.5 +/- 2.0 weeks and of the twins 27.6 +/- 2.0 weeks. There were no differences in mean gestational age, gestational age distribution, mean birth weight, birth weight distribution, gender, or maternal race between the two groups. The pre-discharge survival rate for twins (77%) was not significantly different than that of singletons (82%). There were no differences between twins and singletons in the incidences of neonatal respiratory distress syndrome (63 versus 71%), pulmonary interstitial emphysema (14 versus 16%), patent ductus arteriosus (28 versus 29%), necrotizing enterocolitis (3 versus 5%), intraventricular hemorrhage (11 versus 16%), and retinopathy of prematurity (11 versus 18%). The incidence of bronchopulmonary dysplasia was significantly less in twins (27 versus 46%; P = .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Pregnancy outcome following first-trimester varicella infection.

Varicella infection in the first trimester has been associated with a constellation of congenital abnormalities. The incidence of the congenital varicella syndrome is unknown, although it has been reported to be as high as 9%. In a prospective study performed between 1986-1990, 40 patients were identified who had first-trimester varicella infection. Pregnant patients were referred from physicians in the perinatal regional network after developing the classical picture of varicella infection. Targeted fetal ultrasound examinations were performed between 16-20 weeks' gestation in all cases and neonatal outcome was determined. Of the 40 patients, three had first-trimester losses and another underwent an elective termination of pregnancy after counseling. Of the remaining 36 women, one had fetal omphalocele. Thirty-five pregnancies continued until term, and no infant had features of the congenital varicella syndrome at birth. Other than the case of omphalocele, no major congenital anomalies were identified. This study, the largest series of patients with first-trimester varicella infection, showed an incidence of congenital varicella syndrome of 0% and an incidence of congenital anomalies of 3% (range 0-8% at 95% confidence level).

The efficacy of individual computer heart rate indices in detecting acidemia at birth in growth-restricted fetuses.

OBJECTIVE: To determine the efficacy of individual fetal heart rate (FHR) indices, as determined by computer analysis of the FHR tracing, in detecting fetal acidemia at birth in growth-restricted fetuses. METHODS: The study population consisted of 38 growth-restricted fetuses at 26-37 weeks' gestation from pregnancies with abnormal uterine and/or umbilical artery Doppler velocimetry. The 1-hour FHR tracing was analyzed by computer within 4 hours of cesarean birth before the onset of labor. Umbilical artery cord blood was collected at birth, and pH was determined within 5 minutes of collection. RESULTS: On linear regression, the duration of episodes of low variation in minutes (r = -0.77, r2 = 0.59) and short-term (r = 0.72, r2 = 0.52) and long-term (r = 0.69, r2 = 0.47) variation in milliseconds were significantly related to umbilical artery pH at birth, and more so than the number of accelerations of ten (r = 0.57, r2 = 0.32) and 15 (r = 0.38, r2 = 0.14) beats per minute. There were significant differences in computer measurements of FHR accelerations and variation between the umbilical artery pH categories of acidemia (pH less than 7.20), preacidemia (7.20-7.25), and nonacidemia (greater than 7.25). Stepwise regression revealed that episodes of low variation best described the model for predicting umbilical artery pH at birth (P < .001), with no improvement provided by the addition of other computer-analyzed FHR characteristics. CONCLUSION: In this population of growth-restricted fetuses delivered by elective cesarean, the computer indices of duration of episodes of low variation and short-term and long-term variation were significantly associated with umbilical artery pH and predicted umbilical artery acidemia at birth.