Severe heart disease complicating pregnancy does not preclude a favourable pregnancy outcome: 15 years' experience in a single centre.

Heart disease (HD) in pregnancy remains a major cause of non-obstetric maternal and neonatal mortality and morbidity. This study describes the outcome in 164 pregnant women with HD (158 deliveries in women in New York Heart Association (NYHA) Classes 1 and 2; 17 in NYHA Classes 3 and 4) who received good antenatal care and benefitted from a specific protocol and experience of a dedicated staff. There were no maternal or neonatal deaths; 46 women were diagnosed peripartum. Based on a sub-division into NYHA categories, and when sub-divided by HD, there were no statistically significant differences between groups with regard to maternal age, gestational age at admission or at delivery, birth weight, 5 min Apgar scores, mode of delivery (caesarean delivery), senior obstetric/anaesthesiology staff in attendance or delivery during day/working hours. There was a higher incidence of pre-term deliveries in women with rheumatic heart disease and Marfan syndrome (p = 0.06) relative to others. Babies of women with coronary heart disease had prolonged postpartum course in the NICU (p = 0.0001) and longer total hospital stays for the mother. In conclusion, well-managed, motivated mothers with HD who benefit from comprehensive antenatal care, and are managed primarily by their obstetric and anaesthesia teams, can aspire to a good outcome for themselves and their babies.

PAPP-A levels as an early marker of idiopathic preterm birth: a pilot study.

OBJECTIVE: To evaluate late PAPP-A levels as predictive of preterm birth in symptomatic women. STUDY DESIGN: Prospective cohort study of singleton gestations, 23 to 34 weeks, and symptoms of preterm labor. PAPP-A, IGF-I and IGF-III analysis were performed. Primary end point was delivery < or =7 days. Accuracy and optimally predictive PAPP-A values were based on receiver operator characteristic (ROC) curves. RESULT: In all, 26 women (51%) delivered < or =7 days post-admission (Group 1); 25 women (49%) >7 days (Group 2). Group 1 mean PAPP-A=38 000 vs 55 333 for Group 2 (P<0.04). Group 1 mean gestational age at delivery=29 weeks vs 37 weeks for Group 2 (P<0.00014). PAPP-A level < or =30,000 mU l(-1) had highest specificity (88%), sensitivity (50%), and positive predictive (81%) and negative predictive (62%) values for delivery < or =7 days. ROC area under curve=0.703. CONCLUSION: PAPP-A levels < or =30,000 mU l(-1) at admission was associated with increased risk for preterm birth < or =7 days, supporting active management and therapeutic approach in these women.

Temporizing treatment for the respiratory-compromised gravida: an observational study of maternal and neonatal outcome.

Acute lung disease may originate in pregnancy because of the pregnancy itself or because of an intercurrent etiology. The purpose of this study was to describe the effect of prolonged antepartum mechanical ventilatory support on the mother and the neonate when the strategy was to prolong the pregnancy rather than deliver preterm. Among 72 312 parturients over eight years, three gravidae required mechanical ventilation 12-48 h after admission for different conditions, 45-91 days before delivery. Gestational age at intubation was 21-28 weeks. Appropriate analgesia, broad-spectrum antibiotics, vasopressors and betamethsone for fetal lung maturity were used in all cases. None received tocolysis. Despite uterine distension, respiratory support provided adequate oxygenation and FiO2 could be maintained below critical levels, obviating the need for early delivery. All women survived, were weaned from ventilatory support, discharged, and delivered healthy neonates at term. Mode of delivery was dictated by obstetrical indicators only. All five infants (two sets of twins) are healthy at 12-36 months with appropriate developmental milestones. We conclude that when the maternal condition is amenable to therapy, and given the risks of labor induction and of prematurity, there is only limited benefit of delivery while on mechanical ventilation.

Pulmonary complications following endotracheal intubation for anesthesia in breech extraction.

A 28-year-old, healthy pregnant patient developed bilateral pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum and pneumoperitoneum following endotracheal intubation and manual ventilation during general anesthesia for breech extraction. It is likely that positive-pressure ventilation was the cause for this very rare combination of complications. Early recognition and treatment may prevent such a catastrophe.

Correlation between fasting glucose in the first trimester and glucose challenge test in the second.

OBJECTIVE: To determine if there is a statistically significant correlation between the plasma glucose level obtained following a glucose challenge test at 24-28 weeks' gestation and the fasting plasma glucose level in the first trimester. METHODS: The study population included 621 healthy women with singleton pregnancies followed in the antenatal clinic of the Hadassah Medical Center, with a fasting plasma glucose level performed during the first trimester. Nine women had fasting blood glucose levels above 105 mg/dL and were excluded from the study. Of the remaining 612 women, 425 (69%) had 50-g glucose challenge tests at 24-28 weeks' gestation. RESULTS: The mean (+/-standard deviation [SD]) first-trimester fasting glucose level was 77.8+/-9.7 mg/dL and the mean (+/-SD) glucose level 1 hour after the second-trimester glucose challenge test was 109.1+/-29.8 mg/dL. The fasting plasma glucose level and the glucose level following the glucose challenge correlated significantly but not strongly (=.26, P < .001). However, using a linear regression model in which fasting plasma glucose level and maternal weight were explanatory variables and glucose level following the glucose challenge test was the dependent variable resulted in a very low r2 (.10). CONCLUSION: The correlation between the plasma glucose level obtained following a glucose challenge test and the fasting plasma glucose level in the first trimester is low, indicating that fasting glucose measurement early in pregnancy has no clinical benefits.

Ranking the risk factors for cesarean: logistic regression analysis of a nationwide study.

The risk factors that influenced the decision to perform cesarean were ranked in a nationwide census of deliveries conducted in Israel. The study encompassed 22,815 women who gave birth between November 1, 1983 and January 31, 1984 in the 30 maternity departments in the country; 2179 deliveries were by emergency cesarean. Multivariate stepwise logistic regression technique indicated that the most important risk factors affecting the decision were the presentation of the fetus and the presence of a uterine scar, followed in descending order by placenta previa or abruptio placentae, maternal disease, primiparity, low birth weight, twins, and advanced maternal age. The mother's ethnic background and type of hospital played an insignificant role in the decision-making process. The specific statistical method applied in this work permits listing the indicators that constitute risk factors for cesarean and provides the net effect of each factor on the decision-making process.

Meconium-stained amniotic fluid: increased risk for adverse neonatal outcome.

OBJECTIVE: To determine the risk of adverse neonatal outcome associated with meconium-stained amniotic fluid independent of that related to antepartum or intrapartum abnormalities. METHODS: A cohort of 2200 consecutive deliveries was examined and the fetal heart rate (FHR) tracings analyzed independently. Singleton term pregnancies without fatal malformations were stratified by the consistency of meconium and compared. RESULTS: Moderate or thick meconium increased the risk for adverse outcome more than threefold (relative risk 3.2, 95% confidence interval 2.0-5.2). This risk was independent of fetal heart tracing abnormalities or maternal hypertensive, kidney, or heart disease. CONCLUSION: Thick meconium alone should alert the physician to a high-risk fetal condition. This phenomenon requires continuous FHR monitoring and reassurance of fetal well-being by acid-base assessment or the equivalent, regardless of maternal disease status or the presence of abnormal FHR tracings.

Is the obstetric outcome of in vitro fertilized singleton gestations different from natural ones? A controlled study.

OBJECTIVE: To determine whether singleton IVF pregnancies carry adverse maternal or fetal outcome when compared with naturally conceived gestations. DESIGN: An analysis of the obstetric outcome of singleton IVF pregnancies in comparison with matched, naturally conceived singleton controls. SETTING: In vitro fertilization unit and obstetric service at a tertiary medical center. PATIENT(S): Two hundred sixty consecutive singleton IVF pregnancies and 260 naturally conceived singleton controls matched 1:1 for maternal age, parity, ethnic origin, and location and date of delivery. INTERVENTION(S): In vitro fertilization-ET. MAIN OUTCOME MEASURE(S): The rate of antenatal obstetric complications, nonvertex presentation, cesarean section, preterm labor, low birth weight, small and very small for gestational age, neonatal intensive care unit admissions, and perinatal mortality. RESULT(S): The rates of most antenatal complications were similar in both groups. Urinary tract infection was the only complication diagnosed significantly more frequently after IVF (7.3% versus 1.2%); however, the rates of severe urinary tract infection necessitating hospitalization were similar. The incidence of nonvertex presentation was also similar. The cesarean section rate was significantly higher among IVF patients (41.9% versus 15.5%). The rates of preterm labor, low birth weight, small and very small for gestational age, neonatal intensive care unit admissions, and perinatal mortality were comparable. CONCLUSION(S): When controlling for maternal age, parity, ethnic origin, and location and date of delivery, singleton IVF pregnancies do not carry an increased risk for prematurity, low birth weight, or maternal or fetal complications. Still, these pregnancies are associated with a high rate of cesarean sections.

Pemphigus vulgaris and pregnancy.

Pemphigus vulgaris (PV), an autoimmune bullous dermatosis, is rarely encountered in pregnancy. Two women with PV and their three pregnancies are described. Pregnancy outcome was generally good, although one of the neonates had characteristic PV skin lesions that resolved spontaneously. The pathophysiology, clinical manifestations, and special issues of PV pertaining to pregnancy are discussed. With our cases added, there are now 23 reports in the English literature on PV in pregnancy. From these data it seems that transient skin lesions may occasionally appear in the neonate regardless of the severity of maternal disease. Such lesions are due to passive transplacental transfer of PV antibodies and do not have long-lasting clinical implication. On the other hand, and contrary to past traditional thinking, PV may be associated with poor neonatal outcome including prematurity and fetal death. Such complications seem to be restricted to pregnancies with clinically severe PV.

Grandmultiparity. Is it a perinatal risk?

Increased parity is more common in lower-socioeconomic groups. Additionally, GMPs tend to be older. It is for these reasons that there is a tendency for an increased incidence of antenatal complications, such as hypertension and diabetes, among GMP mothers. It appears that the previous conflicting reports on the effect of high parity on perinatal outcome can be related to differences in the socioeconomic conditions of the parturient population under examination. Previous evidence of the unfavorable influence on perinatal outcome of high parity might have been biased by patient selection, because high parity is often inversely linked to social class. Our recent studies of the Israeli maternal population plus comparable reports from other countries allow us to conclude that GMP is not always a great cause for concern in an economically stable and healthy population that has access to high-quality medical care. As such, the term dangerous multipara should be removed from the medical literature and the focus of concern should shift to the organization and the delivery of quality medical services.

Prevention of neonatal group B streptococcal infections. Is there a rational prevention strategy?

Clinicians, both obstetric and pediatric, are currently faced with the need to choose treatment strategies to reduce the persistent high incidence of early-onset GBS neonatal disease without being equipped with adequate data to choose conclusively which of the proposed strategies is ideal. There is an urgent need for well-designed prospective randomized trials comparing the various prevention protocols so as to resolve conclusively the controversy. The ultimate prevention strategy may well be a successful maternal immunization program.

Congenital afibrinogenemia and recurrent early abortion: a case report.

The role of the fibrinogen molecule in the maintenance of normal pregnancy is not yet well understood; however, several cases have been previously reported in which failure to complete normal pregnancy was associated with either hypofibrinogenemia, dysfibrinogenemia, or deficiency in factor XIII (fibrin-stabilizing factor) which is important for the crosslinking of the fibrin. A case of congenital afibrinogenemia is described. The patient, a 22-yr-old woman, who suffered from a moderate hemorrhagic tendency associated with very low (less than 10 mg/dl) plasma fibrinogen levels, had three consecutive spontaneous abortions. In view of the previous cases reported, the question is raised whether patients with low or abnormal fibrinogen should be treated with plasma transfusions in order to maintain a normal pregnancy.

The effects of the socioeconomic status on the perinatal outcome of grand multipara.

Grandmultiparity has been considered as an obstetric hazard both to the mother and the fetus. Since high paritius tend to be more common in the lower socioeconomic groups, the effect of the socioeconomic status on perinatal outcome was evaluated in this study. This survey covers all the deliveries in Israel (22,815) in a 3 month period. The 1542 grand-multiparous women were divided into two groups: low socioeconomic group (947) and high socioeconomic group (595). Perinatal mortality and low birth weight were found to be in correlation with low socioeconomic status but not with grand multiparity. Maternal diseases complicating pregnancy were found to be significantly more common for grand multipara for both socioeconomic groups. This study shows that the grave association of parity and mortality found for the total population was due to the predominance of parturients of low socioeconomic class in the high birth order group.

The effect of clinical chorioamnionitis on cord blood gas at term.

OBJECTIVE: We sought to determine the effect of clinical chorioamnionitis on cord blood gas values in term pregnancies not complicated by any other disease. STUDY DESIGN: 2200 consecutive deliveries were studied. Following exclusion of twins, non-viable malformations and stillbirths, as well as mothers with high-risk pregnancy diseases--i.e. hypertension, diabetes, preterm labor, third-trimester bleeding, IUGR, postdates, oligohydramnios, i.v. drug abused, decreased fetal movement, maternal viral infection, UTI or pneumonia (n = 897)--two groups of patients remained: term pregnancies complicated only by clinical chorioamnionitis (n = 81) and uncomplicated term pregnancies (n = 1246). RESULTS: Evaluation of mean cord blood gas values revealed a significant difference in pH, PO2, PCO2 and BE values, with the infants of mothers with clinical chorioamnionitis having lower pH values (7.23 +/- 0.07 vs. 7.28 +/- 0.07). However, evaluating the independent effect of chorioamnionitis on arterial cord blood pH (using a logistic regression model) showed that clinical chorioamnionitis, by itself, did not contribute to this change in arterial cord blood pH. CONCLUSION: Chorioamnionitis was neither the explanation nor the cause for differences in arterial cord blood pH found between the two groups in our study. In cases of chorioamnionitis, these differences were attributed to other factors, such as length of labor, mode of delivery, method of delivery and presence of meconium.

Cesarean section is not protective against adverse neurological outcome in survivors of preterm delivery due to overt chorioamnionitis.

OBJECTIVE: To determine whether the mode of delivery has a protective value on the immediate adverse neonatal neurological outcome of infants born from pregnancies complicated by preterm chorioamnionitis. METHODS: A comparison of the immediate and long-term neurological outcome of preterm neonates (24-34 weeks' gestation) of pregnancies complicated by chorioamnionitis, was made between those born by Cesarean section and by vaginal delivery. RESULTS: Of the 73 newborns, 54 (74%) survived the neonatal period; two (2.7%) had incomplete records, leaving 71 for analysis. Thirty (42.2%) were delivered by Cesarean section and 41 (57.7%) vaginally. The obstetric and neonatal characteristics were comparable. Twenty-four (80%) survived in the Cesarean group and 30 (73.2%) in the vaginal delivery group (NS). There was no significant difference in the immediate adverse neonatal neurological outcome between Cesarean and vaginal deliveries. CONCLUSIONS: The mode of delivery did not significantly affect the immediate neurological status of preterm infants exposed to antenatal intrauterine infection.

The effect of maternal age and socioeconomical background on neonatal outcome.

This population-based study examined whether the neonatal outcome of primiparae is determined by maternal age or by her socioeconomic background. Data on all births in Israel during a three-month period was made available from a nation-wide census. Primiparae 30 years of age or older had a significantly (P less than 0.001) higher risk of low birthweight and prematurity. Perinatal mortality rates and low 5-min Apgar scores were not associated with maternal age, but were significantly (P less than 0.001) increased for the socioeconomically disadvantaged parturients. Our results suggest the growth retardation and short gestation among older primiparae may reflect biological aging of maternal tissues and the effect of diseases of pregnancy such as hypertension and preeclampsia, found significantly (P less than 0.001) more common for these mothers. Excessive perinatal mortality, on the other hand, may be attributable to environmental disadvantage of socioeconomically deprived populations.

Outcome of amniotic fluid analysis and neonatal respiratory status in diabetic and nondiabetic pregnancies.

OBJECTIVE: To evaluate the likelihood of mature or immature amniotic fluid analysis and subsequent presence or absence of neonatal pulmonary disease in a large population of diabetic and nondiabetic pregnancies. STUDY DESIGN: Six hundred sixty-eight pregnancies that delivered within seven days of phosphatidylglycerol (PG) and lecithin/sphingomyelin ratio (L/S) testing were analyzed. (PG testing was by Amniostat-FLM and L/S testing by a modified Gluck technique.) Neonatal respiratory outcome and amniocentesis results were stratified by maternal diabetes status and gestational age for comparison. We determined the likelihood of finding correctly mature and correctly immature amniotic fluid analysis for each gestational age category. RESULTS: We found high rates of incorrectly immature results for PG (53%) and L/S (21%) preterm and for PG at term (20%). Diabetic and nondiabetic pregnancies did not differ. CONCLUSION: Population-based information on the a priori chances of amniotic fluid and neonatal pulmonary outcome in diabetic and nondiabetic pregnancies is given for use in determining the utility of amniotic fluid analysis in individual clinical settings.

Recurrent stillbirth. Significance and characteristics.

We sought to identify the significance of recurrent stillbirth and to determine the contributory etiologic factors for this phenomenon. Data were analyzed and retrospective chart review conducted for all stillbirths occurring during a 13-year period. Subjects were divided into two groups: those for whom the current stillbirth was the first and those who had had a previous stillbirth. The study included 48,479 consecutive multiparous women, of whom 403 had delivered stillborn infants (8.31/1,000 live births). For 34 of these subjects, this represented a recurrent stillbirth (84.36/1,000 live births). The recurrent-stillbirth group had a 10.15-fold higher risk for stillbirth. Additionally, this group had a twofold higher incidence of diabetes and hypertensive disease than did those women experiencing their first stillbirths; furthermore, the gestational age and birth weight of the stillborn infants were significantly lower in the recurrent-stillbirth group (P < .0004 and < .007, respectively). Such factors as socioeconomic class, chorioamnionitis and erythroblastosis fetalis, traditionally cited as contributing to repeated fetal loss, were not significant. Although recurrent stillbirth remains an unsolved problem, improving health care to specific groups within high-risk populations may reduce fetal loss.

[The high risk pregnancy unit].

During the past 30 years there has been great progress in perinatology. However, perinatal mortality has remained relatively high. To reduce perinatal mortality and morbidity, high risk pregnancy units have been established throughout the world. Our unit was established in 1976 for women with diseases complicating pregnancy, and in whom evaluation of fetal respiratory and metabolic function is indicated. The cesarean section rate during these 12 years was 33%. There was no maternal mortality. The intrauterine fetal death rate was 10.3 per 1,000 (very low for this unique population) and the corrected perinatal mortality was 3.4 per 1,000. The monitoring and treatment protocols, developed and applied in this unit, resulted in a significant decrease in fetal morbidity and mortality. These dramatically improved results demonstrate and justify the need for high risk pregnancy units.