Maternal anthropometric risk factors for caesarean delivery before or after onset of labour.

OBJECTIVE: To quantify the effects of pre-pregnancy body mass and gestational weight gain, above and beyond their known effects on birthweight, on the risk of primary and repeat caesarean delivery performed before or after the onset of labour. DESIGN: Hospital-based historical cohort study. SETTING: Canadian university-affiliated hospital. POPULATION: A total of 63 390 singleton term (> or = 37 weeks gestation) infants with cephalic presentation. METHODS: We studied prospectively archived deliveries at the Royal Victoria Hospital in Montreal, Canada, from 1 January 1978 to 31 March 2001 using multiple logistic regression models to estimate relative odds of caesarean delivery. MAIN OUTCOME MEASURE: Caesarean delivery, primary or repeat and before or after the onset of labour. RESULTS: Pregravid obesity (body mass index > or = 30 kg/m2) increased the likelihood of primary caesarean delivery before (OR = 2.01, 95% CI 1.39-2.90) and after (OR = 2.12, 95% CI 1.86-2.42) the onset of labour. High net rate of gestational weight gain (> 0.50 kg/week) increased the risk but only after labour onset (OR = 1.40, 95% CI 1.23-1.60). Among women with a previous caesarean, high weight gain modestly increased risk but only before labour (OR = 1.38, 95% CI 1.04-1.83), whereas obesity increased the risk of caesarean delivery both before (OR = 1.85, 95% CI 1.44-2.37) and after (OR = 1.96, 95% CI 1.11-3.47) labour onset. Increased risks of macrosomia accounted for the association between pregravid adiposity and repeat caesarean delivery performed after but not before the onset of labour. CONCLUSIONS: Pregravid obesity increases the risk of caesarean delivery both before and after the onset of labour and both with and without a history of caesarean.

Nutritional supplements with intravenously administered lipid, protein hydrolysate, and glucose in small premature infants.

Nutritional support with intravenously administered fat, protein hydrolysate, and glucose was given to 23 premature infants weighing less than 1,500 gm at birth. Growth in the 19 survivors approximated intrauterine growth rates in all dimensions. Complications included sodium imbalance and transient intolerance of the smallest and sickest infants to all components: carbohydrate, protein, fat, and even water. Autopsies in four patients who died did not reveal any untoward findings clearly related to the use of intravenously given lipids. Intravenously given fat has a potentially useful role in the nutritional support of small premature infants.

Impact of intrauterine growth retardation and body proportionality on fetal and neonatal outcome.

Previous prognostic studies of infants with intrauterine growth retardation (IUGR) have not adequately considered the heterogeneity of IUGR in terms of cause, severity, and body proportionality and have been prone to misclassification of IUGR because of errors in estimation of gestational age. Based on a cohort of 8719 infants with early-ultrasound-validated gestational ages and indexes of body proportionality standardized for birth weight, the consequences of severity and cause-specific IUGR and proportionality for fetal and neonatal morbidity and mortality were assessed. With progressive severity of IUGR, there were significant (all P less than .001) linear trends for increasing risks of stillbirth, fetal distress (abnormal electronic fetal heart tracings)O during parturition, neonatal hypoglycemia (minimum plasma glucose less than 40 mg/dL), hypocalcemia (minimum Ca less than 7 mg/dL), polycythemia (maximum capillary hemoglobin greater than or equal to 21 g/dL), severe depression at birth (manual ventilation greater than 3 minutes), 1-minute and 5-minute Apgar scores less than or equal to 6, 1-minute Apgar score less than or equal to 3, and in-hospital death. These trends persisted for the more common outcomes even after restriction to term (37 to 42 weeks) births. There was no convincing evidence that outcome among infants with a given degree of growth retardation varied as a function of cause of that growth retardation. Among infants with IUGR, increased length-for-weight had significant crude associations with hypoglycemia and polycythemia, but these associations disappeared after adjustment for severity of growth retardation and gestational age.(ABSTRACT TRUNCATED AT 250 WORDS)

Body proportionality and head and length 'sparing' in growth-retarded neonates: a critical reappraisal.

Despite the popular current distinction between "proportional" and "disproportional" intrauterine growth retardation, it has never been shown that variation in body proportions is greater among growth-retarded than nongrowth-retarded infants of the same birth weight, nor that proportionality is distributed bimodally among growth-retarded infants. Based on a cohort of 8719 neonates born between 1980 and 1986 of mothers with concordant (+/- 7 days) menstrual dating and early ultrasound estimates of gestational age, we used a continuous measure of birth weight for gestational age to define four study groups: nongrowth retarded (n = 5163) and mild (n = 411), moderate (n = 226), and severe (n = 147) intrauterine growth retardation. Compared with non-growth-retarded infants of the same gestational age, growth-retarded infants had substantially lower lengths, head circumferences, and proportionality ratios, and the magnitude of the deficits increased significantly with increasing degrees of growth retardation. When the comparison was based on birth weight rather than gestational age, however, growth-retarded infants had slightly but significantly greater lengths and head circumferences, with increased variability in body proportions, but no evidence of the bimodality that would characterize two distinct subtypes. The analysis suggests that proportionality among intrauterine growth-retarded infants represents a continuum, with progressive disproportionality as severity of growth retardation increases. Moreover, despite evidence of some "sparing," the absolute magnitudes of the deficits in length and head growth remain substantial.

Determinants of fetal growth and body proportionality.

Previous studies of fetal growth and body proportionality have been based on error-prone gestational age estimates and on inappropriate comparisons of infants with dissimilar birth weights. Based on a cohort of 8719 infants with validated (by early ultrasonography) gestational ages and indexes of body proportionality standardized for birth weight, potential maternal and fetal determinants of fetal growth and proportionality were assessed. Maternal history of previous low birth weight infants, pregnancy-related hypertension (particularly if severe), diabetes, prepregnancy weight, net gestational weight gain, cigarette smoking, height, parity, and fetal sex were all significantly associated with fetal growth in the expected directions. Consistent with previous reports, maternal age, marital status, and onset or total amount of prenatal care had no significant independent effects. Fetal growth ratio (relative weight for gestational age), pregnancy-related hypertension, fetal sex, and maternal height were the only significant determinants of proportionality. Infants who were growth-retarded, those with taller mothers, those whose mothers had severe pregnancy-related hypertension, and males tended to be longer and thinner and had larger heads for their weight, although these variables explained only a small fraction of the variance in the proportionality measures. Among infants with intrauterine growth retardation, gestational age was not independently associated with proportionality (in particular, late term and post-term infants did not tend to be more disproportional), a finding that does not support the hypothesis that earlier onset of growth retardation leads to more proportional growth retardation. The results raise serious questions about previous studies of proportionality, particularly those suggesting a nutritional etiology for proportional intrauterine growth retardation.(ABSTRACT TRUNCATED AT 250 WORDS)

Knobloch syndrome involving midline scalp defect of the frontal region.

We report on a 4-year-old boy with Knobloch syndrome. He has vitreoretinal degeneration, high myopia, cataract, telecanthus, hypertelorism, and a high-arched palate. He also has a defect of the anterior midline scalp with involvement of the frontal bone as documented by a computed tomography (CT) scan. The brain was normal on CT scan and magnetic resonance imaging. We present a review of the 23 published cases with this syndrome. Our patient illustrates the importance of investigating for underlying ocular and central nervous system pathology whenever midline scalp defects are present.

Possible new variant of Nijmegen breakage syndrome.

We report on a child with microcephaly, small facial and body size, and immune deficiency. The phenotype is consistent with Nijmegen breakage syndrome (NBS), with additional clinical manifestations and laboratory findings not reported heretofore. Most investigations, including the results of radiation-resistant DNA synthesis, concurred with the diagnosis of NBS. Cytogenetic analysis documented abnormalities in virtually all cells examined. Along with the high frequency of breaks and rearrangements of chromosomes 7 and 14, we found breakage and monosomies involving numerous other chromosomes. Because of some variation in the clinical presentation and some unusual cytogenetic findings, we suggest that our patient may represent a new variant of Nijmegen breakage syndrome.

Efficacy and safety of morning versus evening fluoxetine administration.

A total of 120 patients who met DSM-III criteria for unipolar major depressive episode were equally randomized to fluoxetine a.m. or fluoxetine p.m. treatment groups, such that 30 patients were in each group at each of two sites. Patients received 20 to 80 mg of fluoxetine every day for 5 weeks; the dose was based on clinical response. Highly significant within-treatment improvement was reflected by changes in mean scores on the Hamilton Rating Scale for Depression (total score and factors), the Raskin Depression Scale, the Covi Anxiety Scale, the Clinical Global Impressions Scale for Severity, and the Clinical Global Impressions Scale for Improvement. No significant differences occurred between the a.m. and p.m. groups for any efficacy variable. Evaluation of adverse events and vital signs indicated no clinically significant differences between the two treatment groups. The data indicate that fluoxetine is equally efficacious and well tolerated regardless of the time of day it is administered and suggest that fluoxetine may be administered at either time of day without affecting clinical course.

Terminal digit preference, random error, and bias in routine clinical measurement of blood pressure.

We examined the presence, magnitude, and consequences of systematic and random errors caused by terminal digit preference in the measurement of highest systolic blood pressure during prenatal visits in 28,841 non-referred pregnant women who delivered between 1 January 1982 and 31 March 1990. In the overall distribution of terminal digit readings, 78% were read to 0, 15% to even digits other than 0, 5% to 5, and only 2% to odd digits other than 5. This preference for 0's was consistent across the entire distribution of blood pressure and for a variety of maternal characteristics. The relative frequency of the cutoff value of 140 mmHg (i.e. the percentage of readings on 140 mmHg) within the range containing the value (i.e. 138-142 mmHg) was similar to the relative frequency of other multiples of 0. This was true whether the comparison was made in the overall study sample, or in a pre-selected low-risk subgroup or high-risk subgroup, indicating no systematic bias. On the other hand, a strong tendency to read blood pressure values to the nearest 0 had a marked effect on the classification of hypertension. Changing the definition of hypertension from > or = 140 mmHg to > 140 mmHg produced a reduction in prevalence of hypertension from 25.9 to 13.3% in the overall study sample, from 15.4 to 6.3% in the low-risk subgroup, and from 43.3 to 25.3% in the high-risk subgroup. Epidemiologic studies that compare prevalences of hypertension in different populations based on routine clinical measurement of blood pressure and a single cutoff point should assess the consequences of terminal digit preference in defining hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

Causes of fetal death in women of advanced maternal age.

OBJECTIVE: To examine which causes of fetal death occur more often in older women and to determine whether these causes have changed significantly since the 1960 s and early 1970 s. METHODS: Data from the McGill Obstetrical Neonatal Database were used to calculate rates of specific causes of fetal death in women younger than 35 and in women 35 years or older. Among the 101,640 births between 1961 and 1995, there were 715 stillbirths and 822 neonatal deaths. The autopsy rate was 97% and categorization of the causes of fetal death remained consistent over this 34-year period. The rates of specific causes of fetal death per 10,000 total births were determined for an earlier period (1961-1974) and a later period (1978-1995). RESULTS: Compared with the 1961-1974 period, there was a 60% reduction in the rates of both fetal and neonatal deaths during 1978-1995 (P < .001). During 1961-1974, women 35 years or older were more likely than their younger counter-parts to have fetal death due to lethal congenital anomalies (odds ratio [OR] 3.2; 95% confidence interval [CI] 1.5, 6.5); this was no longer true in the 1978-1995 period. From 1978 to 1995, older women were at a statistically significant increased risk for "unexplained" fetal death (OR 2.2; 95% CI 1.3, 3.8); women 35 years of age or older had approximately one in 440 births end in unexplained fetal death, compared to one in 1000 births for women younger than 35. CONCLUSIONS: Advanced maternal age is no longer associated with an increased risk for fetal death due to congenital anomalies. However, older women have a significantly higher risk for unexplained fetal death. The identification of those maternal and fetal characteristics that contribute to unexplained fetal death and its prevention remain important challenges for contemporary obstetric practice.

Fetal macrosomia: prediction, risks, proposed management.

The outcome of delivery of infants weighing more than 4000 g born during two time periods 15 years apart was studied retrospectively. The increased use of cesarean section and other obstetric advances did not reduce the risk of fetal asphyxia and trauma associated with large fetal size. Maternal factors were identified for risk categorization of fetal macrosomia during pregnancy. Macrosomia was rare at 37 weeks and increasingly common thereafter. Fetal size assessment by ultrasound at 36 to 38 weeks' gestation would permit induction of labor for the macrosomic infant before the size became excessive or would make the accoucheur aware of the dangers that may arise during delivery.

The changing pattern of fetal death, 1961-1988.

The aim of this study was to assess any changes in cause-specific fetal death rates in the nonreferred population of a tertiary care unit. The fetal death rate (per 1000 births) among 88,651 births diminished from 11.5 in the 1960s to 5.1 in the 1980s. Fetal death due to intrapartum asphyxia and Rh isoimmunization has almost disappeared. Toxemia and diabetes continue to make similar and small contributions to fetal death rates. There has been a significant decline in unexplained antepartum fetal deaths and in those caused by fetal growth retardation, but no significant change in the death rate due to intrauterine infection or abruptio placentae. During the 1960s, the risk of fetal death was increased in women with hypertension, diabetes, or a history of stillbirth; during the 1980s, only women with a history of insulin-dependent diabetes were at risk. Improved application of current knowledge may help decrease the fetal death rate caused by fetal growth retardation. Reduction in deaths due to abruptio placentae, intrauterine infections, or lethal malformations, as well as unexplained antepartum deaths, appears to depend on better understanding of the etiology of these disorders.

Failed forceps.

Among 53 cases of failed forceps occurring in 6524 uncomplicated primiparous deliveries, depression at birth and encephalopathy occurred with similar frequency as when cesarean section was done for failure to progress in the second stage, and birth trauma was no more common than that with successful midforceps delivery. Factors predisposing to or associated with midforceps deliveries or second stage cesarean sections were short mothers, heavy babies, induced or prolonged labors, and fetal distress or meconium release in labor.

Etiologic determinants of abruptio placentae.

OBJECTIVE: To quantify the roles of suspected sociodemographic, anthropometric, behavioral, and pathologic determinants in the etiology of abruptio placentae. METHODS: We performed a hospital-based cohort study of 36,875 nonreferred births between January 1978 and March 1989. Gestational age was based on menstrual dates confirmed (within 7 days) by early ultrasound. RESULTS: Parity, maternal education, pre-pregnancy weight, and the rate of net gestational weight gain did not have significant independent associations with abruption. Significant determinants included the following: severe small for gestational-age (SGA) birth (odds ratio [OR] 3.99; 95% confidence interval [CI] 2.75, 5.77), chorioamnionitis (OR 2.50; 95% CI 1.58, 3.98), prolonged rupture of membranes (OR 2.38; 95% CI 1.55, 3.65), preeclampsia (OR 2.05; 95% CI 1.39, 3.04), pregnancy-induced hypertension without albuminuria (OR 1.57; 95% CI 1.00, 2.46), pre-pregnancy hypertension (OR 1.77; 95% CI 1.05, 2.99), maternal age at least 35 years (OR 1.50; 95% CI 1.14, 2.01), unmarried status (OR 1.50; 95% CI 1.13, 1.98), cigarette smoking (OR 1.40; 95% CI 1.00, 1.97 for ten to 19 cigarettes per day and OR 1.13; 95% CI 0.81, 1.59 for at least 20 cigarettes per day), and male fetal gender (OR 1.38; 95% CI 1.12, 1.70). Removal of SGA from the regression model resulted in little change in the magnitude of the other associations. CONCLUSIONS: Severe fetal growth restriction, prolonged rupture of membranes, chorioamnionitis, hypertension (before pregnancy and pregnancy-induced), cigarette smoking, advanced maternal age, unmarried status, and male fetal gender are significant etiologic determinants of placental abruption. Non-SGA determinants appear to operate largely independently of their effects on fetal growth.

Determinants of unexplained antepartum fetal deaths.

OBJECTIVE: To assess fetal, maternal, and pregnancy-related determinants of unexplained antepartum fetal death. METHODS: We conducted a hospital-based cohort study of 84,294 births weighing 500 g or more from 1961-1974 and 1978-1996. Unexplained fetal deaths were defined as fetal deaths occurring before labor without evidence of significant fetal, maternal, or placental pathology. RESULTS: One hundred ninety-six unexplained antepartum fetal deaths accounted for 27.2% of 721 total fetal deaths. Two thirds of the unexplained fetal deaths occurred after 35 weeks' gestation. The following factors were independently associated with unexplained fetal death: maternal prepregnancy weight greater than 68 kg (adjusted odds ratio [OR] 2.9; 95% confidence interval [CI] 1.85, 4.68), birth weight ratio (defined as ratio of birth weight to mean weight for gestational age) between 0.75 and 0.85 (OR 2.77; 95% CI 1.48, 5.18) or over 1.15 (OR 2.36; 95% CI 1.26, 4.44), fewer than four antenatal visits in women whose fetuses died at 37 weeks or later (OR 2.21; 95% CI 1.08, 4.52), primiparity (OR 1.74; 95% CI 1.26, 2.40), parity of three or more (OR 2.01; 95% CI 1.26, 3.20), low socioeconomic status (OR 1.59; 95% CI 1.14, 2.22), cord loops (OR 1.75; 95% CI 1.04, 2.97) and, for the 1978-1996 period only, maternal age 40 years or more (OR 3.69; 95% CI 1.28, 10.58). Trimester of first antenatal visit, low maternal weight, postdate pregnancy, fetal-to-placental weight ratio, fetal sex, previous fetal death, previous abortion, cigarette smoking, and alcohol use were not significantly associated with unexplained fetal death. CONCLUSION: In this study, we identified several factors associated with an increased risk of unexplained fetal death.

Successful pregnancy complicated by peritonitis in a 35- year old CAPD patient.

A 35-year old woman conceived six months after initiating continuous ambulatory peritoneal dialysis (CAPD). A medical plan was developed to give the patient adequate dialysis for a 1.5 g/kg/day protein intake. In addition, alterations in calcium, magnesium, and erythropoietin administration were required to reach the objectives set by the obstetrical/renal team. Three weeks prior to delivery, an amniotic leak developed, and vaginal cultures were positive for Escherichia coli. Oral amoxicillin was administered (500 mg per os q.i.d.) until the day of delivery. A 1545-g baby girl was delivered by cesarean section at 32 weeks. Five days postpartum the patient developed severe peritonitis, which subsequently grew E. coli. The patient fully recovered from the peritonitis, but catheter removal was required. Successful pregnancy can be expected on CAPD, and adequacy can be achieved with aggressive dialysis. Cesarean section delivery should probably be accompanied by full peritonitis therapy.

Obstetric implications of low-lying placentas diagnosed in the second trimester.

OBJECTIVES: To determine the obstetrical outcome of pregnancies initially complicated by a low-lying placenta in the second trimester. METHODS: We reviewed the obstetric outcome of all women with singleton deliveries from 1 January 1997 to 31 March 1999 and compared the 703 women with low-lying placentas (placentas in the lower uterine segment) with the 6938 women with placentas that were normally situated in the upper uterine segment at 16-22 weeks' gestation. RESULTS: Pregnancies complicated by a low-lying placenta in the second trimester were not associated with antepartum hemorrhage, preterm births, preterm prelabor rupture of membranes, pregnancy-induced hypertension, fetal growth restriction or cesarean births. However, they had a higher incidence of postpartum hemorrhage (odds ratio 1.768, 95% confidence interval 1.137, 2.748) than women with a normally situated placenta in the second trimester. CONCLUSIONS: Pregnant women with low-lying placentas in the second trimester have a higher incidence of postpartum hemorrhage and hence, it would be prudent to carefully manage the third stage of labor in these women.