Maternal postpartum complications according to delivery mode in twin pregnancies

OBJECTIVE:

We aimed to examine maternal postpartum complications of twin deliveries according to mode of delivery and investigate the associated risk factors.

METHODS:

This was a retrospective cohort review of twin pregnancies with delivery after 26 weeks at a tertiary teaching hospital (1993-2008). The rates of maternal postpartum complications were compared among vaginal, elective cesarean and emergency cesarean deliveries. Significant predictors of complications were investigated with stepwise regression analysis and relative risks were calculated.

RESULTS:

A total of 90 complications were observed in 56/817 (6.9%) deliveries: 7/131 (5.3%) vaginal, 10/251 (4.0%) elective cesarean and 39/435 (9.0%) emergency cesarean deliveries. Significant predictors included high-risk pregnancy, gestational age at birth and delivery mode. The occurrence of complications was significantly increased in emergency compared to elective cesarean deliveries (RR = 2.34).

CONCLUSIONS:

Maternal postpartum complications in twin pregnancies are higher in emergency compared to elective cesarean deliveries and are also related to preexisting complications and earlier gestational age at delivery.     

Risk factors for postpartum hemorrhage after vaginal delivery of twins.

We examined vaginal deliveries of twins to identify factors most strongly associated with the increased risk of postpartum hemorrhage (estimated blood loss > or = 1,000 mL). We reviewed the obstetric records of all 171 twin vaginal deliveries at Japanese Red Cross Katsushika Maternity Hospital from January 2002 through August 2006. Of these deliveries, 41 (24%) were complicated by postopartum hemorrhage. Postpartum hemorrhage was significantly more likely in cases with gestational age > or = 39 weeks (odds ratio [OR], 3.47; 95% confidence interval [CI], 1.65-7.28), a combined birth weight of more than 5,500 g (OR, 2.53; 95% CI, 1.00-6.45), induction of labor (OR, 2.87; 95% CI, 1.38-5.98), oxytocin administration during labor (OR, 2.86; 95% CI, 1.27-6.48), or a duration of labor > or = 24 hours (OR, 2.55; 95% CI, 1.15-5.62). Postpartum hemorrhage is a frequent complication in twin pregnancies. Therefore, special attention should be given after birth to patients with induction of labor or intervened delivery especially at > or = 39 weeks gestation.     

Obstetric and perinatal outcome of children conceived from cryopreserved embryos

The main purpose of this study was to evaluate the obstetric and neonatal outcome of children conceived from cryopreserved embryos. The medical records of 270 infants (163 singletons, 98 twins and nine triplets) were reviewed and compared with two control populations of children born after in-vitro fertilization (IVF) with fresh embryos and children born after spontaneous pregnancies. The controls were matched according to maternal age, parity, plurality and date of delivery. In the cryopreserved group the gestational age at delivery for singletons was 279 +/- 13 days with birthweight 3476 +/- 616 g; for twins gestational age was 257 +/- 19 days with birthweight 2574 +/- 560 g; for triplets gestational age was 228 +/- 3 days with birthweight 1752 +/- 183 g. The incidence of preterm birth (< 37 weeks gestation) was 5.6% for singletons, 44.9% for twins and 100% for triplets. Seven children had major malformations (2.7%) and perinatal mortality occurred in two children (8/1000). Gestational age at delivery, birthweight, the incidence of malformations and the perinatal mortality were comparable with the two control groups both for singletons and twins. Significantly more singletons in the cryopreserved group were delivered by Caesarean section compared with the spontaneous group. The number of infants with low Apgar score (< 7 at 5 min) and the number of infants admitted to neonatal intensive care units were similar in the cryopreserved and spontaneous groups. In conclusion, the cryopreservation process did not seem to adversely influence fetal development and no increased perinatal risk was found.      

Mode of delivery and postpartum morbidity among HIV-infected women: the women and infants transmission study

Cesarean delivery before onset of labor and rupture of membranes (i.e., scheduled cesarean delivery) is associated with a lower risk of vertical transmission of HIV. The following a priori hypotheses were tested: among HIV-infected women, scheduled cesarean delivery is associated with a higher risk of postpartum morbidity, longer hospitalization, and a higher risk of rehospitalization than spontaneous vaginal delivery. Postpartum morbidity occurred following 178 of 1,186 (15%) of deliveries during 1990 to 1998 in The Women and Infants Transmission Study. The most commonly reported postpartum morbidity events were: fever without infection, hemorrhage or severe anemia, endometritis, urinary tract infection, and cesarean wound complications. Several time trends were observed: the median duration of ruptured membranes decreased (p < .001), intrapartum antibiotic use increased (p < .001), the median antepartum plasma HIV RNA concentration decreased (p < .001), and the incidence of any postpartum morbidity decreased (p = .02). With spontaneous vaginal delivery as the reference category, both scheduled (odds ratio [OR] = 4.69; 95% confidence interval [95% CI], 2.03-10.84), and nonscheduled (OR, 2.50; 95% CI, 1.24-5.04) cesarean deliveries were associated with fever without infection; with urinary tract infection (OR, 3.79; 95% CI 1.04-13.85; OR, 3.86; 95% CI, 1.55-9.60, respectively), and with any postpartum morbidity (OR, 3.19; 95% CI 1.69-6.00; OR, 4.10; 95% CI, 2.71-6.19, respectively). Nonscheduled cesarean deliveries were more likely to be complicated by endometritis (OR, 6.98; 95% CI, 3.53-13.78). Adjusted ORs relating mode of delivery and each of the outcomes (fever without infection, urinary tract infection, endometritis, and any postpartum morbidity) were similar to unadjusted ORs. Results of this analysis indicate scheduled cesarean delivery is associated with an increased risk of any postpartum morbidity and, specifically, postpartum fever without infection. The potential for postpartum morbidity with scheduled cesarean delivery should be considered in light of possible adverse events associated with other interventions to decrease the risk of vertical transmission of HIV. Counseling of HIV-infected pregnant women regarding scheduled cesarean delivery as a possible intervention to decrease maternal-infant transmission of HIV should include discussion of these results, as well as new data as they become available, regarding the incidence and severity of postpartum morbidity events among HIV-infected women according to mode of delivery.     

Mode of delivery and risk of allergic rhinitis and asthma

BACKGROUND: It has been hypothesized that cesarean section might increase the risk of developing allergic disease by depriving the fetus and newborn of exposure to maternal microflora. Furthermore, it has been suggested that complicated modes of delivery might be associated with an increased risk of asthma. OBJECTIVE: The purpose of this investigation was to study whether cesarean section and other complicated modes of delivery are associated with an increased risk of allergic rhinitis or asthma. METHODS: Information on self-reported allergic rhinitis, asthma ever, current asthma, and occupation was obtained from 9722 singleton women born in Denmark during the period 1973-1977 who participated in a national cohort study during the period 1997-2001. For these women, information was available on mode of delivery (spontaneous delivery, cesarean section, vacuum extraction, or other complicated mode of delivery, such as rotation/traction or use of forceps), gestational age, birth weight, and length at birth from the Danish Medical Birth Register. Information on parity and maternal age was obtained from the Danish Civil Registration System. RESULTS: The odds ratios (ORs) of allergic rhinitis were 1.16 (95% CI, 0.90-1.49) for cesarean section and 1.06 (95% CI, 0.85-1.32) for other complicated modes of delivery in comparison with spontaneous delivery. The corresponding ORs of asthma ever were 1.33 (95% CI, 1.02-1.74) and 1.18 (95% CI, 0.94-1.49) for cesarean section and other complicated modes of delivery, respectively, and the ORs of current asthma were 1.22 (95% CI, 0.87-1.73) and 1.26 (95% CI, 0.94-1.68), respectively, in comparison with spontaneous delivery. CONCLUSIONS: Our findings do not support the hypothesis that cesarean section or other complicated modes of delivery are associated with the development of allergic rhinitis. However, there might be a positive association with development of asthma--in particular, for cesarean section--that was not explained by gestational age, birth weight, ponderal index, smallness for gestational age, parity, maternal age, or occupation.     

Pregnancy Outcomes in HIV-Infected Women of Advanced Maternal Age

Abstract

Background: There is limited information on pregnancy outcomes in women with HIV who are of a more advanced maternal age.Methods: Data from a national observational study in Italy were used to evaluate the risk of nonelective cesarean section, preterm delivery, low birthweight, major birth defects, and small gestational age-adjusted birthweight according to maternal age (<35 and ≥35 years, respectively).Results: Among 1,375 pregnancies with live births, 82.4% of deliveries were elective cesarean sections, 15.8% were nonelective cesarean sections, and 1.8% were vaginal deliveries. Rates of nonelective cesarean section were similar among mothers ≥35 and <35 years (odds ratio [OR], 1.22; 95% CI, 0.90–1.65;P = .19). Preterm delivery and low birthweight were significantly more common among women ≥35 years in univariate but not in multivariate analyses. Newborns from women ≥35 and <35 years showed no differences inZ scores of birthweight, with a similar occurrence of birthweight <10th percentile (12.1% vs 12.0%; OR, 1.02; 95% CI, 0.71–1.46;P = .93). The overall rate of birth defects was 3.4% (95% CI, 2.4–4.4), with no differences by maternal age (≥35 years, 3.5%; <35 years, 3.3%; OR, 1.05; 95% CI, 0.56–1.98;P = .88).Discussion: In this study of pregnant women with HIV, older women were at higher risk of some adverse pregnancy outcomes, such as preterm delivery and low birthweight. The association, however, did not persist in multivariable analyses, suggesting a role of some predisposing factors associated with older age.     

The influence of gestational age and smoking habits on the risk of subsequent preterm deliveries.

BACKGROUND: Previous preterm delivery and maternal smoking are associated with increased risks of preterm delivery. It is not known whether gestational age at the time of a preterm delivery is correlated with gestational age in successive preterm deliveries and whether changes in smoking habits influence the subsequent risk of preterm delivery. METHODS: We studied the associations among smoking habits, previous very preterm or moderately preterm delivery (before 32 weeks and at 32 to 36 weeks, respectively), and the risk of a subsequent very preterm or moderately preterm delivery in a population-based cohort of 243,858 women in Sweden between 1983 and 1993. The results were adjusted for covariates known to be associated with preterm delivery. RESULTS: The odds ratios for very or moderately preterm delivery in a subsequent pregnancy among women with a previous very preterm delivery, as compared with women who had a previous term delivery, were 12.4 (95 percent confidence interval, 9.1 to 17.0) and 7.1 (95 percent confidence interval, 6.0 to 8.4), respectively. Among women with a previous moderately preterm delivery, the corresponding odds ratios were 2.3 (95 percent confidence interval, 1.9 to 3.0) and 5.9 (95 percent confidence interval, 5.5 to 6.3), respectively. The odds ratios for a very preterm second delivery among the women who smoked 1 to 9 cigarettes per day and those who smoked 10 or more cigarettes per day, as compared with nonsmokers, were 1.4 (95 percent confidence interval, 1.1 to 1.7) and 1.6 (95 percent confidence interval, 1.3 to 2.0), respectively. The corresponding odds ratios for moderate preterm delivery were 1.3 (95% confidence interval, 1.2 to 1.4) and 1.5 (95 percent confidence interval, 1.4 to 1.6). The women who quit smoking between pregnancies were not at increased risk for very or moderately preterm delivery, whereas the women who started to smoke in the second pregnancy had the same risk as those who continued to smoke. CONCLUSIONS: The risk of a very preterm delivery in successive pregnancies is increased primarily among women with a previous very preterm delivery. Changes in smoking habits influence the risk of preterm delivery as well.     

Lower risks of adverse outcome in twins conceived by artificial reproductive techniques compared with spontaneously conceived twins

The outcomes of twins conceived by 136 women after medical assistance (MA) such as ovulation induction with or without assisted reproductive techniques, and twins conceived spontaneously (SP) by 72 women were compared. All 208 women were monitored from < 20 weeks gestation; they all delivered at > or = 24 weeks gestation. The chorionicity of the placenta was diagnosed antenatally and confirmed after delivery. There were 10 perinatal deaths; the physical and neurological status of the remaining 406 infants was assessed at 1 year of corrected age. There were no differences in gestational age at birth, the birth weights of the larger and smaller twins, the birth weight discordance, or the incidence of life-threatening major malformations between groups. Adverse infant outcomes, such as death, cerebral palsy and mental retardation occurred in nine (3.3%) of 272 MA twins compared with 12 (8.3%) of 144 SP twins (P < 0.05). The placenta was monochorionic in only three (2.2%) of 136 MA twin pregnancies compared with 41 (57%) of 72 SP twin pregnancies (P < 0.001). Of the 21 infants with adverse outcomes, nine had monochorionic placentas. Thus, the risk of an adverse outcome was 2.8-fold higher (95% confidence interval (CI) 1.2- 6.4) in monochorionic twins than in dichorionic twins (10 versus 3.7%; P < 0.05). There was no difference in the incidence of adverse infant outcomes between SP (4.8%) and MA (3.4%) twins with dichorionic placentas. These findings suggest that ovulation induction in itself was not associated with an adverse outcome of twin pregnancies. The lower frequency of monochorionic placentas in MA twins may have been responsible for the lower risk of an adverse outcome in MA twins.      

Relationship between twin-to-twin delivery interval and umbilical artery acid-base status in the second twin

The purpose of this study was to determine the effect of twin-to-twin delivery interval on umbilical artery acid-base status of the second twin at birth. This was a retrospective cohort study of all live-born twins with measured acid-base status in umbilical arterial blood who were delivered after 34 weeks' gestation from June 2003 to February 2006. Twins with any maternal or fetal complications were excluded. Subjects were divided into two groups based on the mode of delivery of the first twin: normal cephalic vaginal deliveries (n=40) or cesarean deliveries (n=67). The inter-twin differences in umbilical arterial blood pH, PCO(2), PO(2), and base excess in twin newborns born vaginally were significantly greater than the corresponding differences in those born by cesarean section. A significant positive correlation was found between twin-to-twin delivery interval and inter-twin difference in umbilical arterial blood pH in twin newborns born vaginally. The umbilical arterial blood pH of the second twin was less than 7.0 in 14% (2/14) in cases delivered more than 20 min after the first twin. The umbilical arterial blood gas status of the second twin worsened with increasing twin-to-twin delivery interval, and pathologic fetal acidemia (pH<7.0) might develop in the second twin when the twin-to-twin delivery interval was greater than 20 min.     

A typical postcesarean epithelioid trophoblastic lesion with placenta increta: Case report and literature review

We report an extremely rare case of unusual atypical epithelioid trophoblastic lesion from placenta increta. A 25-year-old Chinese woman with a history of 1 cesarean delivery was admitted to the hospital at 37 weeks’ gestation. Magnetic resonance imaging (MRI) showed the feature of placenta increta. An elective primary cesarean section was scheduled and a healthy baby was born. The patient was suggestive of placenta increta and implantation site was resected. Histology indicated a lesion consisting of epithelioid trophoblastic cells with an intermediate pattern between a classical placental site nodule and an epithelioid trophoblastic tumor. This may be linked to her previous cesarean delivery, which supports the relationship between atypical epithelioid trophoblastic lesion formation and surgical interventions. Her serum human chorionic gonadotropin (hCG) was 352.4 IU/L after delivery and gradually decreased to normal level.     

Urinary incontinence and vaginal squeeze pressure two years post-cesarean delivery in primiparous women with previous gestational diabetes mellitus

OBJECTIVE:

To assess the prevalence of urinary incontinence and associated vaginal squeeze pressure in primiparous women with and without previous gestational diabetes mellitus two years post-cesarean delivery.

METHODS:

Primiparous women who delivered by cesarean two years previously were interviewed about the delivery and the occurrence of incontinence. Incontinence was reported by the women and vaginal pressure evaluated by a Perina perineometer. Sixty-three women with gestational diabetes and 98 women without the disease were screened for incontinence and vaginal pressure. Multiple logistic regression models were used to evaluate the independent effects of gestational diabetes.

RESULTS:

The prevalence of gestational incontinence was higher among women with gestational diabetes during their pregnancies (50.8% vs. 31.6%) and two years after a cesarean (44.8% vs. 18.4%). Decreased vaginal pressure was also significantly higher among women with gestational diabetes (53.9% vs. 37.8%). Maternal weight gain and newborn weight were risk factors for decreased vaginal pressure. Maternal age, gestational incontinence and decreased vaginal pressure were risk factors for incontinence two years after a cesarean. In a multivariate logistic model, gestational diabetes was an independent risk factor for gestational incontinence.

CONCLUSIONS:

The prevalence of incontinence and decreased vaginal pressure two years post-cesarean were elevated among women with gestational diabetes compared to women who were normoglycemic during pregnancy. We confirmed an association between gestational diabetes mellitus and a subsequent decrease of vaginal pressure two years post-cesarean. These results may warrant more comprehensive prospective and translational studies.     

Birth weight in pre-eclamptic and normotensive twin pregnancies: an analysis of discordance and growth restriction

The aim of this study was to verify whether twin pregnancies complicated by pre-eclampsia were associated with a higher rate of inter-twin weight discordance or an increased prevalence of small for gestational age (SGA) neonates than in normotensive twin pregnancies. A 17 year retrospective study was undertaken by examining 76 twin pregnancies complicated by pre-eclampsia and comparing them with 400 normotensive twin pregnancies. The case notes were reviewed in reference to birth weight differences, birth order, pregnancy outcome and inter-twin birth weight discordance. Statistical analyses were performed with t-test, contingency tables, regression curves, rank sum test and non-parametric survival plots. Power analysis was also carried out. Pre-eclamptic twin pregnancies were delivered at similar weeks of gestation to normotensive. They resulted in a smaller size for the second twin the earlier the delivery week, while in normotensive twin pregnancies no significant difference occurred at any week. Twin pregnancies complicated by pre-eclampsia showed higher rates of SGA neonates among second twins than those with normal pressure. The >25% discordance was associated with lower gestational age at delivery in each group [mean (range) 33 weeks (27-38) versus 37 (29-41), P < 0.005 pre-eclampsia and 35 weeks (25-41) versus 38 (25-42), P < 0.001 normotensive]. In pre-eclampsia the concomitant occurrence of SGA second twin and the discordance >25% was associated with shorter gestation while the presence of SGA second twin alone was not.     

Uterine artery Doppler velocimetry and the outcome of pregnancies resulting from ICSI.

BACKGROUND: An increased incidence of pregnancy complications following assisted reproduction has been reported. The use of uterine artery Doppler ultrasound may aid the prediction of such complications. METHODS: Doppler was performed at 18-24 weeks gestation in 114 singleton and 32 twin pregnancies after intracytoplasmic sperm injection (ICSI) and compared with a control group matched for age, parity and plurality. Outcome variables included gestational age at delivery, prematurity, preterm premature rupture of membrane (PPROM), birth weight, birth weight discordance of >20% in twins, small for gestational age (SGA), mode of delivery, development of pre-eclampsia and placental abruption. RESULTS: Compared with the controls, there were no significant differences concerning uterine Doppler parameters, pregnancy complications and the neonatal outcome, either in singleton or in twin pregnancies. According to Doppler results and/or risk factors by medical history, 42% of singleton ICSI and 39% of spontaneous singleton pregnancies were considered as high risk. In singletons, abnormal Doppler findings were associated with pre-eclampsia in 22% and SGA in 26% of ICSI patients, compared with 33 and 21% in controls; in contrast, 0 and 10% in ICSI and 3 and 6% in controls showed these complications but no risk factors respectively. No correlation was found between PPROM, prematurity, the rate of Caesarean section and pathological Doppler results. CONCLUSIONS: Uterine Doppler examination holds the potential to identify patients with an increased risk for developing pregnancy complications. According to our results, this risk is not elevated after ICSI treatment, therefore the decision of offering an intensified antenatal care should be based on the results of Doppler examination or risks by medical history rather than the mode of conception.     

Reduction of multifetal pregnancies to twins does not increase obstetric or perinatal risks.

Selective reduction in cases of multiple fetuses is used more often nowadays due to the increased number of multiple pregnancies resulting from assisted reproduction. In this retrospective study, we investigated whether twin pregnancies derived from fetal reduction carry a higher obstetric and perinatal risk compared to standard twin pregnancies. We found that the rate of miscarriage was 10.6% in the reduction group (n = 158) compared to 9.5% in the controls (n = 135). Mean gestational age at delivery was 35.7 weeks in the reduction group versus 35.1 weeks in the control group. Mean neonatal weight at birth was 2.260 g (800-3.750 g) in the reduction group compared to 2.240 g (540-3.360 g) in controls. Perinatal mortality rate was 49.3 per thousand after reduction and 42.0 per thousand in the control group. There was no statistically significant difference in any of the above parameters. Therefore, multifetal pregnancy reduction to twins does not appear to increase obstetric or perinatal risks.     

Neonatal outcome in a Danish national cohort of 3438 IVF/ICSI and 10,362 non-IVF/ICSI twins born between 1995 and 2000

BACKGROUND: In Denmark, one-third of twin pregnancies are the result of IVF/ICSI treatment. Limited data on neonatal outcome in IVF/ICSI twins are available in the literature. METHODS: A register study was conducted on neonatal morbidity and mortality in a complete national twin cohort including all 3438 (3393 live-born) IVF/ICSI and 10,362 (10,239 live-born) non-IVF/ICSI twins born between 1995 and 2000. Twins were identified in the National Medical Birth Registry and dichotomized into IVF/ICSI and non-IVF/ICSI by cross-reference with the Danish IVF Registry. Data on neonatal morbidity and mortality were retrieved from the Danish Patient Registry and the Danish Registry of Causes of Deaths. In order to exclude monozygotic twins, sub-analyses on unlike-sex twins were conducted. RESULTS: A birth weight discordance of >20% was observed in 20.6% of IVF/ICSI versus 15.7% of control twin pairs (P < 0.001). The risk of discordant birth weight >20% was OR 1.29 (95% CI 1.04-1.58) in unlike-sex IVF/ICSI twins versus control twins. The risk of delivery at <37 completed weeks and birth weight <2500 g was similar in the two cohorts; however, in unlike-sex IVF/ICSI versus control twins the risk of delivery at <37 weeks and birth weight <2500 g was OR 1.22 (95% CI 1.09-1.38) and OR 1.25 (1.11-1.40) respectively. After stratification for maternal age and parity, these risks disappeared. IVF/ICSI twins carried a higher risk of admittance to a neonatal intensive care unit (NICU) than control twins (OR 1.18, 95% CI 1.09-1.27), and this was even more pronounced in unlike-sex twins [OR 1.34 (95% CI 1.19-1.51)]. No differences were observed in malformation or mortality rates between the two cohorts. CONCLUSIONS: Despite higher birth weight discordance and more NICU admissions among IVF/ICSI twins, neonatal outcome in IVF/ICSI twins seems to be comparable with that of non-IVF/ICSI twins, when only dizygotic twins were considered in the comparisons.     

Risk factors for peripartum blood transfusion in women with placenta previa: a retrospective analysis

BACKGROUND: The incidence of placenta previa has been increasing. It is of a great importance to determine the clinical risk factors for peripartum blood transfusion in women with placenta previa in an effort to anticipate cases of severe hemorrhage. METHODS: A total of 129 consecutive cases of placenta previa (64 cases of complete placenta previa and 65 cases of marginal placenta previa), including 43 cases requiring blood transfusion, were retrospectively analyzed. Maternal and neonatal clinical data were examined with univariate and multivariate logistic regression analyses for potential risk factors for peripartum blood transfusion. RESULTS: The independent risk factors for blood transfusion were maternal age greater than 34 years (adjusted odds ratio [OR]=3.7; 95% confidence interval [CI]=1.5-7.5, p<0.05), history of having undergone dilatation and curettage more than once (adjusted OR=4.8; 95% CI=1.1-26.2, p<0.05), and complete placenta previa (adjusted OR=2.6, 95% CI=1.2-5.9, p<0.05). Body mass index, gravidity, parity, previous cesarean section, antepartum hemorrhage, use of tocolytic agents, gestational age at delivery, preoperative anemia, emergent surgery, birth weight, and Apgar score were not associated with the incidence of blood transfusion. CONCLUSION: Risk factors for blood transfusion in women with placenta previa are advanced maternal age, repeat dilatation and curettage, and complete placenta previa. Women with placenta previa who are at risk for blood transfusion should be carefully managed with sufficient preparation for blood transfusion.     

Pregnancy outcome after multifetal pregnancy reduction to twins compared with spontaneously conceived twins

Multifetal pregnancy reduction (MFPR) appears to be an efficaciousmethod for improving the perinatal outcome of ‘high order’multifetal gestations. The present study was undertaken to evaluatepregnancy outcomes after MFPR to twins in comparison with spontaneouslyconceived twins. In all, 10 patients with quadruplet gestations(group 1) and 30 patients with triplet gestations (group 2),who underwent MFPR to twins, were prospectively enrolled. Pregnancycomplications, gestational age at delivery, mode of deliveryand birthweights were compared with 30 consecutive spon-taneoustwin gestations (group 3) matched by maternal age and parity.Mean gestational age at delivery and mean birthweights weresignificantly lower in group 1, compared with groups 2 and 3(33.2, 35.9, 36.9 weeks, and 1843, 2209, 2361 g respectively).The incidence of pregnancy complications was significantly higherin group 1 compared with group 3. There was also a clear trendof increased incidence of specific pregnancy complications ingroup 1 compared with groups 2 and 3, especially premature contractions(PMC; 50, 27 and 13% respectively), and pregnancy-induced hypertension(PIH; 40, 23 and 7% respectively). In conclusion, the initialnumber of fetuses before reduction was inversely correlatedwith gestational age at delivery and birthweight, and positivelycorrelated with pregnancy complications. Contrary to previousstudies, we found a higher incidence of pregnancy complicationsafter MFPR compared with spontaneous twins, especially PMC andPIH.     

Risk of uterine rupture during labor among women with a prior cesarean delivery.

BACKGROUND: Each year in the United States, approximately 60 percent of women with a prior cesarean delivery who become pregnant again attempt labor. Concern persists that a trial of labor may increase the risk of uterine rupture, an uncommon but serious obstetrical complication. METHODS: We conducted a population-based, retrospective cohort analysis using data from all primiparous women who gave birth to live singleton infants by cesarean section in civilian hospitals in Washington State from 1987 through 1996 and who delivered a second singleton child during the same period (a total of 20,095 women). We assessed the risk of uterine rupture for deliveries with spontaneous onset of labor, those with labor induced by prostaglandins, and those in which labor was induced by other means; these three groups of deliveries were compared with repeated cesarean delivery without labor. RESULTS: Uterine rupture occurred at a rate of 1.6 per 1000 among women with repeated cesarean delivery without labor (11 women), 5.2 per 1000 among women with spontaneous onset of labor (56 women), 7.7 per 1000 among women whose labor was induced without prostaglandins (15 women), and 24.5 per 1000 among women with prostaglandin-induced labor (9 women). As compared with the risk in women with repeated cesarean delivery without labor, uterine rupture was more likely among women with spontaneous onset of labor (relative risk, 3.3; 95 percent confidence interval, 1.8 to 6.0), induction of labor without prostaglandins (relative risk, 4.9; 95 percent confidence interval, 2.4 to 9.7), and induction with prostaglandins (relative risk, 15.6; 95 percent confidence interval, 8.1 to 30.0). CONCLUSIONS: For women with one prior cesarean delivery, the risk of uterine rupture is higher among those whose labor is induced than among those with repeated cesarean delivery without labor. Labor induced with a prostaglandin confers the highest risk.     

The physician factor in cesarean birth rates

To investigate the influence of physicians' practice styles on the rate of deliveries by cesarean section, we studied 1533 affluent women at low risk of obstetrical complications who were cared for by 11 obstetricians in a single community hospital. The mean rate of delivery by cesarean section was 26.9 percent, but the rate ranged from 19.1 to 42.3 percent, according to the physician. The mean rate of primary cesarean section (i.e., the rate for women without previous cesarean deliveries) was 17.2, with a range of 9.6 to 31.8 percent. A stepwise logistic-regression model of the determinants of primary cesarean section, including the individual physician, parity, birth weight, and maternal age and excluding specific medical indications, showed that only nulliparity (P less than 0.0001) was more important than the identity of the physician (P less than 0.001) in its influence on the rate of cesarean section. Variation in cesarean-section rates among physicians was not attributable to the practice setting, the patient population, the degree of obstetrical risk, or the physician's recent medicolegal experience, and it was not accompanied by corresponding differences in neonatal outcome. We conclude that individual practice style may be an important determinant of the wide variations in the rates of cesarean delivery among obstetricians. Our data do not permit us to say with certainty whether the procedure is overused by some obstetricians or underused by others, but we found no obvious differences in neonatal outcome associated with differences in the cesarean-section rate.     

Time of delivery and perinatal outcome

The purpose of this study was to examine the association between time of delivery and perinatal outcomes in singleton deliveries at Japanese Red Cross Katsushika Maternity Hospital. We performed a retrospective cohort study of all singleton deliveries at ≥ 22 weeks' gestation from 2002 through 2009 at our hospital. During the nighttime period (12 midnight to 8 am), although the rate of delivery of high-risk pregnancies was low, the rate of low umbilical artery pH (< 7) was higher than that during the daytime periods (8 am to 4 pm) (odds ratio 1.9, 95% confidence interval 1.1-3.4, p = 0.02). During the nighttime period, in addition, the rate of low umbilical artery pH in patients with emergent cesarean delivery was significantly higher than that during the daytime period (odds ratio 6.9; 95% confidence interval 2.5-19, p < 0.01). In our hospital, the rate of adverse neonatal outcomes associated with cesarean birth was increased at nighttime period.