Changes in fetal heart rate and uterine patterns associated with uterine rupture

OBJECTIVE: To determine changes in fetal heart rate (FHR) and uterine patterns preceding complete uterine rupture. STUDY DESIGN: FHR and uterine patterns of 50 women with uterine rupture were compared with 601 tracings of controls without scarred uteri. Tracings were interpreted using the National Institute of Child Health and Human Development Research Planning Workshop guidelines. RESULTS: Interobserver and intraobserver agreements of FHR and uterine tracings in the uterine rupture group were excellent (kappa of .96 for both variables). Comparing tracing patterns during the first stage, higher rates of severe fetal bradycardia (4.0% vs. 1.0%, P = .064), fetal tachycardia (8.0% vs. 2.3%, P = .042), reduced baseline variability (24.0% vs. 12.5%, P = .021), uterine tachysystole (10.0% vs. 0.8%, P < .001) and disappearance of contractions (6.0% vs. 0, P < .001) were noted among patients with uterine rupture as compared to the controls. During the second stage of labor, patients with uterine rupture had significantly higher rates of reduced baseline variability (47.8% vs. 7.7%, P < .001), severe variable decelerations (26.1% vs. 6.4%, P = .004), uterine tachysystole (22.0% vs. 0.5%, P < .001) and disappearance of contractions (13.0% vs. 0, P < .001). Using a backward, stepwise multiple logistic regression model, severe fetal bradycardia (OR = 8.2, 95% CI 2.2-31.0, P = .002) and uterine tachysystole (OR = should alert the 8.0, 95% CI 1.7-37.9, P = .008) were found to be independent patterns preceding uterine rupture during the first stage of labor. Likewise, during the second stage, reduced baseline variability (OR = 4.2, 95% CI 1.4-12.3, P = .009) and uterine tachysystole (OR = 42.3, 95% CI 10.6-168.3, P < .001) were independently associated with uterine rupture in another multivariable analysis. CONCLUSION: Abnormal monitor patterns among women presenting with risk factors for uterine rupture, specifically uterine tachysystole, reduced baseline variability and severe bradycardia, should act as warning signs to the obstetrician.     

Obstetric characteristics and perinatal outcome of pregnancies with uterine leiomyomas

OBJECTIVE: To determine the rate, obstetric characteristics and perinatal outcome of pregnancies with uterine leiomyomas. STUDY DESIGN: A population-based study comparing all singleton deliveries between the years 1988 and 1999 in women with and without uterine leiomyomas was performed. Patients lacking prenatal care were excluded from the analysis. Multivariable analysis, adjusting for possible confounders, such as maternal age, parity and gestational age, was performed to investigate associations between uterine leiomyomas and selected outcomes. RESULTS: There were 105,909 singleton deliveries with 690 (0.65%) complicated by uterine leiomyomas during the study period. Using a multivariable analysis, the following conditions were significantly associated with uterine leiomyomas: nulliparity (odds ratio [OR]=4.0, 95% confidence interval [CI] 3.3-4.7, P<.001), chronic hypertension (OR=1.9, 95% CI 1.6-2.4, P<.001), hydramnios (OR=1.5, 95% CI 1.2-2.0, P<.001), diabetes mellitus (OR=1.4, 95% CI 1.1-1.7, P=.001) and advanced maternal age (OR=1.2, 95% CI 1.1-1.2, P<.001). Higher rates of perinatal mortality (2.2% vs. 1.2%, OR=1.8, 95% CI 1.1-3.2, P<.001) were found in the uterine leiomyoma group as compared to the control group. While adjusting for maternal age, parity, gestational age and malpresentation, pregnancies with uterine leiomyomas had higher rates of cesarean deliveries (OR=6.7, 95% CI 5.5-8.1, P<.001), placental abruption (OR=2.6, 95% CI 1.6-4.2, P<.001) and preterm deliveries (<36 weeks' gestation, OR=1.4, 95% CI 1.1-1.7, P=.009) as compared to pregnancies without uterine leiomyomas. Conversely, no significant differences were noted regarding perinatal mortality (OR=1.4, 95% CI 0.7-2.8, P=.351) after controlling for maternal age, parity and gestational age using a multivariable analysis. CONCLUSION: Uterine leiomyomas increase the risk of adverse pregnancy outcomes, thus emphasizing the importance of appropriate intrapartum management of these high-risk pregnancies.     

Oral, vaginal and sublingual misoprostol for induction of labor.

OBJECTIVE: To evaluate the effectiveness and safety of different administration routes of misoprostol for induction of labor. METHOD: PubMed, Cochrane Library and EMBASE searches were carried out using the keywords oral, vaginal, sublingual, buccal, misoprostol, labor induction, identifying randomized case-controlled trials comparing different routes for giving misoprostol to induce labor, published in English between 1994 and 2004. RESULTS: Seventeen studies (3549 participants) were included. Compared to vaginal administration, oral misoprostol was associated with higher failure rates for achieving vaginal delivery within 24 h (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.23-2.10), higher rates of uterine hyperstimulation without fetal heart rate (FHR) changes (OR 2.21, 95% CI 1.12-4.34) and lower cesarean section rates (OR 0.74, 95% CI 0.56-0.97). A lower dose of oral misoprostol (50 microg) compared to the 25-50 microg administered vaginally was associated with a higher rate of vaginal delivery not being achieved within 24 h (OR 3.60, 95% CI 2.10-6.18), more need for oxytocin augmentation (OR 2.19, 95% CI 1.65-2.92), less uterine hyperstimulation both without FHR changes (OR 0.58, 95% CI 0.42-0.80) and with FHR changes (OR 0.34, 95% CI 0.17-0.67) and fewer cesarean sections (OR 0.69, 95% CI 0.51-0.91). Compared to vaginal administration, buccal misoprostol resulted in a higher rate of failure to achieve vaginal delivery after 24 h, more frequent uterine hyperstimulation and lower rates of cesarean section, but these differences were not significant. When 50 mug of misoprostol used sublingually was compared to oral administration, the sublingual misoprostol was associated with less failure to achieve vaginal delivery after 24 h, less oxytocin augmentation and reduced cesarean section, but none of the differences were statistically significant. CONCLUSIONS: Vaginal misoprostol appears more effective than the equivalent dosage administered orally. However, the vaginal route appears to be associated with a higher risk of uterine hyperstimulation. Sublingual misoprostol seems an effective route of administration, but a lack of data necessitates more clinical trials to establish the effectiveness and safety of the buccal/sublingual route.     

Oral versus vaginal misoprostol for induction of labor: a double-blind randomized controlled trial

OBJECTIVE: To determine the efficacy of oral misoprostol (50 microg) administered every 3 hours compared to vaginal misoprostol (50 microg) administered every 6 hours for induction of labor. STUDY DESIGN: In this double-blind randomized trial, 126 women received misoprostol (50 microg) either orally every 3 hours or vaginally every 6 hours for induction of labor. Outcomes included time from induction to delivery, oxytocin augmentation, incidence of hyperstimulation and tachysystole, mode of delivery, and neonatal outcomes. RESULTS: Median time to delivery was shorter in those women who were receiving vaginal misoprostol (vaginal 14.3 hours vs oral 23.1 hours; P =.0004) and more women in the oral group required oxytocin augmentation of labor (73% vs 42%) (RR, 1.98; 95% CI, 1.29 to 3.06). The incidence of hyperstimulation was similar between the groups, but there was an increased incidence of tachysystole in the vaginal group (26.5% vs 9.7%)(RR, 2.74; 95% CI, 1.16 to 6.51). There was no difference between the groups with respect to mode of delivery or neonatal outcome. CONCLUSION: Vaginal misoprostol administered every 6 hours is more effective for induction of labor than oral misoprostol administered every 3 hours. The higher rates of tachysystole with use of vaginal misoprostol in the current study warrant further investigation.     

A META-ANALYSIS OF CONTROLLED-RELEASE PROSTAGLANDIN FOR CERVICAL RIPENING AND LABOUR INDUCTION

OBJECTIVES: to examine the effectiveness and safety of controlled-release prostaglandin for cervical ripening. DATA SOURCES: we conducted a computerized search of Medline using the keywords "Cervidil"; or "Propess"; or "prostaglandin/dinoprostone" and "pessary"; or "prostaglandin/dinoprostone" and "controlled" and "release"; or "prostaglandin/dinoprostone" and "vaginal" and "insert"; identifying studies in the English literature published between January 1980 and December 1999. STUDY SELECTION: we included all randomized trials that compared controlled-release vaginal prostaglandin with a retrieval string with any other method of cervical ripening or with a placebo. Nine studies were identified.TABULATION, INTERACTION, AND RESULTS: the two coauthors independently abstracted the data and evaluated the studies for methodologic quality, blinded to each other's results. Homogeneity of results was evaluated, and if present, the summary odds ratio and 95 percent confidence intervals were determined. Compared with placebo, controlled-release prostaglandin resulted in cervical change (summary odds ratio [OR] = 3.99, 95% confidence interval [CI] = 2.71-5.86), a higher rate of vaginal delivery in 12 hours (OR = 29.01, 95% CI = 7.08-118.87), less need for oxytocin (OR = 0.14, 95% CI = 0.06-0.32), but a higher incidence of excessive uterine activity (P<0.0001) and hyperstimulation (P = 0.004). When compared with Prepidil, there was a higher rate of excessive uterine activity with controlled-release prostaglandin (P = 0.03), but less need for oxytocin (OR = 0.09, 95% CI = 0.01-0.53). When compared with Prepidil/immediate oxytocin, there was a lower rate of active labour in 12 hours with controlled-release prostaglandin (OR = 0.27, 95% CI = 0.10-0.72). There was a lower rate of vaginal delivery in 12 hours and higher incidence of oxytocin use with controlled-release prostaglandin as compared with misoprostol (OR = 0.53, 95% CI = 0.34-0.83 and OR = 1.58, 95% CI = 1.08-2.32 respectively). The induction to delivery interval was shorter with controlled-release prostaglandin than with placebo or Prepidil, but longer than with Prepidil/immediate oxytocin, or misoprostol. Although no differences were seen with maternal morbidity (such as Caesarean delivery) or neonatal outcomes, the sample size was not adequate to evaluate these outcomes. CONCLUSION: controlled-release prostaglandin appears to be an effective cervical ripening agent as compared with Prepidil, but may result in an increased incidence of excessive uterine activity. Controlled-release prostaglandin may not be as effective as misoprostol or Prepidil/immediate oxytocin. Further randomized trials with larger sample sizes are needed to evaluate maternal morbidity and neonatal outcomes.     

Obstetric management and outcome of pregnancy in women with a history of caesarean section in the Netherlands

OBJECTIVE: To determine mode of delivery and occurrence of uterine rupture in women with a previous caesarean section (CS) in the Netherlands. MATERIALS AND METHODS: During a 1-year period 38 hospitals in the Netherlands registered prospectively mode of delivery, use of prostaglandins or oxytocin and occurrence of uterine rupture in all women with a previous CS. RESULTS: There were 4569 women with a previous CS. Trial of labour (TOL) was attempted in 71.7%, of whom 76.0% delivered vaginally. The vaginal birth after caesarean (VBAC)-rate was 54.4%. Forty-nine uterine ruptures occurred (1.1%), of which 48 occurred during a TOL (1.5%). There were four perinatal deaths (1.2/1000 TOL) and 3 hysterectomies (0.9/1000 TOL) related to the rupture. Use of prostaglandin E2 alone or combined with oxytocin was significantly associated with an increased risk of uterine rupture (OR 6.8, 95% CI 3.2-14.3, OR 4.8, 95% CI 1.6-14.6, respectively). The same held for augmentation with oxytocin (OR 2.2, 95% CI 1.04-5.0). CONCLUSION: The success rate of TOL was 76%, resulting in a VBAC rate of 54%. Uterine rupture occurred in 1.5% during a TOL, with a risk of perinatal death of 1.2 per 1000. The risk of uterine rupture increased significantly when labour was induced with prostaglandins alone or combined with oxytocin or when labour was augmented with oxytocin.     

Uterine rupture during induced or augmented labor in gravid women with one prior cesarean delivery.

OBJECTIVE: Our purpose was to examine the risk of uterine rupture during induction or augmentation of labor in gravid women with 1 prior cesarean delivery. STUDY DESIGN: The medical records of all gravid women with history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. The current analysis was limited to women at term with 1 prior cesarean delivery and no other deliveries. The rate of uterine rupture in gravid women within that group undergoing induction was compared with that in spontaneously laboring women. The association of oxytocin induction, oxytocin augmentation, and use of prostaglandin E(2) gel with uterine rupture was determined. Logistic regression analysis was used to examine these associations, with control for confounding factors. RESULTS: Of 2774 women in the analysis, 2214 had spontaneous onset of labor and 560 women had labor induced with oxytocin or prostaglandin E(2) gel. The overall rate of rupture among all patients with induction of labor was 2.3%, in comparison with 0.7% among women with spontaneous labor (P =.001). Among 1072 patients receiving oxytocin augmentation, the rate of uterine rupture was 1.0%, in comparison with 0.4% in nonaugmented, spontaneously laboring patients (P =.1). In a logistic regression model with control for birth weight, use of epidural, duration of labor, maternal age, year of delivery, and years since last birth, induction with oxytocin was associated with a 4.6-fold increased risk of uterine rupture compared with no oxytocin use (95% confidence interval, 1.5-14.1). In that model, augmentation with oxytocin was associated with an odds ratio of 2.3 (95% confidence interval, 0.8-7.0), and use of prostaglandin E(2) gel was associated with an odds ratio of 3.2 (95% confidence interval, 0.9-10.9). These differences were not statistically significant. CONCLUSION: Induction of labor with oxytocin is associated with an increased rate of uterine rupture in gravid women with 1 prior uterine scar in comparison with the rate in spontaneously laboring women. Although the rate of uterine rupture was not statistically increased during oxytocin augmentation, use of oxytocin in such cases should proceed with caution.     

Uterine tachysystole in spontaneous labor at term

Objectives: The objective of this study is to determine the incidence of uterine tachysystole and its association with spontaneous labor at term.

Methods: A retrospective cohort study of 8008 women in spontaneous labor (without prostaglandins or oxytocin). Fetal heart tracings and uterine activity were recorded every 15?min. Primary outcome: occurrence of tachysystole (> 5 uterine contractions /10?min over 30?min periods). Secondary outcomes: non-reassuring fetal heart tracings (NRFHT), NICU admissions, and cesarean deliveries.

Results: About 890 patients (11.1 %) had at least one episode of tachysystole. Non-whites have higher incidence of uterine tachysystole; adjusted odds ratio (aOR) was 1.66 for Hispanics (95% CI 1.28–2.05), 1.58 for African Americans (95% CI 1.05–2.38), and 1.51 for Asians (95% CI?=?1.13–2.0). The use of epidural analgesia was higher in the tachysystole group (62.2% versus 40.9%, aOR 1.89, CI 1.58–2.26; p?< 0.001). Tachysystole was more frequent among nulliparous women and in women carrying higher weight fetuses. Oligohydramnios (aOR 1.62, CI 0.70–3.72; p?<?0.004), and NRFHT were more common in the tachysystole group (4.2% versus 2.5%, p?=?0.002). Newborns in the tachysystole group were two times more likely to be admitted to NICU (30 /890 [3.4%] versus 122 /7118 [1.7%], OR?=?2, p=0.001). There was no difference in the frequency of meconium-stained amniotic fluid or Apgar scores <7 at 5?min.

Conclusion: Uterine tachysystole occurs in more than 10% of spontaneous labors and is associated with NRFHR, increased rate of caesarean deliveries and NICU admissions. It is not associated with low Apgar scores or meconium-stained amniotic fluid.     

Excessive uterine activity accompanying induced labor

OBJECTIVE: To estimate the incidence and timing of excessive uterine activity accompanying induction of labor with misoprostol using different routes (oral or vaginal) and forms (intact tablet or crushed) and to compare these with dinoprostone gel, oxytocin, and spontaneous labor. METHODS: This retrospective cohort study included 519 women at term who had labor induced and 86 women at term in spontaneous labor. Induction agents included misoprostol, dinoprostone, or oxytocin. Fetal heart rate and uterine activity tracings were analyzed independently by three maternal-fetal medicine physicians. The diagnosis of tachysystole or hyperstimulation required the agreement of two or more reviewers. RESULTS: The incidence of tachysystole was highest with misoprostol administered by vaginal tablet (misoprostol vaginal tablet 50 microg every 4 hours, 48.6%; vaginal tablet crushed 50 microg and suspended in hydroxyethyl gel every 4 hours, 30.7%, P =.009; oral tablet 50 microg every 4 hours, 22.2%, P =.001; oral tablet crushed 50 microg every 4 hours, 15.5%, P <.001; dinoprostone gel, 33.0%, P =.022; intravenous oxytocin, 30.2%, P =.027; and spontaneous onset of labor, 23.3%, P <.001). Hyperstimulation occurred more often with dinoprostone gel (16.5%) than with other forms of induction or spontaneous labor. Hyperstimulation occurred significantly more often with vaginal misoprostol crushed tablet (7.9%) and vaginal misoprostol intact tablet (7.6%) than with crushed oral misoprostol (1.0%) (P =.016 and.018, respectively). There was a shorter time to tachysystole with increasing doses of vaginal misoprostol tablet (P =.01). CONCLUSION: The incidence of tachysystole and hyperstimulation, and time to tachysystole, varied depending on the route and form of misoprostol given.     

Complications in pregnancy, labor, and delivery with uterine leiomyomas: a population-based study

OBJECTIVE: To determine the extent to which uterine leiomyomas are associated with characteristics of pregnancy, labor, and neonatal outcome recorded on birth certificates. METHODS: In a population-based series of women who delivered singleton live infants in Washington state from 1987-1993, we linked computerized birth certificates and hospital discharge records to investigate the relationship between uterine leiomyomas and complications in pregnancy and delivery. Subjects were 2065 women with uterine leiomyomas noted on computerized hospital discharge records. From the remaining records, a comparison group of women without uterine leiomyomas diagnoses were selected at random and frequency-matched by birth year to women with leiomyomas. We used unconditional logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of pregnancy or delivery complications in relation to uterine leiomyomas after multivariate adjustment. RESULTS: Women with leiomyomas were more likely than controls to be over age 35 at delivery, nulliparous, or black. We observed independent associations between uterine leiomyomas and abruptio placentae (OR 3. 87, 95% CI 1.63, 9.17), first trimester bleeding (OR 1.82, 95% CI 1. 05, 3.20), dysfunctional labor (OR 1.85, 95% CI 1.26, 2.72), and breech presentation (OR 3.98, 95% CI 3.07, 5.16). The risk of cesarean was also higher among women with uterine leiomyomas (OR 6. 39, 95% CI 5.46, 7.50), but a portion of the excess risk might have been due to biased detection of leiomyomas at cesarean delivery. CONCLUSION: Leiomyomas appear to increase likelihood of complications during pregnancy, labor, and delivery.     

Randomized trial in multiparous patients: investigating a single vs. two-dose regimen of intravaginal misoprostol for induction of labor

BACKGROUND: Multiparous patients have a higher risk of hyperstimulation and uterine rupture than nulliparous patients. The minimum possible dose of uterotonic drug should be used in induction of labor for multiparous patients to avoid excessive uterine activity, which could increase both maternal and fetal risks. METHODS: One hundred and four women were randomized to either a single dose of 50 micro g of intravaginal misoprostol in 24 h, or two consecutive doses of intravaginal 50 micro g misoprostol 6 h apart. RESULTS: The mean induction to delivery interval (789 min [95% CI: 637-941] vs. 576 min [95% CI: 484-667], p = 0.018) and delivery rate within 12 h (63% vs. 83%, p = 0.035) were higher in the two-dose group. The oxytocin augmentation rate (14% vs. 2%, p = 0.03) was higher in the single-dose group. There was a higher rate of clinician input related to suspicious cardiotocographic readings in the single-dose arm (p = 0.04). There was no statistical difference (p > 0.05) between the one- and two-dose regimens with respect to the rates of tachysystole (21% vs. 15%), hyperstimulation (3.9% vs. 0%), and meconium staining at delivery (9.8% vs. 13.2%). CONCLUSIONS: The two-dose regimen was most efficient, but both regimens were well tolerated by the fetuses.     

CLINICAL ASSISTED REPRODUCTION: Uterine Leiomyomas and Their Effect on In Vitro Fertilization Outcome: A Retrospective Study

Purpose: The effect of uterine leiomyomas on the outcome of in vitro fertilization (IVF) treatment has been controversial. This study was undertaken to clarify influence of fibroids on IVF success, in a large population with age and other potential confounding variables controlled for in the analysis.Methods: A population of 141 patients with and 406 without leiomyomata undergoing their first IVF cycle was studied.Results: The association between uterine leiomyomas and assisted reproduction treatment outcome was not statistically significant (OR = 0.73, 95% CI: 0.49–1.19, p = 0.21) after controlling for age and other risk factors. Also, fibroids neither affected the risk of spontaneous abortion (OR = 1.06, 95% CI: 0.44–2.60) nor the risk of ectopic pregnancy (OR = 0.78, 95% CI: 0.08–8.02). Location of fibroids (intramural vs. submucosal/subserosal) and their size had no significant effect on pregnancy outcome.Conclusions: Results from our analyses indicated that in vitro fertilization outcome was not affected by the presence of uterine leiomyomas. Therefore, in patients with normal uterine cavities and fibroids less than a certain size (i.e., <7 cm), undergoing myomectomies as a prerequisite for assisted reproduction treatment is seriously questionable.     

Efficacy and safety of misoprostol compared with the dinoprostone for labor induction at term: a meta-analysis

Objective: The purpose of this study was to compare the efficacy and safety of intravaginal misoprostol and the dinoprostone vaginal insert for labor induction at term.

Method: PubMed, EMBASE, MEDLINE, CNKI, EBSCO and the Cochrane Library were searched for articles published in English language from 2000 to 2014, Using the keywords misoprostol, dinoprostone, labor induction.

Results: Eight of 436 studies (1669 women) identified met the criteria for meta-analysis. We assigned a quality rating to each included article. The use of misoprostol showed less oxytocin augmentation when compared with dinoprostone (RR?=?0.78, 95% CI?=?0.67–0.90). There was no difference in the risk of tachysystole (RR?=?1.18, 95% CI?=?0.78–1.79), uterine hyperstimulation (RR?=?1.24, 95% CI?=?0.75–2.06), vaginal delivery within 24?h (RR?=?1.10, 95% CI?=?1.00–1.20), cesarean delivery (RR?=?0.84, 95% CI?=?0.56–1.24), Neonatal Intensive Care Unit admission (RR?=?0.86, 95% CI?=?0.58–1.28), Apgar scores <7 in 5?min (RR?=?1.18, 95% CI?=?0.39–3.63) between misoprostol and dinoprostone.

Conclusion: Misoprostol compared with dinoprostone appears to show less oxytocin augmentation for labor induction at term. The other outcomes of both drugs were similar. However, these findings were based on small-scale trials. Further studies assessing the effectiveness and safety of misoprostol and dinoprostone in selected groups of patients are warranted.     

Effect of oxytocin during labor on neonatal acidemia

Objective: To assess the factors affecting neonatal acidemia, including occurrence of tachysystole/hypertonus in fetuses exposed to oxytocin during labour and with continuously-monitored fetal heart rate (FHR) tracings.

Methods: Prospective observational study of all women with term pregnancies who received oxytocin for induction/augmentation of labour. FHR tracings were prospectively classified using ACOG classification. Independent predictors of neonatal acidemia were identified using multivariate linear regression with p?<?0.05 considered significant.

Results: We included 430 women, 236 of whom (54.9%) had spontaneous onset of labour. The duration of active phase of the second stage of labour and the presence of abnormal FHR tracing during labour were significantly associated with UA pH (p?<?0.001) and BE (p?<?0.001), while maximum dose of oxytocin (p?<?0.17; p?<?0.7) and tachysystole (p?<?0.9; p?<?0.8) were not. At logistic regression, the duration of active phase of the second stage of labour was independently predictive of neonatal acidemia (p?<?0.009) while abnormal FHR tracing approached significance (p?<?0.088).

Conclusions: In women receiving oxytocin during labour, the duration of active phase of the second stage of labour correlates with neonatal acidemia, whereas maximum dose of oxytocin, duration of oxytocin administration and occurrence of tachysystole during labour do not.     

Uterine leiomyoma among women who conceived following fertility treatment

Objective The objective was to determine if uterine leiomyoma increases the risk of cesarean section (CS) among women who conceived following fertility treatment.Study design The study population consisted of all women who conceived after fertility treatment with singleton gestation and who delivered between the years 1988 and 1999 in the Soroka University Medical Center. A comparison was performed between patients with and without uterine leiomyomas. The Mantel–Haenszel procedure was used to obtain the weighted odds ratio (OR) for CS, while controlling for confounding variables.Results During the study period 1,995 women conceived following fertility treatment. Of these, 63 patients had uterine leiomyomas (3.2%). Women treated for fertility with uterine leiomyomas had statistically significant higher rates of CS than those without uterine leiomyomas (61.9% vs. 28.1%, OR=4.2, 95% CI 2.4–7.2; P<0.001). Stratified analysis (the Mantel–Haenszel technique) was used to control for possible confounders, such as gestational diabetes, hypertensive disorders, maternal age, failure of labor to progress, placental abruption, malpresentation, hydramnios, oligohydramnios, and a previous CS. None of those variables changed the significant association or explained the higher incidence of CS in the uterine leiomyoma group.Conclusions Uterine leiomyoma is an independent risk factor for CS among women who conceived following fertility treatment.     

Clinical characteristics indicating adenomyosis at the time of hysterectomy: a retrospective study in 291 patients

Purpose

To better characterize adenomyosis as a disease entity.

Methods

We retrospectively reviewed the medical records of women undergoing hysterectomy with a histologic diagnosis of adenomyosis, adenomyosis and leiomyomas, and leiomyomas alone.

Results

The study included 291 women: 38 with adenomyosis alone, 56 with adenomyosis and leiomyomas, and 197 with leiomyomas alone. In univariate analysis, women with adenomyosis were younger (p?=?0.018) and had lower uterine weights (p?p?=?0.008). In multinomial logistic regression analysis, a lower uterine weight (OR 0.99, CI 95% 0.99–1.0), pelvic pain (OR 4.8, CI 95% 1.5–15.2), a history of smoking (OR 2.6, CI 95% 1.1–6.5) and at least one delivery (OR 4.3, CI 95% 1.5–12.3) were associated with a greater likelihood of having adenomyosis but not leiomyomas alone.

Conclusions

Women undergoing hysterectomy with adenomyosis alone have different clinical characteristics from women with adenomyosis and leiomyomas and from those with only leiomyomas.     

The clinical significance of bleeding during the second trimester of pregnancy

OBJECTIVE: This study aimed at investigating the clinical importance and pregnancy outcome in women suffering from bleeding during the second half of their pregnancies. METHODS: A population-based study including all deliveries between the years 1988 and 2005 was conducted. Comparison was performed between patients with and without vaginal bleeding during the second half of pregnancy. Pregnancies, which terminated before 22 weeks, multiple gestations and women lacking prenatal care were excluded from the analysis. Stratified analyses, using the Mantel-Haenszel technique, and a multiple logistic regression model were performed to control for confounders. RESULTS: During the study period, 175,093 singleton deliveries occurred in our institute. Of these, 2,010 (1.1%) were complicated with bleeding upon admission during the second half of pregnancy. The cases were mostly attributed to placental abruption (63.5%; n = 1,276) and placenta previa (36.5%; n = 734). Independent risk factors associated with bleeding, using a backward, stepwise multivariate analysis were oligohydramnios, polyhydramnions, [odds ratio (OR) = 1.6; 95% confidence interval (CI) 1.2-2.0; P = 001 and 1.5; 1.2-1.8; P < 0.01, respectively], suspected intra uterine growth restriction (IUGR, 3.2; 2.6-4.0; P < .001), gestational age, previous abortions and maternal age. These patients subsequently were more likely to deliver by cesarean section (CS, 72.9 vs. 12.1%, OR = 19.5; 95% CI 17.6-19.9; 14.9 vs. 1.1%; P < 0.001). Perinatal mortality among patients admitted due to second half bleeding was significantly higher as compared to patients without bleeding (P < .001). CONCLUSION: Bleeding upon admission during the second half of pregnancy is an independent risk factor for perinatal mortality. Careful surveillance, including fetal monitoring, is suggested in these cases in order to reduce the adverse perinatal outcome.     

Identifying risk factors for peripartum cesarean hysterectomy. A population-based study

OBJECTIVE: To determine the incidence of, and obstetric risk factors for, emergency peripartum hysterectomy. STUDY DESIGN: A population-based study comparing all singleton deliveries between the years 1988 and 1999 that were complicated with peripartum hysterectomy to deliveries without this complication. Statistical analysis was performed with multiple logistic regression analysis. RESULTS: Emergency peripartum hysterectomy complicated 0.048% (n = 56) of deliveries in the study (n = 117,685). Independent risk factors for emergency peripartum hysterectomy from a backward, stepwise, multivariable logistic regression model were: uterine rupture (OR = 521.4, 95% CI 197.1-1379.7), placenta previa (OR = 8.2, 95% CI 2.2-31.0), postpartum hemorrhage (OR = 33.3, 95% CI 12.6-88.1), cervical tears (OR = 18.0, 95% CI 6.2-52.4), placenta accreta (OR = 13.2, 95% CI 3.5-50.0), second-trimester bleeding (OR = 9.5, 95% CI 2.3-40.1), previous cesarean section (OR = 6.9, 95% CI 3.7-12.8) and grand multiparity (> 5 deliveries) (OR = 3.4, 95% CI 1.8-6.3). Newborns delivered after peripartum hysterectomy had lower Apgar scores (< 7) at 1 and 5 minutes than did others (OR = 11.5, 95% CI 6.2-20.9 and OR = 27.4, 95% CI 11.2-67.4, respectively). In addition, higher rates of perinatal mortality were noted in the uterine hysterectomy vs. the comparison group (OR = 15.9, 95% CI 7.5-32.6). Affected women were more likely than the controls to receive packed-cell transfusions (OR = 457.7, 95% CI 199.2-1105.8) and had lower hemoglobin levels at discharge from the hospital (9.9 +/- 1.3 vs. 12.8 +/- 5.7, P < .001). CONCLUSION: Cesarean deliveries in patients with suspected placenta accreta, specifically those performed due to placenta previa in women with a previous uterine scar, should involve specially trained obstetricians. In addition, detailed informed consent about the possibility of emergency peripartum hysterectomy and its associated morbidity should be obtained.     

Cervical ripening with transcervical foley catheter and the risk of uterine rupture

OBJECTIVE: To estimate whether the rate of uterine rupture in patients with a previous cesarean delivery is related to labor induction and/or cervical ripening using transcervical Foley catheter. METHODS: Charts of all patients who had a trial of labor after a previous cesarean delivery in our institution between 1988 and 2002 were reviewed. The rates of successful vaginal birth after cesarean delivery and uterine rupture in patients with spontaneous labor (control group) were compared with those of patients who underwent a labor induction by means of amniotomy with or without oxytocin and patients who underwent a labor induction/cervical ripening using a transcervical Foley catheter. Logistic regression analysis was performed to adjust for confounding variables. RESULTS: Of 2479 patients, 1807 had a spontaneous labor, 417 had labor induced by amniotomy with or without oxytocin, and 255 had labor induced by using transcervical Foley catheter. The rate of successful vaginal birth after cesarean delivery was significantly different among the groups (78.0% versus 77.9% versus 55.7%, P <.001), but not the rate of uterine rupture (1.1% versus 1.2% versus 1.6%, P =.81). After adjusting for confounding variables, the odds ratio (OR) for successful vaginal birth after cesarean delivery was 0.68 (95% confidence interval [CI] 0.41, 1.15), and the OR for uterine rupture was 0.47 (95% CI 0.06, 3.59) in patients who underwent an induction of labor using a transcervical Foley catheter when compared with patients with spontaneous labor. CONCLUSION: Labor induction using a transcervical Foley catheter was not associated with an increased risk of uterine rupture.     

Rupture of the scarred uterus

OBJECTIVE: To assess the risk of uterine rupture of the scarred uterus according to mode of delivery in subsequent births recorded as spontaneous labour, labour induced by oxytocin, labour after ripening with prostaglandin E2, and planned cesarean section. METHODS: Retrospective study of 2,128 births with a low transversal scar after a previous cesarean section. The study population was realised in a level III university hospital from 1995 to 2003. The association between mode of delivery and uterine rupture was studied in a multivariate logistic regression model, and adjusted for specific antenatal confounding factors. RESULTS: Over 9 years, we collected 22 cases (1%), including 11 asymptomatic ruptures in a population of 2,128 scarred uteri out of 28,248 deliveries. Uterine rupture occurred at a rate of 0.3 per 100 among women with repeated cesarean delivery without labour, 1 per 100 among women with spontaneous onset of labour, 1.4 per 100 among women with oxytocin-induced labour, and 2.2 per 100 among women with prostaglandin cervical ripening. Compared to women with a planned cesarean section, women with spontaneous onset of labour were more likely to have uterine rupture (OR: 4.0; 95% CI: 0.8-42.0). A greater relative risk was observed among women with oxytocin-induced labour (OR: 4.3; 95% CI: 0.3-60.0), and particularly those with prostaglandin-induced labour (OR: 8.7; 95% CI: 1.5-97.3, p=0.01). CONCLUSION: In women with a scarred uterus, prostaglandin E2 induction of labour is a risk factor for uterine rupture. The practice of a systematic cesarean section in cases with Bishop score<3, appropriate induction procedure, and rigorous monitoring of the labour, could make for a safer delivery.