Obstetric factors and relative risk of neonatal germinal layer/intraventricular hemorrhage

One hundred fifty-five inborn infants with a birth weight <- 1,500 gm were prospectively evaluated for germinal layer/intraventricular hemorrhage. Maternal characteristics, obstetric factors, and neonatal condition in the immediate newborn period were analyzed as possible risk factors for germinal layer/intraventricular hemorrhage. Early germinal layer/intraventricular hemorrhage or hemorrhages identified during the first 24 hours of life were observed in 85 (55%) of these infants. Another 37 (24%) had germinal layer/intraventricular hemorrhage after 24 hours of age (late germinal layer/intraventricular hemorrhage). None of the maternal and obstetric variables, including labor, mode of delivery, and presentation, appeared to increase the risk of germinal layer/intraventricular hemorrhage. The immediate neonatal condition, birth weight, gestational age, and intrauterine growth, all influenced the occurrence of germinal layer/intraventricular hemorrhage, especially early germinal layer/intraventricular hemorrhage. We suggest that future studies to investigate the role of maternal or obstetric factors in the pathogenesis of germinal layer/intraventricular hemorrhage should discriminate early from late germinal layer/intraventricular hemorrhage. Obstetric factors are more likely to influence the early onset of germinal layer/intraventricular hemorrhage; their effect, if any, becomes less discernible later.     

Indomethacin tocolysis and intraventricular hemorrhage

OBJECTIVE: To determine the association between indomethacin tocolysis and neonatal intraventricular hemorrhage. METHODS: Fifty-six preterm neonates with intraventricular hemorrhage were matched by gestational age with neonates (n = 224) without this morbidity. Maternal and neonatal charts were reviewed to ascertain the type of tocolytic exposure experienced by the neonate. Other maternal and neonatal demographic and outcome data were also abstracted. Results were analyzed using the Student t test, chi(2) analysis, and multivariable logistic regression. The number of studied subjects provided 80% power to determine if antenatal exposure to indomethacin was twice as likely among infants with intraventricular hemorrhage. RESULTS: Univariate analysis revealed that there were no significant differences between the study and control groups with respect to maternal age, parity, or betamethasone exposure. Infants with intraventricular hemorrhage were significantly more likely to be born at an earlier gestational age, a lower birth weight, after maternal chorioamnionitis, after vaginal delivery, and after exposure to either indomethacin alone or a combination of indomethacin and magnesium. Additionally, their neonatal course was significantly more likely to be complicated by sepsis and respiratory distress syndrome. In a multivariable logistic model, only gestational age, chorioamnionitis, vaginal delivery, and respiratory distress syndrome continued to be significantly associated with intraventricular hemorrhage. Indomethacin exposure, either as single-agent (adjusted odds ratio 1.3, 95% confidence interval 0.5, 3.3) or combination tocolytic therapy (adjusted odds ratio 2.0, 95% confidence interval 0.8, 4.8), was not significantly associated with intraventricular hemorrhage. CONCLUSION: Indomethacin tocolysis is not associated with an increased risk of intraventricular hemorrhage.     

The role of obstetric factors in postpartum depression

Abstract

A large sample of primiparous women was screened for postpartum depression and for depression occurring before childbirth. Obstetric risk data, rated on the Peripartum Events Scale (O'Hara etal., 1986, 1991), were analysed for women identified as having suffered from depression, and for a control group. Obstetric risk was unrelated to the occurrence of postpartum depression in the population as a whole; but in women with a previous history of depressive disorder obstetric risk (delivery by forceps or Caesarean section) was significantly related to the occurrence of postpartum depression. This finding did not arise as a consequence of a previous psychiatric history predisposing women to higher obstetric risk. The results suggest that it may be profitable to institute routine antenatal recording of information concerning psychiatric history. This would enable additional support to be directed to women experiencing difficult deliveries who may be particularly vulnerable to postnatal depression.     

Pathogenesis and prevention of intraventricular hemorrhage

Despite improvements in the mortality rates of preterm infants, rates of germinal matrix intraventricular hemorrhage (IVH) have remained static with an overall incidence of 25% in infants less than 32 weeks. The importance of the lesion relates primarily to the underlying injury to the developing brain and the associated long-term neurodevelopmental consequences. This clinical-orientated review focuses on the pathogenesis of IVH and discusses the evidence behind proposed prevention strategies.     

Early and late germinal matrix hemorrhage may have different antecedents

The time of occurrence of germinal matrix hemorrhage (GMH) in preterm babies might convey information about risk. We compared the risk profile of babies whose GMH was evident on a cranial ultrasonogram before the 12th postnatal hour (i.e., early GMH) to that of babies whose GMH did not become evident until after that time (i.e., late GMH). Overall, the two groups were similar. Babies with early GMH, however, were more likely to have been born after a course of labor (p = 0.03), for the first measurement of arterial blood pH to have been less than 7.2 (p = 0.02), and to have received bicarbonate (p = less than 0.00001). These findings lend support to the view that the risk profiles of early and late GMH are not identical, and also to the view that intranatal and immediate postnatal factors contribute to the early onset of GMH in susceptible babies.     

Management of obstetric hemorrhage

A reluctance to proceed with hysterectomy for obstetric hemorrhage may be a more likely cause of preventable death in obstetrics than a lack of surgical or medical skills. Every obstetric unit should have protocols available to deal with hemorrhage and, in addition, have specific guidelines for patients who object to blood transfusions for various reasons. Risk factors for hemorrhage should be identified antenatally, using all possible imaging modalities available, and utilizing multidisciplinary resources whenever possible. Novel strategies for prenatal diagnosis of abnormal placentation include advanced sonography and magnetic resonance imaging. Placement and utilization of arterial catheters for uterine artery embolization is becoming more widespread and new surgical technology such as the argon beam coagulator seems promising. When intra or postpartum hemorrhage is encountered, a familiar protocol for dealing with blood loss should be triggered. Timely hysterectomy should be performed for signs of refractory bleeding. Application of medical and surgical principles combined with recent technologic advances will help the obstetrician avoid disastrous outcomes for both mother and fetus.     

The role of obstetric factors in perinatal mortality trends

In the Perinatal Unit of the New Jersey Medical School, Newark the combined neonatal mortality and stillbirth rates declined from more than 51 per 1000 to less than 17 per 1000 between 1971 and 1983. This change is comparable to the reduction of perinatal mortality rates nationwide since the Second World War. Because the improvement in the fetal and neonatal survival rates occurred in a static population and against well identifiable changes in the structure, equipment, policies and management patterns of the obstetric unit, it was possible to assess the impact of various factors upon perinatal outcome. In the environment of this institution adherence to conservative concepts of obstetric management, avoidance of manipulative and extraction procedures, an increase of the rate of cesarean sections from about 7 to 15% and emphasis upon infection control appeared to be the crucially important factors. Antepartum sonography and fetal stress and non-stress testing significantly impacted upon the results. The role of intrapartum electronic monitoring was less clearly definable and seemed to be effective only in the hands of experienced physicians. The results did not seem to be adversely affected by the fact that the program de-emphasized invasive procedures, including fetal scalp pH sampling.     

Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy

Objective To determine risk factors for third degree obstetric perineal tears and to give recommendations for prevention.
Design Retrospective case–control study.
Setting A teaching hospital in The Netherlands.
Participants and methods One hundred and twenty cases of vaginal delivery complicated by third degree perineal tear and 702 uncomplicated vaginal deliveries were compared, with respect to possible risk factors.
Results In a multivariate model high birthweight, forceps delivery, induced labour, epidural anaesthesia and parity were risk factors for anal sphincter tear. In addition, mediolateral episiotomy was associated with fewer sphincter injuries. Separate analysis of nulli- and multiparous women demonstrated that high birthweight and epidural anaesthesia (increased risk) and mediolateral episiotomy (decreased risk) were factors associated with anal sphincter tear only in nulliparous women.
Conclusions We found several risk factors for anal sphincter tear. Nulliparous women are at higher risk than multiparous women. Mediolateral episiotomy may be sphincter-saving especially in nulliparous women and therefore prevent them from chronic faecal incontinence.     

Early-onset intraventricular hemorrhage in preterm neonates: incidence of neurodevelopmental handicap.

The neurodevelopmental outcome of very low birth weight infants experiencing early-onset intraventricular hemorrhage (IVH) occurring within the first 6 postnatal hours was compared with that of their peers without early-onset IVH at 3 years corrected age. The 440 surviving preterm infants (birth weight 600 to 1,250 g) who had been enrolled in a multicenter, prospectively randomized, controlled trial evaluating the efficacy of postnatal indomethacin to prevent IVH were evaluated with the Stanford-Binet Intelligence Scale and neurological examinations at 3 years corrected age. All study infants had echoencephalography between 5 and 11 hours of life, and testing is reported for all children residing in English monolingual households at 3 years corrected age (i.e., from the obstetric due date). Fifty five of the 73 (75%) infants with IVH within the first 5 to 11 hours survived to 3 years of age, compared with 385 of the 432 (89%) children without early-onset hemorrhage who were alive at 3 years corrected age (P<.001). Eleven of the 29 (38%) English monolingual children with early-onset IVH had Stanford-Binet intelligence quotient scores of less than 70, compared with 47 of the 249 (19%) children without early IVH (P = .03). Similarly, 7 of 28 (25%) early IVH children were found to have cerebral palsy, compared with 20 of 241 (8%) children without early IVH (P = .01). These data suggest that infants who experience the early onset of IVH are at high risk for both cognitive and motor handicaps at 3 years corrected age.     

产科出血的器官功能保护

临床一旦发生产科出血，病情进展迅速，且易发展为多脏器功能障碍综合征(multiple organ dysfunction syndrome, MODS)，早期开展病因救治是根本，同时需密切关注循环、呼吸、泌尿及凝血系统状况，积极进行多器官功能保护。     

A non-inflatable anti-shock garment for obstetric hemorrhage.

OBJECTIVES: Maternal death from hemorrhage in low resource settings is frequently due to long delays in transportation to referral centers and/or in obtaining blood and surgical interventions. This case series was designed to demonstrate the feasibility, efficacy and safety of the non-inflatable anti-shock garment (NI-ASG) for resuscitation and hemostasis in the initial management of obstetric hemorrhage and shock. METHODS: Fourteen cases of obstetric hemorrhage and hypovolemic shock at Memorial Christian Hospital, Sialkot, Pakistan were managed with a specific clinical protocol based on using NI-ASG as the primary intervention. RESULTS: The NI-ASG was used to resuscitate and stabilize women with hypovolemic shock from 18 to 57 h. Thirteen patients survived without evidence of morbidity, but one had prolonged shock followed by multiple organ failure and death. CONCLUSIONS: This study confirmed that the NI-ASG quickly restored the vital signs of most women in severe hemorrhagic shock and stabilized them while awaiting blood transfusion.     

Incidence and severity of intraventricular hemorrhage: 1981-1984

We have examined the trend in the incidence and mortality of intraventricular hemorrhage (IVH) in low birthweight infants from 1981 through 1984. During this time we admitted 407 infants in the first week of life with a birthweight less than or equal to 1500 gm in whom a cranial ultrasonogram or autopsy had been performed. Though the mean birthweight and gestational age, proportion of infants who were inborn, and percentage of infants requiring mechanical ventilation did not change over the 4 years, cesarean deliveries were performed more frequently (P less than .001). The overall incidence of IVH was 62% in 1981, 56% in 1982, 49% in 1983, and 58% in 1984, thus no significant trend was evident. Although the incidence of minor hemorrhages (grades I and II) remained relatively constant, there was a decrease in the incidence of grade III IVH (1981, 11%; 1984, 2%, P = .01). The incidence of grade IV hemorrhage did not change during the 4 years and ranged from 7 to 9%. Mortality rate for all infants weighing less than or equal to 1500 gm and for infants with a minor hemorrhage remained unchanged; however, the mortality rate for infants with a major hemorrhage (grade III or IV) tended to decrease (P = .07). We conclude that although some minor changes in the incidence and mortality have occurred, IVH continues to be a major problem in very-low-birthweight infants at our institution.     

An overview of obstetric hemorrhage

Obstetric hemorrhage is the leading cause of maternal morbidity and mortality in the world. Disparities in the prevalence of obstetric hemorrhage and its related mortality both on a global scale and locally in the United States indicate that a significant proportion is preventable. In many parts of the world, including the United States, there has also been an unexplainable increase in rates of postpartum hemorrhage. Efforts should focus on implementing comprehensive hemorrhage toolkit/bundles, which research has shown may have the potential to reduce severe maternal morbidity from hemorrhage.     

Risk factors for intraventricular hemorrhage in a birth cohort of 3721 premature infants

AIMS: In our study we determined possible risk factors for intraventricular hemorrhage grade III to IV (IVH) based on a regional German neonatal data base and tried to build a logistic-regression model to predict the risk of IVH according to gestational age. MATERIALS: We identified 3721 premature infants, 22 to 36 completed weeks of gestational age, born from 1994 through 1997. 136 (3.7%) IVH were diagnosed sonographically. 60 (44%) infants with IVH died. We examined the following variables as risk factors for IVH: gestational age, sex, blood pH of 7.2 or less, body temperature of 35 degrees C or less, multiple birth, small-for-gestational age, intubation after birth, transport to another hospital. RESULTS: In the full logistic regression model sex, blood pH of 7.2 or less, multiple birth, and small-for-gestational age were not associated with a significant risk of IVH. Body temperature of 35 degrees C or less was associated with an increased risk of IVH (adjusted odds ratio, 1.92; 95% confidence interval, 1.09 to 3.40). Intubation after birth increased the risk of IVH in neonates under 28 weeks of gestational age (OR, 3.72; 95% CI, 1.65 to 8.38) only to a moderate extent, but significantly in neonates 32 to 36 weeks of gestational age (OR, 16.51; 95% CI: 7.35 to 36.18). The risk of IVH was mainly related to gestational age. Neonates delivered before 28 weeks of gestation (OR, 75.72; 95% CI, 46.14 to 124.30) faced the highest risk of IVH. Transport to another hospital was connected with an increased risk of IVH regardless of gestational age (adjusted OR, 1.95; 95% CI, 1.07 to 2.56). CONCLUSION: The frequency of IVH could be reduced significantly, if extremely premature infants, the vast majority of patients suffering from IVH, did not have to be transferred postnatally to another hospital.     

Tocolysis with calcium-channel blockers and intraventricular hemorrhage

ObjectiveTo determine the possible association between intraventricular hemorrhage (IVH) in very premature infants and calcium-channel blockers used as tocolytics.Materials and methodsWe performed a case-control study (from October 1999 to December 2002) including 51 premature infants under 30 weeks with IVH (all grade) and 112 premature infants under 30 weeks without IVH. In this study only premature infants issued from spontaneous prematurity were included. The exposure frequency to calcium-channel blockers and to other tocolytics were compared between the two groups by univariate analysis and by logistic regression analysis.ResultsCalcium-channel blockers were used in monotherapy before birth in 16% of infants without IVH and in 20% of infants with IVH (P = 0.55). An exposure to a bitherapy or a tritherapy with a calcium-channel blocker and one or several other tocolytics has been found in 43% of infants with IVH and in 26% of infants without IVH (P < 0.05). However this association disappears after adjustment for gestational age.ConclusionWe did not find a significant association between calcium-channel blockers used as tocolytics and an increased risk of intraventricular hemorrhage in premature infants less than 30 weeks.     

Placenta previa: obstetric risk factors and pregnancy outcome.

OBJECTIVE: To determine the incidence, obstetric risk factors and perinatal outcome of placenta previa. STUDY DESIGN: All singleton deliveries at our institution between 1990 and 1998 complicated with placenta previa were compared with those without placenta previa. RESULTS: Placenta previa complicated 0.38% (n = 298) of all singleton deliveries (n = 78 524). A back-step multiple logistic regression model found the following factors to be independently correlated with the occurrence of placenta previa: maternal age above 40 years (OR 3.1, 95% CI 2.0-4.9), infertility treatments (OR 3.1, 95% CI 1.8-5.6), a previous Cesarean section (OR 1.8, 95% CI 1.4-2.4), a history of habitual abortions (OR 1.3, 95% CI 1.3-2.7) and Jewish ethnicity (OR 1.3, 95% CI 1.1-1.8). Pregnancies complicated with placenta previa had significantly higher rates of second-trimester bleeding (OR 156.0, 95% CI 87.2-277.5), pathological presentations (OR 7.6, 95% CI 5.7-10.1), abruptio placentae (OR 13.1, 95% CI 8.2-20.7), congenital malformations (OR 2.6, 95% CI 1.5-4.2), perinatal mortality (OR 2.6, 95% CI 1.1-5.6), Cesarean delivery (OR 57.4, 95% CI 40.7-81.4), Apgar scores at 5 min lower than 7 (OR 4.4, 95% CI 2.3-8.3), placenta accreta (OR 3.6, 95% CI 1.1-9.9) postpartum hemorrhage (OR 3.8, 95% CI 1.2-10.5), postpartum anemia (OR 5.5, 95% CI 4.4-6.9) and delayed maternal and infant discharge from the hospital (OR 10.9, 95% CI 7.3-16.1) as compared to pregnancies without placenta previa. In a multivariable analysis investigating risk factors for perinatal mortality, the following were found to be independent significant factors: congenital malformations, placental abruption, pathological presentations and preterm delivery. In contrast, placenta previa and Cesarean section were found to be protective factors against the occurrence of perinatal mortality while controlling for confounders. CONCLUSION: Although an abnormal implantation per se was not an independent risk factor for perinatal mortality, placenta previa should be considered as a marker for possible obstetric complications. Hence, the detection of placenta previa should encourage a careful evaluation with timely delivery in order to reduce the associated maternal and perinatal complications.     

Umbilical artery catheter position and intraventricular hemorrhage

A historical cohort study was designed to examine high (T6-T11) versus low (L3-L5) umbilical artery catheter (UAC) positioning as a risk factor for subependymal/intraventricular hemorrhage (SEH/IVH) in very low birthweight infants. High and low UAC groups were similar for mode of delivery, severity of pulmonary disease, weight, gestation, Apgar scores, and air leak. Seventeen of 36 infants with high UACs and 6 of 44 infants with low UACs developed SEH/IVH. The incidence (P less than .001) and severity (P less than .01) of SEH/IVH was significantly greater in the high UAC positioning group. Retrograde arterial flow with or without embolization to the cerebral circulation from high UAC positioning is suggested as a possible cause for the association between high UAC positioning and SEH/IVH.