Postterm pregnancy: how can we improve outcomes?

Postterm pregnancy is defined as one which has progressed to 42 0/7 weeks or beyond. The most common reason to be diagnosed with a postterm pregnancy is inaccurate pregnancy dating, but it is also associated with obesity, nulliparity, and a prior history of postterm pregnancy. The rate of postterm pregnancy appears to be decreasing whether due to improved pregnancy dating or an increase in induction of labor. Postterm pregnancy is associated with both maternal and neonatal morbidity and fetal and neonatal mortality; similarly pregnancies beyond 41 weeks' gestation are associated with increases in these perinatal complications. Prevention of postterm pregnancies may include stripping or sweeping the membranes and unprotected coitus. Management of such pregnancies may include induction of labor and fetal antenatal monitoring. Individual patient management should involve careful counseling regarding the risks and benefits of each of the components of care. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to recall the increasing risks of poor outcomes associated with prolonged pregnancy, demonstrate knowledge regarding gestational dating and use of cervical ripening agents in their care of pregnant women, and use evidence-based information when counseling their term patients regarding postterm pregnancy management.     

Effect of membrane sweeping at term pregnancy on duration of pregnancy and labor induction: a randomized trial

AIM: To evaluate the efficacy of sweeping of fetal membranes for induction of labor in uncomplicated term pregnancies. METHODS: A randomized controlled trial was performed in 122 pregnant women beyond 39 weeks of gestation with no complications. The women were assigned to have their membranes swept or not (controls) for labor induction. The main outcome measures included duration of pregnancy and possible complications of sweeping of membranes, including rupture of membranes, postpartum infections, and vaginal bleeding. RESULTS: Twenty-one patients did not give birth in our hospital and were, therefore, excluded from the study; 101 women completed the study (51 patients in the control group and 50 women in the study group). There were no statistically significant differences in maternal age, parity, birth weight, and Bishop score in the two groups. The mean interval between sweeping (stripping) and vaginal examination until delivery was 7.7 +/- (SD) 6.9 and 7.1 +/- 5.6 days in the sweeping and in the control group, respectively (p = 0.61). Of the 101 pregnant women, only 6 patients had premature rupture of membranes (2 in the sweeping group and 4 in the control group). There were no statistically significant differences between these individuals (p = 0.68). Significant vaginal bleeding was not observed in the two groups. Meconium-stained amniotic fluid was seen in 13 women: 8 in the sweeping group and 5 in the control group. There were no statistically significant differences among the women who had meconium-stained fluid in case and control groups (p = 0.39). There were no differences between women who had puerperal fever (3 in the sweeping group and 2 in the control group; p = 0.68). 12 of the 101 women (6 in each group) had cesarean section performed, but there was no difference between the two groups. CONCLUSION: Sweeping of membranes at 39 weeks of gestation has no significant clinical effect on the duration of pregnancy.     

Cervical score and onset of spontaneous labor in prolonged pregnancy dated by second-trimester ultrasonic scan

The interval from expected day of delivery to spontaneous onset of labor was correlated with parity and cervical score in 103 women with uncomplicated prolonged pregnancy (greater than 294 days). All women had a routine ultrasonic scan in weeks 16-18 for the purpose of dating. The mean (+/- SD) modified Bishop score on entry to the study was 4.15 +/- 2.0 for nulliparas and 4.90 +/- 2.1 for multiparas. The duration beyond 294 days to spontaneous onset of labor varied little (mean 3.5-4.5 days) for nulliparas with scores greater than 2 and for multiparas regardless of score. Nulliparous women with a poor score (less than 3) had spontaneous onset of labor and delivery within a mean of 9.8 days. Half of the multiparas (50.0%) and 43.9% of the nulliparas gave birth within 3 days. About 90% of all women gave birth within 7 days. All but three had a vaginal delivery; the instrumental vaginal delivery rate was 16.3%. The results suggest that in postterm women dated with a second-trimester ultrasonic scan, the cervical scores are in general more favorable than previously reported in series not dated with early scans. The postterm group is also much smaller, and the time interval from entry into the postterm period to spontaneous onset of labor is shorter.     

Management of recurrent preterm labor in twin gestations with nifedipine tocolysis

We examined outcomes of twin pregnancies complicated by recurrent preterm labor receiving nifedipine tocolysis. In a retrospective study design, twin pregnancies receiving outpatient preterm labor surveillance services and oral nifedipine tocolysis following a diagnosis of preterm labor were identified from a database ( N = 1421). Eligible for inclusion were patients subsequently rehospitalized with recurrent preterm labor symptoms ( N = 862). Included were patients at < 35 weeks' gestation, having intact membranes, and remaining undelivered for > 48 hours after recurrent preterm labor ( N = 656). Pregnancy outcomes of women resuming nifedipine tocolysis ( N = 418) following hospitalization were compared with those having an alteration in treatment ( N = 238) to continuous subcutaneous terbutaline. Alteration of tocolytic treatment versus resuming nifedipine resulted in increased pregnancy prolongation (34.7 +/- 18.8 days versus 27.5 +/- 19.9 days, P < 0.001), with delivery of fewer low birth weight (67.2% versus 78.3%, P < 0.001) and very low birth weight infants (6.5% versus 15.0%, P < 0.001) and a decreased incidence of neonatal intensive care unit admission (44.7% versus 52.9%, P = 0.005). In twin pregnancies receiving nifedipine tocolysis, alteration of tocolytic treatment to subcutaneous terbutaline following hospitalization for recurrent preterm labor symptoms had a positive impact on pregnancy prolongation and neonatal outcomes.     

Membrane sweeping to induce labor in low-risk patients at term pregnancy: A randomised controlled trial

Objective.?To evaluate the efficacy of membrane sweeping at initiation of labor induction in low-risk patients at term pregnancy (38–40 gestational weeks).

Methods.?This prospective study included 351 antenatal women who were randomly assigned to one of two groups: a sweeping of the membranes group (n?=?181) and a no sweeping control group (n?=?170). The primary outcome measure was the proportion of women who entered spontaneous labor within 1 week of entry into the study. Secondary outcome measures included mode of delivery and maternal and fetal complications.

Results.?Five patients (two in the sweeping group and three in the no sweeping group) were excluded from the study because of breech presentation at labor. There were no statistically significant differences between the two groups regarding maternal age, parity or Bishop score. The proportion of subjects who entered spontaneous labor before 41 weeks of gestation was significantly different between the two groups (p?<?0.0001). The mode of delivery did not differ significantly between the groups and there was no statistically significant difference in maternal or fetal complications.

Conclusions.?Sweeping of membranes is a safe method to reduce the length of term in pregnancy and the incidence of prolonged gestation in a low-risk population. There is no evidence that sweeping the membranes increases the risk of maternal or neonatal adverse outcomes.     

Effects of digital vaginal examinations on latency period in preterm premature rupture of membranes.

OBJECTIVE: To compare the clinical outcome in patients with preterm premature rupture of membranes (PROM) who had a sterile speculum examination with those having a digital vaginal examination. METHODS: We studied 271 singleton pregnancies complicated by preterm PROM from the Memorial Medical Center of Long Beach Perinatal Outreach program that met the criteria for expectant treatment from January 1986 to April 1990. Patients were not included in the study if they had multiple gestations, cerclage, advanced labor, or any indication for delivery on admission (eg, mature lung profile, chorioamnionitis). All subjects were maternal transports to our tertiary care facility and were managed similarly by our perinatal group. The women were questioned as to whether a digital vaginal examination had been performed before transport. Latency period and other obstetric characteristics were then compared. The latency period, defined as days from rupture of membranes until active intervention was initiated or labor began spontaneously, was also stratified by gestational age. RESULTS: One hundred twenty-seven subjects had a digital vaginal examination and 144 had a sterile speculum examination. A significantly (P less than .0001) shorter mean latency period (2.1 +/- 4.0 versus 11.3 +/- 13.4 days) was found in those who had a digital vaginal examination. In addition, a shorter latency period was noted for each gestational age. No difference in uterine activity or cervical dilatation and effacement was noted between the groups on admission. CONCLUSION: Digital vaginal examinations performed on patients whose pregnancies are complicated by preterm PROM appear to shorten significantly the latency period.     

Treatment of premature labor in insulin-dependent diabetic women

This retrospective study was designed to analyze the safety and efficacy of beta-sympathomimetic agents used to treat premature labor in insulin-dependent diabetic women. The study evaluated 12 insulin-dependent diabetic women who experienced 15 pregnancies complicated by premature labor. A group of 30 insulin-dependent diabetic women who delivered at term served as matched controls. Treatment consisted of parenteral and oral administration of beta-sympathomimetic drugs (ritodrine and isoxsuprine). Premature labor was diagnosed, and tocolytic treatment was initiated at a mean gestational age of 31.5 +/- 0.9 weeks. The mean gestational age at the time of delivery was 35.8 +/- 0.5 weeks. Delivery was delayed in the study group by a mean of 30.5 +/- 6.6 days. No fetal or infant deaths occurred in the study group, and there was no difference between the two groups in the incidence of neonatal morbidity. No maternal complications occurred. There were no significant differences in hemoglobin A1 levels between the two groups at any period of gestation. Thus, beta-sympathomimetic drugs may be used safely to treat premature labor in patients with insulin-dependent diabetes, provided they are administered under strictly controlled clinical settings.     

Outpatient misoprostol cervical ripening without subsequent induction of labor to prevent post-term pregnancy

BACKGROUND: Interventions that may help shorten the duration of pregnancy in an African setting where facilities for fetal monitoring in post-term pregnancy are limited, and induction is not without its hazards, are needed. AIM: To determine whether outpatient administration of intravaginal misoprostol safely decreases the interval to delivery in postdate pregnancies. DESIGN: Open randomized controlled trial. SETTING: Zonal district hospitals, Kwale, Southern Nigeria (August 2000 to October 2001). METHODS: Seventy-seven women were randomized at 40 weeks gestation to receive either 25 microg misoprostol intravaginally (38) or gentle cervical assessment only (39) on an outpatient basis. Subjects were then allowed to go into spontaneous labor unless an indication for induction developed. MAIN OUTCOME MEASURES: Interval to delivery, duration of labor, and incidence of side-effects. RESULTS: Misoprostol was associated with significant decrease in mean time to delivery (4.5 +/- 4.1 versus 7.4 +/- 5.2 days; P = 0.008), earlier gestational age at delivery (40.6 +/- 0.6 versus 41.4 +/- 0.05 weeks; P < 0.001) and shorter duration of active labor (6.1 +/- 4.0 versus 8.2 +/- 5.3 h; P = 0.028), without any significant increase in fetal distress, low Apgar score at delivery or other side-effects. CONCLUSION: Outpatient administration of low-dose misoprostol can safely shorten the length of gestation in postdate pregnancies.     

Preterm premature rupture of membranes: risks of recurrent complications in the next pregnancy among a population-based sample of gravid women

OBJECTIVE: The purpose of this study was to ascertain the predictive value of antecedent preterm premature rupture of membranes for recurrent preterm premature rupture of membranes and preterm delivery rates in the next pregnancy compared with background rates among a population-based sample of women at a single institution. STUDY DESIGN: Records of patients with index singleton pregnancies that were complicated by preterm premature rupture of membranes whose next delivery resulted in a delivery at >or=20 weeks at the same institution were reviewed for the incidence and gestational age of recurrent preterm premature rupture of membranes and preterm delivery. All subjects were patients of physicians whose obstetric practices were based at a single institution. Background rates of preterm premature rupture of membranes and preterm delivery in this population were generated from a systematically selected comparison group composed of the two deliveries after each of the study group's second delivery. RESULTS: The rates of recurrent preterm premature rupture of membranes (16.7%) and preterm delivery (34.2%) in the 114 study group patients were substantially greater (odds ratio, 20.6; 95% CI, 4.7-90.2; and odds ratio, 3.6; 95% CI, 2.1-6.4) than noted background rates (0.96% and 12.5%) but considerably less than the recurrence rates of either preterm premature rupture of membranes or preterm delivery that were reported by others. The gestational age of preterm premature rupture of membranes in the index pregnancy affected neither the magnitude of risk nor the gestational age of recurrent preterm premature rupture of membranes or preterm delivery in the subsequent pregnancy. Stratification of outcome measures into three subgroups that were based on the gestational age of index preterm premature rupture of membranes demonstrated no significant differences in the incidence of preterm premature rupture of membranes or preterm delivery. CONCLUSION: After a pregnancy that was complicated by preterm premature rupture of membranes, the risk for recurrent preterm premature rupture of membranes is increased by 20-fold and for recurrent preterm delivery by almost 4-fold. Gestational age of antecedent preterm premature rupture of membranes is predictive of neither risk nor timing of recurrent complications. Estimates of recurrence risks appear to be moderated by limiting analysis to a population-based sample of gravid women when compared with previous studies.     

A comparative study of fetal umbilical velocimetry with continuous- and pulsed-wave Doppler ultrasonography in high-risk pregnancies: relationship to outcome

Systolic/diastolic ratios of umbilical velocimetry obtained with either continuous-wave or pulsed-wave Doppler ultrasonography have been used to assess downstream placental vascular resistance and fetal well-being. The purpose of this study is to compare the efficacy of systolic/diastolic ratios obtained by continuous-wave and pulsed-wave Doppler ultrasonography in the prediction of poor pregnancy outcome. Continuous-wave and pulsed-wave umbilical velocimetry was performed and systolic/diastolic ratios were measured in 200 high-risk pregnancies in the third trimester by use of Angioscan III and a General Electric RT 3600 scanner, respectively. A total of 165 study participants had normal systolic/diastolic ratios and 35 participants had elevated ratios (greater than 3.0) with both continuous-wave and pulsed-wave Doppler ultrasonography. Both methods identified 35 participants with abnormal ratios, and none of the women was misclassified by either method. The pulsed-wave and continuous-wave values for 35 participants with elevated ratios were 6.35 +/- 1.52 and 6.23 +/- 1.58, respectively; values for 165 participants with normal ratios were 1.95 +/- 0.40 and 1.96 +/- 0.41, respectively (not significantly different). Participants with elevated systolic/diastolic ratios within 7 days of delivery had significantly higher incidence of adverse pregnancy outcome as judged by small-for-gestational-age fetuses, presence of meconium at delivery, fetal distress in labor, cesarean sections and 5-minute Apgar scores less than 7. Fetuses with elevated ratios were delivered at an earlier gestational age (34 +/- 1.2 weeks), had lower birth weights (1422 +/- 151 gm), and spent more time in the neonatal intensive care unit (17.1 +/- 5.2 days), compared with fetuses with normal ratios (delivered at 38.5 weeks +/- 0.9 weeks, 3100 +/- 210 gm birth weights, and 2 +/- 0.2 days spent in neonatal intensive care units, respectively, p less than 0.05). We therefore conclude that continuous-wave and pulsed-wave Doppler ultrasonography produce similar results with regard to systolic/diastolic ratios in high-risk pregnancies, and either method appears to be a valuable adjunct in the surveillance of high-risk pregnancies.     

Maternal serum levels of dehydroepiandrosterone sulfate and labor induction in postterm pregnancies.

OBJECTIVES: To study the relationship between maternal endogenous dehydroepiandrosterone sulfate (DHEAS) levels, success of labor induction, and Bishop scores in postterm pregnancies. METHODS: There were 65 postterm pregnancies. Group 1 consisted of women spontaneously in the active phase of labor, and group 2 of women with hypotonic uterine contractions whose labor was inducted by oxytocin. Levels of DHEAS were studied from venous blood samples. Demographic data and Bishop scores were recorded. RESULTS: The demographic characteristics of patients were similar, but DHEAS levels were higher in group 1 than in group 2 (P<0.001). Linear regression analysis showed a significant relationship between DHEAS and Bishop scores. DHEAS levels in women delivered vaginally were significantly higher than in women delivered by cesarean section. From the receiver operating characteristics (ROC) curve, DHEAS levels might determine the mode of delivery and success of labor induction; however, Bishop scores do not. CONCLUSIONS: DHEAS levels may be an important factor influencing the efficiency of labor and the success of labor induction in postterm pregnancies.     

Active induction management of labor for diabetic pregnancies at term; mode of delivery and fetal outcome--a single center experience

OBJECTIVES: To evaluate the mode of delivery in diabetic pregnancies at term following induction of labor with vaginal application of prostaglandin E2 (PGE2), and to identify possible predictors of successful vaginal delivery. PATIENTS AND METHODS: The study group consisted of 105 women with diabetic pregnancies at term admitted for induction of labor; 84 (80%) had gestational diabetes (GDM) and 21 (20%) type 1 diabetes. Findings were compared with women who underwent elective induction of labor (n=115), and women with normal spontaneous onset of labor (n=510). Women with previous cesarean section (CS) were excluded from both study and control groups. RESULTS: Maternal age and gravidity were significantly higher in the study group than the control groups (age: 31.4+/-5, 28+/-5.0 and 28.1+/-4.8 years, respectively; gravidity: 3.0+/-1.9, 2.5+/-1.6, and 2.1+/-1.4, respectively; P<0.001 for both) and gestational age and nulliparity rate were significantly lower (gestational age: 38.6+/-1.1, 40.2+/-1.3 and 39.3+/-2.7 weeks, respectively; nulliparity: 34.6, 45.2, 51.6%, respectively; P<0.002 for both). There were no between-group differences in the incidence of oligohydramnios, number of PGE2 applications used, birth weight, rate of non-reassuring fetal heart rate pattern leading to CS, and rate of low 5 min Apgar score (<7). The rate of CS in the study group (18.2%) was significantly higher than in the spontaneous labor group (9%) but similar to the elective induction group (14.8%). On stepwise analysis, only nulliparity (OR 4.56, 95% CI 1.11-18.67, P=0.035) was independently and significantly associated with increased risk of CS. Within the study group (R2=0.257, P=0.002), type 1 diabetes (OR 2.4, 95% CI 1.04-5.51) was independently and significantly associated with increased risk of CS. CONCLUSION: In diabetic pregnancies, induction of labor at term with vaginal PGE2 is successful in approximately 82% of patients, but yields a significantly higher CS rate compared to uncomplicated pregnancies. Nulliparity and diagnosis of type 1 diabetes are independently and significantly associated with increased risk of CS. CONDENSATION: In diabetic pregnancies, induction of labor at term is successful in 82% of patients, but yields higher CS rates compared to uncomplicated pregnancies.     

Postterm infants: too big or too small?

Concern over the postterm pregnancy has shifted from that of the difficult delivery of an excessively large fetus to the current concern with death in utero of an undernourished, small-for-date fetus. Studies of postterm pregnancy before the availability of ultrasonography may have included a large proportion of erroneous menstrual dates. The present study of 7000 infants was undertaken to reassess fetal growth in postterm pregnancies in which the expected date of confinement from last normal menstrual period dating was confirmed (+/- 7 days) by early ultrasonography. Results show a gradual shift toward higher birth weight and greater crown-heel length and head circumference between 273 and 300 days of gestational age. No evidence of postterm weight loss or lower weight for length could be demonstrated. Concern in postterm pregnancy should be for fetal macrosomia, not for intrauterine growth retardation.     

C-reactive protein in normal pregnancy

Maternal serum C-reactive protein (CRP) has been studied extensively as an adjunct in the diagnosis of subclinical infection among pregnant women with preterm labor or preterm rupture of membranes. However, before the utility of CRP can be studied in pregnancies with these complications, the effects of normal pregnancy and labor on maternal serum CRP levels must be established. We determined CRP levels serially from 22 weeks' gestation until delivery in healthy pregnant women without antepartum complications. Median CRP values for women not in labor ranged from 0.7-0.9 mg/dL, depending on gestational age; 95% of the values were 1.5 mg/dL or lower. No consistent change in CRP levels with gestational age was found among serially sampled women not in labor. The median CRP value for women in labor at term was 1.3 mg/dL, and 32% of values were over 1.5 mg/dL. Median CRP values in normal pregnancies appear to be higher than standardized values for nonpregnant individuals, and CRP values are further elevated in labor. Understanding the physiology and temporal course of the increase in CRP in normal pregnancy and labor may help to clarify the appropriate use of CRP in complicated pregnancies.     

Detection of the cervical gland area in threatened preterm labor using transvaginal sonography in the assessment of cervical maturation and the outcome of pregnancy

OBJECTIVES: To detect the cervical gland area in threatened preterm labor, and to determine its detection rate and relationship with cervical maturation and outcome of pregnancy in preterm labor. METHODS: This was a mixed longitudinal and cross-sectional study involving 615 transvaginal scans performed to detect the cervical gland area and measure cervical length in 101 singleton pregnancies with threatened preterm labor. The patients were treated with intravenous administration of ritodrine chloride for regular uterine contractions at 16-35 weeks of gestation. 260 normal singleton pregnancies served as controls. Simultaneously conventional digital examination was used to assess the cervical maturation index. The detection rates of the cervical gland area, measurements of cervical length by sonography, and assessment of the cervical maturation index by digital examination in threatened preterm labor were compared with those of normal singleton pregnancies. In the threatened labor group, the outcome of pregnancy was assessed according to the sonographic absence or presence of the cervical gland area. RESULTS: In the normal pregnancy group, the detection rate of the cervical gland area remained practically constant until the 31st week of pregnancy (97%), but substantially decreased thereafter (70.2% in gestational weeks 32-35). In the threatened preterm labor group, the detection rate of the cervical gland area was constantly lower (44.5%) and the cervical maturation index was higher (4.65 score) than in the normal pregnancy group (83.1% and 1.80 score, respectively). The outcome of pregnancy in the threatened preterm labor group was poorer in the subgroup with the absence of a cervical gland area than in the subgroup with the presence of a cervical gland area (duration of pregnancy 257.0 vs. 271.0 days, birth weight 2,597.2 vs. 2,990.0 g, and admission to delivery interval 38.8 vs. 60.8 days). Highly significant correlations were noted among the detection rates of a cervical gland area and cervical length, cervical maturation index, and outcome of pregnancy. CONCLUSIONS: This study demonstrates for the first time that the sonographic absence of the cervical gland area reflects cervical maturation and could be considered as a predictor of threatened preterm labor and a sign of poor outcome of pregnancy in this condition.     

Demographic and obstetric factors influencing pregnancy outcome in twin gestations

OBJECTIVE: Our purpose was to identify the influence of parity and previous preterm delivery on pregnancy outcome in twin gestations. STUDY DESIGN: A retrospective comparative analysis of women with twin gestations completing an outpatient preterm labor surveillance program between April 1995 and February 2000 was performed. Included were those enrolled at <24 weeks' gestation. Parity, maternal age, prepregnancy body mass index (BMI), cerclage, tocolytic use, and pregnancy outcome were identified. Data were divided into nulliparas, multiparas without previous preterm delivery, and those with previous preterm delivery. Analysis of variance and the Pearson chi2 test were used for statistical analysis. RESULTS: Data were analyzed for 1268 twin pregnancies. The mean gestational age at delivery for the multiparous women without a history of previous preterm delivery (35.3 +/- 2.7 weeks) was significantly greater than the mean gestational age at delivery for nulliparous (34.4 +/- 3.2 weeks) and multiparous women with a previous preterm delivery (34.0 +/- 3.1 weeks), P <.001. The greater gestational age at delivery in the multiparous women without a previous preterm delivery was associated with a significantly shorter newborn hospital stay and a lower need for mechanical ventilation use compared with the other groups (all P values < or =.001). CONCLUSION: In twin gestations, multiparous women without history of previous preterm delivery have a significantly greater gestational age at delivery, a lower incidence of cerclage, and a reduced neonatal hospital stay than do nulliparous women or those with a history of a previous preterm delivery.     

Renal artery Doppler investigation of the etiology of oligohydramnios in postterm pregnancy

OBJECTIVE: To investigate the etiology of oligohydramnios in postterm pregnancy using Doppler velocimetry. METHODS: Renal and umbilical artery Doppler velocimetry were performed in women with singleton postterm (287 days' or more gestation) pregnancies. The renal and umbilical artery Doppler resistance index (RI) and end-diastolic velocity were measured. Stepwise logistic regression and the two-tailed t test were used to determine whether the Doppler indices correlated with oligohydramnios (amniotic fluid index less than 5 cm). RESULTS: We studied 147 well-dated, singleton, postterm pregnancies, of which 21 (14.3%) had oligohydramnios. For the study cohort, the mean (+/-standard deviation) gestational age at Doppler was 41.4 +/- 0.45 weeks and at delivery 41.8 +/- 0.47 weeks. Stepwise logistic regression using renal and umbilical artery Doppler indices found the renal RI to be the only significant predictor of oligohydramnios: beta = -10.4186, P <.05 (odds ratio [95% confidence interval (CI)] = 0, 0.88). The renal artery RI was significantly higher in cases with oligohydramnios (RI: mean (+/-standard error) = 0.8843 +/- 0.11 versus 0.8601 +/- 0.05, P 相似文献   

Favorable outcome following emergency second trimester cerclage.

BACKGROUND: To evaluate the outcome of midtrimester emergency cerclage with or without bulging of membranes. METHODS: A retrospective cohort study of 99 women who underwent emergency second trimester cerclage (16-27 gestational weeks). In 75 women the cervix was dilated and effaced but without bulging of membranes (group 1), and in 24 women the dilation and effacement of the cervix were accompanied by bulging of membranes into the vagina in an hourglass formation (group 2). McDonald technique was applied in all patients. RESULTS: Prolongation of pregnancy was significantly longer in group 1 compared to group 2 (14.3+/-6.5 vs 9.3+/-4.8 weeks, p=0.007). The mean gestational age at delivery was significantly higher in group 1 compared to group 2 (34.6+/-4.6 vs 29.5+/-3.2 weeks, p=0.001). The incidence of chorioamnionitis was higher in group 2 compared to group 1 but statistically insignificant (25% vs 15%, p=0.2). The overall neonatal survival was 83% (82 out of 99 neonates), without statistical difference between the two groups (86% in group 1 and 71% in group 2, p=0.2). CONCLUSIONS: Favorable neonatal outcome may be accomplished in patients with cervical incompetence in the second trimester of pregnancy following cervical emergency suturing even performed when the membranes are bulging through the cervix into the vagina.     

Oral nifedipine maintenance therapy after acute intravenous tocolysis in preterm labor

AIMS: Our aim was to evaluate the efficacy of maintenance oral nifedipine in pregnant women initially treated with intravenous ritodrine plus verapamil for preterm labor. METHODS: The study included 73 patients with preterm labor with intact membranes. Patients were randomized to receive either maintenance oral nifedipine therapy (n=37) administered 20 mg every six hours or no treatment (controls, n=36) after discontinuation of acute intravenous tocolysis. RESULTS: Compared to the control group, the mean +/- SD time gained from initiation of maintenance therapy to delivery (26.65 +/- 18.89 vs. 16.14 +/- 12.91 days, p=0.007) and the gestational age at delivery (37.03 +/- 2.06 vs. 35.1 +/- 3 weeks, p=0.003) were higher in the nifedipine maintenance therapy group. The proportion of patients who required one or more courses of subsequent intravenous therapy and perinatal outcomes were similar in the maintenance therapy and control groups. CONCLUSIONS: The gestational age and time gained from initiation of maintenance therapy to delivery were longer in women receiving oral maintenance tocolysis with nifedipine. However, maintenance therapy did not decrease the recurrence of preterm labor episodes or improve perinatal outcomes.     

Elevated amniotic fluid leptin levels in early second trimester are associated with earlier delivery and lower birthweight in twin pregnancy

OBJECTIVE: To explore the possibility of using early second trimester amniotic fluid leptin levels as a predictor of pregnancy outcome in twin pregnancy. STUDY DESIGN: Amniotic fluid leptin levels from 18 twin-pregnant women in early second trimester were analyzed for their correlation with gestational age at delivery and fetal birthweight. Leptin levels in 16 amniotic fluid samples collected from small for gestational age (SGA) twin pregnancies were compared with those in 20 amniotic fluid samples collected from non-SGA twin pregnancies. RESULTS: A significant correlation was observed between amniotic fluid leptin levels and gestational age at delivery (r = 0.71, p < 0.001) as well as fetal birthweight (r = 0.72, p < 0.001). There was also a significant correlation between gestational age at delivery and fetal birthweight (r = 0.92, p < 0.001). The average gestational age at delivery was 30.4 +/- 1.4 weeks in the SGA group, with a mean birthweight of 1552 +/- 200 g at delivery. For the non-SGA group, the values were 37.3 +/- 0.5 weeks and 2759 +/- 115 g ( p < 0.001), respectively. Amniotic fluid leptin levels were found to be significantly higher ( p < 0.001) for women in the SGA group (11.4 +/- 1.5 ng/mL) than for those in the non-SGA group (5.4 +/- 0.5 ng/mL). CONCLUSION: Higher amniotic fluid leptin levels in early second trimester were associated with both lower gestational age at delivery and lower birthweight. Our results suggest that amniotic fluid leptin levels in early second trimester may be a good marker for the prediction of perinatal complications in twin pregnancy.