Prospective randomized controlled trial of fetal fibronectin on preterm labor management in a tertiary care center

OBJECTIVE: The purpose of this study was to investigate the effect of the rapid fetal fibronectin on the length of hospital stay and the use of preterm labor interventions in a tertiary care center. STUDY DESIGN: Women who were seen in the Labor and Delivery Unit with symptoms of preterm labor were assigned randomly to receive fetal fibronectin (n=46 women) or to preterm labor management without fetal fibronectin (n=51 women). Physicians were not blinded to the result; groups were compared. RESULTS: There was no difference between groups in demographic or obstetric characteristics, the hours spent in labor and delivery, the number of women who were admitted to the antepartum service, the length of stay, or medical interventions. When the results for women with a negative fetal fibronectin test were compared to women with a positive fetal fibronectin test, a significant difference was found in admissions to the antepartum service (P=.032) and the length of stay (P=.008). CONCLUSIONS: A negative fetal fibronectin test was associated with fewer admissions to the antepartum ward and a shorter length of stay.     

Pregnancy Outcome in Patients Requiring Parenteral Nutrition

Objective: The purpose of this retrospective study was to evaluate maternal and perinatal outcomes and complications of parenteral nutrition during pregnancy in our institution.

Methods: This study was a review of medical records of all women who required parenteral nutrition during pregnancy at our institution from 1990–1997. The frequency of maternal and perinatal complications was calculated.

Results: Twenty-six pregnancies required parenteral nutrition for the following indications: hyperemesis gravidarum (n = 16), cholecystitis/pancreatitis (n = 3), small bowel obstruction (n = 2), intracranial bleed (n = 2), ulcerative colitis (n = 1), and other (n = 2). The mean gestational age at initiation of therapy was 16.2 weeks and the mean duration of therapy was 30.6 days. Five pregnancies were terminated prior to fetal viability. Of the remaining pregnancies, obstetric complications occurred in 11, including two cases of idiopathic preterm labor resulting in preterm deliveries. Maternal complications resulting from the central venous catheters included four infections, two thromboses, one occlusion, one pneumothorax, and one catheter dislodgment. The complication rate for centrally inserted central catheters (50%) was significantly greater than the rate for peripherally inserted central catheters (9%).

Conclusions: Successful outcomes can be achieved in obstetric patients requiring parenteral nutrition. In this group of patients, the frequency of maternal complications secondary to centrally inserted central venous catheters was greater than that reported in nonpregnant patients. Peripherally inserted central catheters may be preferable when parenteral nutrition is required during pregnancy.     

Predicting preterm birth: Cervical length and fetal fibronectin

Spontaneous preterm birth remains the leading cause of neonatal morbidity and mortality worldwide, and accounts for a significant global health burden. Several obstetric strategies to screen for spontaneous preterm delivery, such as cervical length and fetal fibronectin measurement, have emerged. However, the effectiveness of these strategies relies on their ability to accurately predict those pregnancies at increased risk for spontaneous preterm birth (SPTB). Transvaginal cervical shortening is predictive of preterm birth and when coupled with appropriate preterm birth prevention strategies, has been associated with reductions in SPTB in asymptomatic women with a singleton gestation. The use of qualitative fetal fibronectin may be useful in conjunction with cervical length assessment in women with acute preterm labor symptoms, but data supporting its clinical utility remain limited. As both cervical length and qualitative fetal fibronectin have limited capacity to predict preterm birth, further studies are needed to investigate other potential screening modalities.     

Percutaneous management of lymphocoeles following pelvic lymphadenectomy for cervical carcinoma.

Eighteen patients with 26 pelvic lymphocoeles following radical hysterectomy underwent percutaneous therapeutic intervention with either needle aspiration, or catheter drainage. In eight patients a percutaneous needle aspiration under sonographic control was performed. Five out of eight patients were successfully managed with needle aspiration, three of them requiring repetitive aspirations. Thirteen patients, with a total of 21 lymphocoeles underwent catheter drainage. Seventeen of the 21 lymphocoeles completely resolved. Redrainage was performed in four cases and it was successful in two of them. The duration of the catheter drainage was 8 to 34 days. Nine of the lymphocoeles were infected at initial drainage. Two patients underwent surgery because of increased volume of output. Percutaneous drainage is a safe and effective method and should be considered as the initial treatment for all patients with postoperative lymphocoeles.     

Evaluation of blunt abdominal trauma in the third trimester of pregnancy: maternal and fetal considerations

With the active life-style of today's pregnant women, the effects of trauma have become an important obstetric concern. A protocol was developed to monitor pregnancies complicated by major blunt abdominal trauma in the third trimester, looking specifically for delayed placental and/or fetal problems. Of the 84 pregnancies studied, the most serious complication was placental abruption. Although abruption occurred in only two cases, one case was associated with a ruptured uterus and fetal death. There were no cases of delayed abruption or delayed fetal compromise. The most common complication was preterm labor, occurring in 28% of cases when the traumatic insult happened before 37 weeks' gestation. Of these 17 patients, 15 were successfully treated with tocolysis. There were no cases of direct fetal injury or Rh-isoimmunization. A revised protocol is recommended for limited outpatient observation with nonstress testing and screening ultrasonography to rule out preterm labor and placental abruption and to document fetal well-being.     

腰麻及硬膜外麻醉联合应用于产科分娩镇痛的临床观察

目的探讨联合应用腰麻及硬膜外麻醉（ＣＳＥＡ）减轻或消除产痛以及对产程、胎儿、分娩方式的影响。方法选择８０例无产科、麻醉禁忌证的初产妇（观察组）,在宫口开大２～３ｃｍ时,给予联合腰麻及硬膜外麻醉,并与同期条件相似、未给予任何镇痛方法的８０例初产妇进行对照（对照组）。比较两组产痛程度、产程进展速度、分娩方式及对胎儿的影响。结果观察组镇痛有效率较对照组明显升高（Ｐ＜０．０１）。观察组活跃期较对照组缩短,宫颈扩张速度加快、剖宫产率下降,经阴道助产分娩率增高（Ｐ＜０．０５）。胎儿窘迫及新生儿窒息、产后出血发生率两组比较,差异均无显著性（Ｐ＞０．０５）。结论ＣＳＥＡ应用于产科,可达到分娩镇痛、加速产程、降低剖宫产率的作用,且对胎儿无不良影响,值得推广应用     

胎儿纤维连接蛋白评估抗生素治疗先兆早产疗效的研究

目的:探讨应用胎儿纤维连接蛋白评估抗生素治疗先兆早产的疗效。方法:选择妊娠28～33+6周先兆早产孕妇67例,随机分成两组:研究组35例,连续使用抗生素以及硫酸镁治疗3天;对照组32例,硫酸镁治疗3天,未使用抗生素。检测治疗前、治疗3天后宫颈阴道分泌物中的胎儿纤维连接蛋白(fFN)和血清中的C-反应蛋白(CRP)。结果:(1)研究组保胎成功29例,占82.8%(29/35);对照组保胎成功19例,占59.4%(19/32);比较两组保胎成功率,差异有统计学意义(P<0.05);(2)比较两组治疗后fFN阳性率和CRP值,差异均有统计学意义(P<0.05);(3)比较经治疗后fFN阳性CRP正常组与fFN阴性CRP异常组的妊娠结局,差异有统计学意义(P<0.05)。在预测早产方面,fFN敏感性为78.9%,特异性为87.5%;CRP敏感性为52.6%,特异性为79.1%。结论:胎儿纤维连接蛋白可作为评价先兆早产疗效的一项指标。     

Fetal complications after placement of an intrauterine pressure catheter: A report of two cases and review of the literature

Background. Uterine contractions during labor can be monitored by external tocodynamometry or by the use of an intrauterine pressure catheter (IUPC). Since an IUPC measures the frequency of contractions as well as their strength and duration, it is thought to be more accurate than external tocodynamometry. However, limited evidence on this subject suggests that IUPC may not improve maternal or perinatal outcomes. Moreover, the use of IUPC may cause fetal complications.

Cases. We describe the placement of an IUPC during induction of labor with oxytocin in two cases, one presenting with a singleton pregnancy and the other a twin pregnancy. After introduction of the IUPC, both cases were complicated by blood loss and signs of fetal distress on cardiotocography. An emergency cesarean section was performed in both cases. In the first case, extramembranous placement of the IUPC was observed, whereas in the second case, the IUPC had lacerated an arteriovenous anastomosis in the membranes, resulting in perinatal death.

Conclusion. Placement of an intrauterine pressure catheter instead of external tocodynamometry has a small risk for serious fetal complications.     

High levels of fetal cell-free DNA in maternal serum: a risk factor for spontaneous preterm delivery

OBJECTIVE: This study was conducted to determine whether there is a relationship between the concentration of fetal cell-free DNA in maternal serum and the duration of pregnancy in women who are at high risk for preterm delivery because of either preterm labor or preterm premature rupture of the membranes. STUDY DESIGN: Sera were collected and frozen from 71 women with a male fetus. Maternal serum fetal cell-free DNA concentration was measured with the use of real-time polymerase chain reaction amplification of DYS1. Fetal cell-free DNA concentrations were converted to multiples of the median. The following groups were studied: group 1: women with preterm labor and intact membranes who were delivered at > or = 36 weeks of gestation (n = 21); group 2: women with preterm labor who were delivered at <36 weeks of gestation (n = 29); and group 3: women with preterm premature rupture of the membranes in labor (n = 20) or not in labor (n = 1) who were delivered prematurely (<36 weeks of gestation). Kaplan-Meier and Cox regression analyses were used to analyze the relationship between fetal cell-free DNA concentrations and the likelihood of preterm delivery. RESULTS: A cut-off value for fetal cell-free DNA of 1.82 multiples of the median was chosen for analysis. The cumulative rate of early preterm delivery (<30 weeks of gestation) was significantly higher for women with fetal cell-free DNA concentrations of > or = 1.82 multiples of the median than those with fetal cell-free DNA concentrations below this cut-off (45% [95% CI, 36%-74%] vs 18% [95% CI, 11%-25%]; P = .008]. The cumulative rate of preterm delivery (<36 weeks of gestation) was also significantly higher at > or = 1.82 multiples of the median (73% [95% CI, 52%-93%] vs 66% [95% CI, 54%-79%]; P = .02). After adjustment for covariates, Cox analysis showed that fetal cell-free DNA at > or = 1.82 multiples of the mechanisms of disease that are associated with a mean hazard rate of delivery of 1.57 (P = .005). CONCLUSION: High concentrations of fetal cell-free DNA in maternal serum are associated with an increased risk of spontaneous preterm delivery. This observation may have implications for the understanding of the mechanisms of disease that is associated with preterm labor.     

基质金属蛋白酶-8和环氧合酶-2在早产、胎膜早破时胎膜中的表达及其意义

目的 :探讨基质金属蛋白酶 8(matrixmetalloproteinase -8,MMP -8)和环氧合酶 2 (cyclooxygenase -2 ,COX- 2 )在早产、胎膜早破 (PROM)发病机制中的作用。方法 :用免疫组化法 (SP法 )检测 8例早产临产、11例早产PROM、2 0例足月PROM、10例足月临产及 12例足月未临产正常产妇 (对照组 )宫颈胎膜和宫体胎膜组织中MMP 8和COX- 2的分布和表达。结果 :(1)MMP- 8和COX -2在羊膜及绒毛膜上皮细胞和间质细胞中均可见表达 ;(2 )前 4组产妇宫颈胎膜组织中MMP 8表达的免疫组化积分分别是 5 .2 5± 0 .89、5 .73±0 .4 7、4 .0 0± 1.95、3.70± 2 .2 6 ,均高于对照组的 2 .0 8± 1.5 6 (P <0 .0 5 ) ;同时亦均高于同组产妇宫体胎膜组织MMP 8的表达 ,分别是 3.38± 1.6 9、2 .2 7± 2 .2 8、2 .2 5± 2 .0 5与 1.70± 1.6 4(P <0 .0 5 ) ;而对照组宫颈和宫体胎膜组织中MMP 8的表达差异无显著性 (P >0 .0 5 ) ;(3) 5组产妇之间宫体胎膜组织中MMP- 8的表达差异无显著性 (P >0 .0 5 ) ;(4)宫颈和宫体胎膜组织中COX -2表达的免疫组化积分 ,早产临产组为 5 .75± 0 .4 4、5 .6 3±0 .5 2 ,足月临产组为 4 .4 0± 1.4 3、3.70± 1.77,均高于对照组的 2 .92± 1.31、2 .2 5± 1.6 6 (P<0 .0 5 ) ;其中早产临产组明显增?     

Simple one-step catheter placement for the treatment of infected lymphocele

OBJECTIVE: A pelvic lymphocele is a cystic collection of lymph fluid in the pelvis following pelvic lymphadenectomy. This retrospective study was undertaken to show the efficacy and safety of simple one-step catheter placement for the treatment of infected lymphocele. STUDY DESIGN: Ten infected lymphoceles were treated in nine patients. The percutaneous drainage procedures were performed using simple one-step trocar technique under sonographical guidance. The one-step pig tail catheter system consists of an 18-gauge needle, stylet, and 7F drainage tube. A 33% povidone-iodine solution was instilled and left in the cavity for 30 min twice daily. RESULTS: Overall, 9 of the 10 infected lymphoceles were successfully treated with one-step catheter drainage. Percutaneous catheter drainage was maintained for 2-17 days. One of the patients required open surgery for the persistence of infected lymphocele due to the catheter dislodgment. No patients encountered sepsis, bowel perforation, and neurovascular injury. CONCLUSION: Simple one-step procedure enables long-term drainage and is a well-tolerated, safe, and effective technique in the management of infected lymphocele.     

Antepartum hemorrhage of unknown origin--what is its clinical significance?

BACKGROUND: Antepartum hemorrhage of unknown origin is a common antenatal complication, accounting for more than half of the cases of antepartum hemorrhage. Few investigators had reported the importance of this condition and the proper management. METHOD: The present study reviewed retrospectively 718 cases with singleton pregnancies diagnosed as having antepartum hemorrhage of unknown origin after 24 weeks from 1991 to 1996 and compared their pregnancy outcomes with controls who delivered during the same period of time as the study cases. Clinical and ultrasound examinations were performed in all recruited cases to exclude accidental hemorrhage, placenta previa or lower genital tract bleeding. RESULTS: Patients with antepartum hemorrhage of unknown origin ran a higher risk of spontaneous preterm labor (p<0.001). The birthweight, when adjusted for gestation, did not differ between the two groups. Labor induction rate and cesarean section rates were significantly higher in the antepartum hemorrhage group. The incidences of major antepartum complications and neonatal complications did not differ between the two groups. There were more babies with congenital abnormalities in the antepartum hemorrhage group (p<0.001) and perinatal mortality rate was also higher, though this difference was not statistically significant. CONCLUSION: The main fetal risks associated with antepartum hemorrhage of unknown origin is preterm labor and its subsequent fetal complications. A small but significant proportion of these pregnancies might be associated with fetal congenital abnormalities. Routine induction at term for this group of patients is of questionable value as adverse fetal outcomes are mostly associated with those that delivered prematurely, or with babies with congenital malformations. When gross fetal abnormalities could be reasonably excluded, labor induction at term should only be contemplated in the presence of other obstetric indications.     

非糖尿病性巨大儿175例临床特征及相关因素探讨

目的探讨非糖尿病性巨大儿及其母亲的临床特征及相关因素.方法通过本院近5年出生的175例非糖尿病性巨大儿或其母亲与随机选择同期出生的174例正常体重儿或其母亲的回顾性对照分析.结果非糖尿病性巨大儿的平均胎龄、体重、身高、双顶径及男性比例均显著高于对照组;其母亲的平均孕龄、年龄、身高、孕末期体重指数及围产期发病率、剖宫产率均显著高于对照组.结论非糖尿病性巨大儿是生长发育全面成熟且有生机活力的,以男性为多;其发生与其母亲孕龄、年龄、身高、产次等非糖尿病性因素有关,并导致其母亲围产期发病率、剖宫产率均显著增高;积极预防非糖尿病性巨大儿的发生是降低围产期发病率和提高产科质量的重要措施之一.     

Does the station of the fetal head during epidural analgesia affect labor and delivery?

OBJECTIVE: To assess whether the station of the fetal head when lumbar epidural analgesia is administered influences the duration or the mode of delivery in low-risk laboring women. METHODS: We prospectively evaluated 131 consecutive cases of low-risk parturients at term who requested intrapartum epidural analgesia. Obstetric outcome of 65 parturients who underwent epidural analgesia when the fetal head was low in the birth canal was compared to 66 patients whose fetal head station was above the ischial spine. RESULTS: Both groups were similar in their obstetric characteristics. Cervical dilatation when performing the epidural analgesia was similar in both groups. The duration of labor and mode of delivery, as well as percentage of malpositions, were not significantly different in the two groups. CONCLUSIONS: The station of the fetal head while initiating epidural analgesia does not influence the duration of labor or the mode of delivery. Therefore, there is no justification to delay epidural analgesia in labor until the presenting fetal part is engaged.     

Is the management of epidural analgesia associated with an increased risk of cesarean delivery?

OBJECTIVE: The aim of this study was to quantify the association of cesarean delivery with epidural analgesia management, specifically with the timing of epidural catheter placement in relation to labor, the type of epidural analgesia, and the use of bolus dosing.Study Design: A retrospective cohort design was used to investigate 1561 consecutive nulliparous parturients whose labor occurred between November 1, 1996, and June 30, 1997, at Northwestern Memorial Hospital and who were delivered of term, singleton neonates in a cephalic presentation. The relationship between the management of epidural analgesia and the risk for cesarean delivery was determined with stepwise logistic regression to control for potential confounding variables. RESULTS: There was a significantly increased risk of cesarean delivery associated with decrements in cervical effacement (P =.001), cervical dilatation (P =.001), and fetal station (P =.001) at the time of epidural catheter placement. An increasing number of epidural boluses during the first stage of labor was also associated with increased risk of cesarean delivery (P =.001). After we controlled for maternal age, maternal body mass index, gestational age, infant birth weight, induction of labor, use of magnesium sulfate, and presence of chorioamnionitis, the adjusted odds of cesarean delivery associated with fetal station (odds ratio, 1.45; 95% confidence interval, 1.2-1.7) and epidural boluses (odds ratio, 1.55; 95% confidence interval, 1.3-1.8) during the first stage of labor remained significant. CONCLUSION: The management of epidural analgesia during labor was associated with the potential for increased risk of cesarean delivery. This risk increased with higher stations of the fetal head at the time of epidural catheter placement and with more frequent epidural boluses of local anesthetic during the first stage of labor.     

The influence of maternal epidural analgesia upon intrapartum fetal oxygenation

Objective. The use of maternal epidural analgesia in labor may be associated with non-reassuring fetal heart rate (FHR) patterns. We aimed to assess changes in fetal oxygen saturation (FSpO₂) during epidural analgesia in labor.

Methods. This was a prospective observational study. Twenty healthy parturients were enrolled following the inclusion criteria. Informed consent was obtained. Mode of delivery, use of oxytocin, maternal blood pressure, umbilical cord blood analysis, Apgar score, and neonatal outcomes were evaluated. Ropivacaine at a low concentration of 0.1% (1 mg/mL) co-administered with an opioid (fentanyl 2.5 µg/mL) was used. The values of fetal oxygen saturation were registered continuously 10 minutes before the administration of the analgesic drug and during the following 30 minutes after administration. Pulse oximetry was used simultaneously with cardiotocography (CTG).

Results. The average value for fetal oxygen saturation before the analgesic drug administration was 44.3 ± 8.8%; during the first 10 minutes following administration it was 41.3 ± 7.2% (p = 0.25) and during the following 20 minutes it was 43.05% ± 6.9% (p = 0.63). There was no direct relationship between non-reassuring CTG pattern appearance and FSpO₂ <30% (RR = 1.11, 95% CI 0.76–1.64). No significant correlation was found between FSpO₂ values within the first 30 minutes of epidural analgesia and neonatal acidotic status (pH ≤7.00; RR = 0.33, 95% CI 0.04–3.09, and base excess ≤?12 mmol/L; RR = 1, 95% CI 0.21–4.71).

Conclusions. There were no differences in FSpO₂ values in the first 30 minutes following administration of analgesic drugs and most of the cases with non-reassuring CTG patterns had values of FSpO₂ constantly ≥30%.     

Dystocia in nulliparous patients monitored with fetal pulse oximetry

OBJECTIVE: A critical analysis of the United States randomized controlled trial of fetal pulse oximetry concluded that nonreassuring fetal heart rate patterns used for study entry may have been a marker for dystocia. We prospectively studied nulliparous women in labor whose progress was monitored with fetal pulse oximetry to examine the relationship between nonreassuring fetal heart rate patterns and operative delivery for dystocia. STUDY DESIGN: A prospective nonrandomized observational cohort study compared two distinct classes of nonreassuring fetal heart rate patterns (class I: intermittent, mildly nonreassuring; class II: persistent, progressive, and moderate to severely nonreassuring) among nulliparous patients with the use of fetal pulse oximetry to confirm fetal well-being. Definitions of dystocia included the cessation of labor progress in the first (3 hours) or second (2 hours) stage of labor, despite adequate uterine activity that was assessed with an intrauterine pressure catheter. Independent review confirmed the classification of nonreassuring fetal heart rate patterns and study entry criteria. RESULTS: Two hundred seventy-four patients met study criteria and had sufficient information for fetal heart rate tracing interpretation. Two hundred thirty-seven patients (86.5%) were class II, and 37 patients (13.5%) were class I. The two classes of patients were comparable in a variety of obstetric, demographic, and perinatal variables. Twelve percent of all patients were delivered for nonreassuring fetal status. Significantly more class II patients (22%) were delivered by cesarean for dystocia than were class I patients (8%). Higher doses and a longer number of hours of oxytocin were required among class II patients. Significantly more occiput posterior positions were noted among all patients who underwent cesarean delivery for dystocia compared with other modes of delivery. CONCLUSION: Significantly nonreassuring fetal heart rate patterns predict cesarean delivery for dystocia among nulliparous patients with normally oxygenated fetuses in a setting of a standardized labor management protocol. This confirms the observations in the randomized controlled trial of fetal pulse oximetry in the United States and may provide insight into the treatment of nonprogressive labor in contemporary practice.     

Preterm corticosteroid therapy and fetal immobility. Case report

We report a case of fetal immobility following antenatal corticosteroid therapy administered to women in thirty weeks at risk of preterm labor. The short-term side effect of corticosteroid, a decrease in fetal heart rate variation are well known. This case report presents the difficulty of therapy choice in front of fetal immobility and acute fetal distress. We chose a medical supervision. A review of the literature suggests other criteria, such as Doppler of umbilical artery, which could help therapeutical choice.     

Absceso epidural y de psoas bilateral tras anestesia epidural obstétrica: una complicación poco frecuente

Epidural abscess is a rare but serious complication of epidural anesthesia. We present the case of a healthy parturient who developed spinal epidural and psoas muscle abscesses following spinal analgesia for uneventful labor and delivery. Diagnosis requires a high index of suspicion and magnetic resonance imaging. Early surgical decompression and prolonged antibiotic therapy are the mainstays of epidural abscess treatment, while percutaneous drainage under imaging guidance with antibiotic coverage is an effective front-line treatment of psoas muscle abscess. Epidural abscess can be a catastrophic consequence of epidural anesthesia. Early diagnosis is essential to prevent permanent neurological damage.     

Results of treatment of severe fetal hydrothorax with bilateral pleuroamniotic catheters

Unusual antenatal treatment of a case of severe fetal hydrothorax with secondary polyhydramnios and preterm labor is presented and illustrated. Bilateral pleural drainage catheters were placed antenatally to decompress the fetal chest in an effort to prolong pregnancy because of immature pulmonary studies and poor prognosis. Catheter migration occurred and effective drainage ceased after three days, but with tocolysis and bilateral thoracentesis, delivery was delayed another 48 hours to allow steroid therapy. With ventilatory therapy and chest drainage the infant survived and is doing well at one year of age.