Outcome of pregnancies progressing beyond 28 weeks gestation in women with a history of recurrent miscarriage

Ninety-seven women who had had three or more miscarriages had also had at least one pregnancy with a singleton birth that had reached 28 weeks gestation. Information was available on these 118 babies: 30% were small-for-gestational age (birthweight less than or equal to 10th centile using figures from Scotland 1973-79), 28% were born preterm, and the perinatal mortality rate (excluding babies of less than 28 weeks gestation) was 161/1000 births, all of which are significantly increased above the prevalence for a normal obstetric population. These observations may serve to alert the clinician to the increased risk of these complications when dealing with women who have a history of recurrent miscarriage.     

Customised birthweight centiles are useful for identifying small-for-gestational-age babies in women with type 2 diabetes

Background: Customised birthweight centiles identify small-for-gestational-age (SGA) babies at increased risk of morbidity more accurately than population centiles, but they have not been validated in obese populations.
Aims: To compare the rates of SGA by population and customised birthweight centiles in babies of women with type 2 diabetes and examine perinatal outcomes in customised SGA infants.
Methods: Data were from a previous retrospective cohort study detailing pregnancy outcomes in 212 women with type 2 diabetes. Customised and population birthweight centiles were calculated; pregnancy details and neonatal outcomes were compared between groups that delivered infants who were SGA (birthweight < 10th customised centile) and appropriate weight for gestational age (AGA) (birthweight 10–90th customised centile).
Results: Fifteen (7%) babies were SGA by population centiles and 32 (15%) by customised centiles. Two babies of Indian women were reclassified from SGA to AGA by customised centiles. Nineteen babies were reclassified from AGA to SGA by customised centiles; of these, 15 (79%) were born to Polynesian women, five (26%) were born less than 32 weeks and two (11%) were stillborn. Customised SGA infants, compared with AGA infants, were more likely to be born preterm (19 (59%) vs 20 (16%), P  < 0.001) and more likely to be stillborn (4 (13%) vs 0 P  = 0.001). After excluding still births, admission to the neonatal unit was also more common (19 of 28 (68%) vs 43 of 127 (34%), P  < 0.001).
Conclusions: In our population more babies were classified as SGA by customised compared with population centiles. These customised SGA babies have high rates of morbidity.     

Association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth

OBJECTIVE: To determine the association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth. DESIGN: Multicentre prospective cohort study. SETTING: Ten European centres offering prenatal screening for toxoplasmosis. POPULATION: Deliveries after 23 weeks of gestation in 386 women with singleton pregnancies who seroconverted to toxoplasma infection before 20 weeks of gestation. Deliveries after 36 weeks in 234 women who seroconverted at 20 weeks or later, and tested positive before 37 weeks. METHODS: Comparison of infected and uninfected births, adjusted for parity and country of birth. MAIN OUTCOME MEASURES: Differences in gestational age at birth, birthweight and birthweight centile. RESULTS: Infected babies were born or delivered earlier than uninfected babies: the mean difference for seroconverters before 20 weeks was -5.4 days (95% CI: -1.4, -9.4), and at 20 weeks or more, -2.6 days (95% CI: -0.5, -4.7). Congenital infection was associated with an increased risk of preterm delivery when seroconversion occurred before 20 weeks (OR 4.71; 95% CI: 2.03, 10.9). No significant differences were detected for birthweight or birthweight centile. CONCLUSION: Babies with congenital toxoplasmosis were born earlier than uninfected babies but the mechanism leading to shorter length of gestation is unknown. Congenital infection could precipitate early delivery or prompt caesarean section or induction of delivery. We found no evidence for a significant association between congenital toxoplasmosis and reduced birthweight or small for gestational age birth.     

The impact of prenatal care on neonatal deaths in the presence and absence of antenatal high-risk conditions

OBJECTIVE: The purpose of this study was to determine the association between prenatal care in the United States and the neonatal death rate in the presence and absence of antenatal high-risk conditions. STUDY DESIGN: Data were derived from the national perinatal mortality data sets for the years 1995 through 1997, which were provided by the National Center for Health Statistics. Analyses were restricted to singleton live births that occurred after 23 completed weeks of gestation. Multivariable logistic regression analyses were used to adjust for the presence or absence of various antenatal high-risk conditions, maternal age, gestational age at delivery, and birth weight. RESULTS: Of 10,530,608 singleton live births, 18,339 (1.7/1000 births) resulted in neonatal death. Neonatal death rates (per 1000 live births) were higher for African American infants compared with white infants in the presence (2.7 vs 1.5, respectively) and absence (10.7 vs 7.9, respectively) of prenatal care. Lack of prenatal care was associated with an increase in neonatal deaths, which was greater for infants born at > or =36 weeks of gestation (relative risk, 2.1; 95% CI, 1.8, 2.4). Lack of prenatal care was also associated with increased neonatal death rates in the presence of preterm premature rupture of the membranes (relative risk, 1.3; 95% CI, 1.1, 1.5), placenta previa (relative risk, 1.9; 95% CI, 1.2, 2.9), fetal growth restriction (relative risk, 1.7; 95% CI, 1.2, 1.6), and postterm pregnancy (relative risk, 1.4; 95% CI, 1.0, 2.9). CONCLUSION: In the United States, prenatal care is associated with fewer neonatal deaths in black and white infants. This beneficial effect was more pronounced for births that occurred at > or =36 weeks of gestation and in the presence of preterm premature rupture of the membranes, placenta previa, fetal growth restriction, and postterm pregnancy.     

Placenta previa: neonatal death after live births in the United States

OBJECTIVE: The purpose of this study was to describe neonatal mortality rates among live births that were complicated by placenta previa in the United States. STUDY DESIGN: This was a population-based retrospective cohort study of 1997 United States singleton live births. Neonatal deaths among pregnancies that were complicated by placenta previa were compared with deaths among pregnancies with no placenta previa. Adjusted and unadjusted hazard ratios were generated from a proportional hazards regression model. RESULTS: Of 3,773,369 live births, 9656 were complicated by placenta previa (2.6 cases per 1000). Among cases of placenta previa, 114 neonatal deaths occurred (11.8 per 1000) versus 14951 (4 per 1000) among non-placenta previa neonates (P <.0001). The adjusted relative risk of death was three times higher among placenta previa neonates (hazard ratio, 3.06; 95% CI, 2.40-3.94). Placenta previa-related death was mediated through preterm delivery rather than small for gestational age. CONCLUSION: Placenta previa triples the rate of neonatal mortality, which is mediated mainly through preterm birth.     

Placenta previa and the risk of preterm delivery.

OBJECTIVES: We aimed to quantify the risk of preterm delivery and maternal and neonatal morbidities associated with placenta previa. STUDY DESIGN: We conducted a retrospective cohort study of singleton births that occurred between 1976 and 2001, examining outcomes including preterm delivery and perinatal complications. Multivariate logistic regression was used to control for potential confounders. Kaplan-Meier survival curves were constructed to compare preterm delivery in pregnancies complicated by previa vs. no previa. RESULTS: Among the 38 540 women, 230 women had previas (0.6%). Compared to controls, pregnancies with previa were significantly associated with preterm delivery prior to 28 weeks (3.5% vs. 1.3%; p = 0.003), 32 weeks (11.7% vs. 2.5%; p < 0.001), and 34 weeks (16.1% vs. 3.0%; p < 0.001) of gestation. Patients with previa were more likely to be diagnosed with postpartum hemorrhage (59.7% vs. 17.3%; p < 0.001) and to receive a blood transfusion (11.8% vs. 1.1%; p < 0.001). Survival curves demonstrate the risk of preterm delivery at each week and showed an overall higher rate of preterm delivery for patients with a placenta previa. CONCLUSIONS: Placenta previa is associated with maternal and neonatal complications, including preterm delivery and postpartum hemorrhage. These specific outcomes can be used to counsel women with previa.     

A late-preterm,early-term stratified analysis of neonatal outcomes by gestational age in placenta previa: defining the optimal timing for delivery

Objective: Though no official guidelines address the issue of the optimal timing of delivery in placenta previa, common practice is to conduct delivery between 36 and 37 weeks gestation. Given the rising concerns regarding unnecessary premature deliveries, the objective of this study was to compare neonatal outcomes among pregnancies complicated by placenta previa delivered at the late-preterm period (35, 36 weeks) relative to the early-term period (37 and 38 weeks).

Methods: We conducted a retrospective, population-based, cohort study using the CDC's Linked Birth-Infant Death data files from the U.S. for the year 2004. We stratified the cohort according to gestational age and placenta previa status. Using 38 weeks gestation as reference controls, the effect of delivery in a pregnancy with placenta previa at 35, 36 and 37 weeks gestation on the risk of several neonatal outcomes was estimated using logistic regression analysis, adjusting for relevant confounders.

Results: We analyzed a total of 4?118?956 births, of which 5675 (0.1%) met inclusion criteria. Late-preterm delivery was associated with lower birthweight and increased adequacy of care. Relative to neonates born at 38 weeks, birth at 35, 36 and 37 weeks was associated with no greater odds of meconium passage, fetal distress, fetal anemia, neonatal seizures, increased ventilator needs, or infant death at 1 year. However, odds of 5-min APGAR scores <7 were greater at 35 and 36 weeks (aOR [95% CI]): 3.33 [1.71–6.47] and 2.17 [1.11–4.22], respectively; as were odds of NICU admission rates: 2.25 [2.01–2.50] and 1.57 [1.38–1.76], respectively.

Conclusions: Barring maternal indications, early-term delivery in placenta previa is associated with fewer complications and no greater risk than late-preterm delivery. This information may be helpful in the development of future guidelines, which are currently needed to guide the management of these pregnancies.     

Pregnancy-induced hypertension and infant mortality: Roles of birthweight centiles and gestational age

OBJECTIVE: To assess the effect of pregnancy-induced hypertension (PIH) on infant mortality in different birthweight centiles (small for gestational age [SGA], appropriate for gestational age [AGA], and large for gestational age [LGA]) and gestational ages (early preterm, late preterm, and full term). DESIGN: Retrospective cohort study. SETTING: Linked birth and infant death data set of USA between 1995 and 2000. POPULATION: A total of 17 464 560 eligible liveborn singleton births delivered after 20th gestational week. METHODS: Multivariate logistic regression models were applied to evaluate the association between PIH and infant mortality, with adjustment of potential confounders stratified by birthweight centiles and gestational age. MAIN OUTCOME MEASURE: Infant death (0-364 days) and its three components: early neonatal death (0-6 days), late neonatal death (7-27 days), and postneonatal death (28-364 days). RESULTS: PIH was associated with decreased risks of infant mortality, early neonatal mortality, and late neonatal mortality in both preterm and term SGA births, and PIH was associated with lower postneonatal mortality in preterm SGA births. PIH was associated with decreased risks of infant mortality, early neonatal mortality, late neonatal mortality and postneonatal mortality in preterm AGA births. Decreased risk of infant mortality and early neonatal mortality was associated with PIH in early preterm LGA births. CONCLUSIONS: The association between PIH and infant mortality varies depending on different birthweight centiles, gestational age, and age at death. PIH is associated with a decreased risk of infant mortality in SGA births, preterm AGA births, and early preterm LGA births.     

Role of vaginal infection in fetal and neonatal mortality

Preterm delivery is the chief problem in obstetrics today and the main determinant of infant mortality and morbidity. Despite the dramatic decrease in infant mortality rate during the past several years, the percentage of preterm (<37 weeks gestation) and low birth weight (LBW) (<2500) rates remain elevated. Approximately 10% of all births are preterm, with a rate of 1-2% of infant born before the end of the 32 weeks of gestation and with a weight <1500 g. Despite the importance of the problem, the majority of preterm live births remain unexplained, and programmatic attempts at reversing the high level of preterm births have not been successful. Numerous studies have linked bacterial vaginosis, chorioamniotitis and endometritis with preterm birth and LBW, especially among African women. The number of preterm live births among African women is twice the one among Caucasians. Bacterial vaginosis is an independent risk factor for preterm and LBW births and the mechanism by which bacterial vaginosis causes the preterm birth of an infant with LBW is unknown. The aim of this article was to underline the importance of the treatment and early identification of vaginal infection, in particular if due to bacterial vaginosis, as it can have a substantial affect on the incidence of preterm delivery with LBW.     

Birth weight centiles,risk of intrapartum compromise,and adverse perinatal outcomes in term infants

Objective: The objective of this study is to evaluate the association between birth weight centiles and the risk of intrapartum compromise and adverse neonatal outcomes in term pregnancies.

Methods: Retrospective study of 32?468 term singleton births at a major tertiary maternity hospital in Australia. Data comprised gestation, mode, and indication for delivery and adverse perinatal outcomes. Fetal sex and gestational age-specific birth weight centiles were the main exposure variable.

Results: Neonates?<21st birth weight centile had an increased risk of intrapartum compromise, the highest risk was in babies?<3rd centile (OR 4.04, 95% CI 3.34–4.89). The risk of adverse perinatal outcomes was increased in neonates?<21st and?>91st birth weight centiles. The highest risk was in those?<3rd centile (OR 2.35, 95% CI 2.00–2.75).

Conclusions: Fetal size measurements near term may be used as part of screening test for identifying fetuses at an increased risk of intrapartum compromise and adverse perinatal outcomes.     

Admission of Term Infants to Neonatal Intensive Care: A Population‐Based Study

ABSTRACT: Background: Neonatal intensive care and special care nurseries provide a level of care that is both high in cost and low in volume. The aim of our study was to determine the rate of admission of term babies to neonatal intensive care in association with each method of giving birth among low‐risk women. Methods: We examined the records of 1,001,249 women who gave birth in Australia during 1999 to 2002 using data from the National Perinatal Data Collection. Among low‐risk women, we calculated the adjusted odds of admission to neonatal intensive care at term separated for each week of gestational age between 37 and 41 completed weeks. We also calculated the odds of admission to neonatal intensive care in association with cesarean section before or after the onset of labor, and vacuum or instrumental birth compared with unassisted vaginal birth at 40 weeks’ gestation. Results: The overall rate of admission to neonatal intensive care of term babies was 8.9 percent for primiparas and 6.3 percent for multiparas. After a cesarean section before the onset of labor, the adjusted odds of admission among low‐risk primiparas at 37 weeks’ gestation were 12.08 (99% CI 8.64–16.89); at 38 weeks, 7.49 (99% CI 5.54–10.11); and at 39 weeks, 2.80 (99% CI 2.02–3.88). At 41 weeks, the adjusted odds were not significantly higher than those at 40 weeks’ gestation. Among low‐risk multiparas who had a cesarean section before the onset of labor, the adjusted odds of admission to neonatal intensive care at 37 weeks’ gestation were 15.40 (99% CI 12.87–18.43); at 38 weeks, 12.13 (99% CI 10.37–14.19); and at 39 weeks, 5.09 (99% CI 4.31–6.00). At 41 weeks’ gestation, the adjusted odds of admission were significantly lower than those at 40 weeks (AOR 0.64, 99% CI 0.47–0.88). Babies born after any operative method of birth were at increased odds of being admitted to neonatal intensive care compared with those born after unassisted vaginal birth at 40 weeks’ gestation. Conclusions: The adjusted odds of admission to neonatal intensive care for babies of low‐risk women were increased after birth at 37 weeks’ gestation. In a climate of rising cesarean sections, this information is important to women who may be considering elective procedures. (BIRTH 34:4 December 2007)     

Term birthweight centiles for babies from New Zealand's main ethnic groups

BACKGROUND: There are significant differences in mean birthweights between New Zealand's main ethnic groups. Birthweight centiles developed predominantly from babies of European ethnicity may therefore not be appropriate to classify babies from other ethnic groups. AIMS: To develop ethnic specific birthweight centiles for New Zealand babies delivered at term (>37 weeks). METHODS: Births from the National Women's Hospital database from 1993 to 2000 who also had scan data at <24 weeks comprised the study population (n = 10 292). Multiple pregnancies, fetal abnormalities, stillbirths and preterm births were excluded. For six ethnic groupings, born at gestational weeks from 38 to 41, sex specific centiles were generated and smoothed. RESULTS: Birthweight centiles were constructed from 5203 European, 801 Maori, 825 Samoan, 577 Tongan, 1058 Chinese, 433 Indian and 1395 other ethnic group births. Mean birthweights by ethnic group were: European 3521 g, Maori 3467 g, Samoan 3691 g, Tongan 3791 g, Chinese 3418 g, Indian 3192 g and other 3466 g. Tongan and Samoan babies were significantly heavier and Indian babies were significantly lighter than babies from all other ethnic groups (P < 0.001 for all comparisons). Overall Maori babies were approximately 50 g lighter than European babies but this difference was not statistically significant (P = 0.08), whereas Chinese babies were significantly lighter with a mean birthweight 100 g less than European (P < 0.001). CONCLUSIONS: These ethnic specific centile charts are likely to identify term babies with inappropriate growth better than population centiles generated predominantly from one ethnic group.     

Preventing preterm birth and neonatal mortality: exploring the epidemiology, causes, and interventions

Globally, each year, an estimated 13 million infants are born before 37 completed weeks of gestation. Complications from these preterm births are the leading cause of neonatal mortality. Preterm birth is directly responsible for an estimated one million neonatal deaths annually and is also an important contributor to child and adult morbidities. Low- and middle-income countries are disproportionately affected by preterm birth and carry a greater burden of disease attributed to preterm birth. Causes of preterm birth are multifactorial, vary by gestational age, and likely vary by geographic and ethnic contexts. Although many interventions have been evaluated, few have moderate-to high-quality evidence for decreasing preterm birth: smoking cessation and progesterone treatment in women with a high risk of preterm birth in low- and middle-income countries and cervical cerclage for those in high-income countries. Antepartum and postnatal interventions (eg, antepartum maternal steroid administration, or kangaroo mother care) to improve preterm neonatal survival after birth have been demonstrated to be effective but have not been widely implemented. Further research efforts are urgently needed to better understand context-specific pathways leading to preterm birth; to develop appropriate, efficacious prevention strategies and interventions to improve survival of neonates born prematurely; and to scale-up known efficacious interventions to improve the health of the preterm neonate.     

Placenta previa and the risk of preterm delivery

Objectives. We aimed to quantify the risk of preterm delivery and maternal and neonatal morbidities associated with placenta previa.

Study design. We conducted a retrospective cohort study of singleton births that occurred between 1976 and 2001, examining outcomes including preterm delivery and perinatal complications. Multivariate logistic regression was used to control for potential confounders. Kaplan–Meier survival curves were constructed to compare preterm delivery in pregnancies complicated by previa vs. no previa.

Results. Among the 38 540 women, 230 women had previas (0.6%). Compared to controls, pregnancies with previa were significantly associated with preterm delivery prior to 28 weeks (3.5% vs. 1.3%; p = 0.003), 32 weeks (11.7% vs. 2.5%; p < 0.001), and 34 weeks (16.1% vs. 3.0%; p < 0.001) of gestation. Patients with previa were more likely to be diagnosed with postpartum hemorrhage (59.7% vs. 17.3%; p < 0.001) and to receive a blood transfusion (11.8% vs. 1.1%; p < 0.001). Survival curves demonstrate the risk of preterm delivery at each week and showed an overall higher rate of preterm delivery for patients with a placenta previa.

Conclusions. Placenta previa is associated with maternal and neonatal complications, including preterm delivery and postpartum hemorrhage. These specific outcomes can be used to counsel women with previa.     

Relationship among placenta previa, fetal growth restriction, and preterm delivery: a population-based study

OBJECTIVE: To examine the independent contributions of prematurity and fetal growth restriction to low birth weight among women with placenta previa. METHODS: A population-based, retrospective cohort study of singleton live births in New Jersey (1989-93) was performed. Mother-infant pairs (n = 544,734) were identified from linked birth certificate and maternal and infant hospital discharge summary data. Women diagnosed with previa were included only if they were delivered by cesarean. Fetal growth, defined as gestational age-specific observed-to-expected mean birth weight, and preterm delivery (before 37 completed weeks) were examined in relation to previa. Severe and moderate categories of fetal smallness and large for gestational age were defined as observed-to-expected birth weight ratios below 0.75, 0.75-0.85, and over 1.15, respectively, all of which were compared with appropriately grown infants (observed-to-expected birth weight ratio 0.86-1.15). RESULTS: Placenta previa was recorded in 5.0 per 1000 pregnancies (n = 2744). After controlling for maternal age, education, parity, smoking, alcohol and illicit drug use, adequacy of prenatal care, maternal race, as well as obstetric complications, previa was associated with severe (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.25, 1.50) and moderate fetal smallness (OR 1.24, 95% CI 1.17, 1.32) births. Preterm delivery was also more common among women with previa. Adjusted OR of delivery between 20-23 weeks was 1.81 (95% CI 1.24, 2.63), and 2.90 (95% CI 2.46, 3.42) for delivery between 24-27 weeks. OR for delivery by each week between 28 and 36 weeks ranged between 2.7 and 4.0. Approximately 12% of preterm delivery and 3.7% of growth restriction were attributable to placenta previa. CONCLUSION: The association between low birth weight and placenta previa is chiefly due to preterm delivery and to a lesser extent with fetal growth restriction. The risk of fetal smallness is increased slightly among women with previa, but this association may be of little clinical significance.     

Obstetrical and neonatal outcomes of triplet births – spontaneous versus assisted reproductive technology conception

Objective: To determine the average gestational age at birth and to compare obstetrical and neonatal outcomes of triplet births conceived spontaneously versus via assisted reproductive technology (ART).

Methods: A retrospective chart review of triplet pregnancies that resulted in three live babies was conducted at Mount Sinai Hospital (Toronto, Canada) from January 2000 to June 2013.

Results: A total of 230 women and 690 fetuses were identified. The mean gestational age at birth was 32.0?±?3.8 weeks. Obstetrical outcomes included preterm premature rupture of the membranes in 29%, preterm labor in 26%, preeclampsia or HELLP syndrome in 19% and gestational diabetes in 10%. The mean birth weight of infants born after 24 weeks was 1655?±?550?g and the rate of small for gestational age was 28%. The neonatal mortality rate prior to discharge was 7%. Aside from respiratory distress syndrome (30.6 versus 46.6%; p?=?0.02), there were no differences in gestational age at birth, obstetrical or neonatal outcomes between spontaneous versus ART triplet conception. Monochorionicity carried a higher risk of small for gestational age, congenital anomalies and neonatal mortality compared to trichorionicity.

Conclusion: Rates of preterm birth and related complications remain high in triplet gestation. However, obstetrical and neonatal outcomes were similar for triplets conceived spontaneously versus via ART.     

凶险性前置胎盘的妊娠结局及其与产后出血的高危因素分析

目的:探讨凶险性前置胎盘(PPP)的母婴结局及其与产后出血的高危因素。方法:回顾性分析2011年1月至2015年12月上海市第六人民医院住院分娩的前置胎盘患者181例,PPP患者72例(PPP组,其中发生产后出血34例,非产后出血38例),无剖宫产史妊娠的前置胎盘患者109例(非PPP组)。比较PPP组和非PPP组孕妇的年龄、孕周、孕次、产后出血率、输血率、胎盘植入率、子宫切除率、早产率、新生儿窒息率之间的差异;采用单因素与二项分类Logistic回归分析PPP组发生产后出血的高危因素。结果:PPP妊娠总占比0.44%;PPP组孕妇年龄、孕次、产次、前壁胎盘率、中央型前置胎盘率、胎盘粘连率、胎盘植入率、产后出血量、产后出血发生率、子宫切除率、输血率、早产率均明显高于非PPP组(P0.05),PPP组分娩孕周与新生儿体质量明显低于非PPP组(P0.05)。单因素分析显示:PPP患者产后出血组胎盘粘连率、胎盘植入率、中央型前置胎盘率、二级及以下医院剖宫产史占比、非产程中剖宫产史占比、前置胎盘史占比明显高于无产后出血组(P0.05);Logistic回归分析显示:胎盘粘连与中央型前置胎盘是PPP患者产后出血的独立危险因素(P0.05)。结论:产后出血与早产是PPP主要的不良妊娠结局;对于前次剖宫产史此次妊娠合并中央型前置胎盘或胎盘粘连患者,应警惕产后出血发生;降低剖宫产率是防止PPP发生与减少产后出血的关键因素。     

Placenta previa: aggressive expectant management

We report the outcomes of 95 expectantly managed cases of placenta previa; all were diagnosed after 21 weeks' gestation. Patients at risk for preterm delivery because of hemorrhage or preterm labor received aggressive care, including multiple transfusions, volume expansion and tocolytic therapy, and amniotic fluid surfactant determinations, to achieve the goal of delivery at 37 weeks' gestation with mature fetal lung function. We present guidelines for outpatient management and double setup examination prior to delivery. The role of ultrasound in diagnosis (three asymptomatic cases; 13 cases with preterm labor) and serial placental localization to determine the timing, route, and place of delivery is presented. Eighty-six percent of 19 infants born weighing less than 2500 gm were managed expectantly. Hemorrhage was the determinant in delivery timing in 50 cases. All four deaths were neonatal with birth weights less than 2200 gm. This is the lowest perinatal mortality rate (4.2%) published to date. Use of this aggressive approach is particularly suitable for patients cared for in a teritary center.     

Below median birth weight in appropriate-for-gestational-age preterm infants as a risk factor for bronchopulmonary dysplasia

AIMS: To assess the presence of chorioamnionitis and intrauterine growth as prenatal risk factors for broncho pulmonary dysplasia (BPD) in appropriate-for-gestational-age (AGA) infants of <28 weeks' gestation. METHODS: Gender, race, birth weight, gestational age, histology of the placenta, diagnosis of BPD at 36 weeks' gestation, postnatal dexamethasone treatment, and death were recorded in 150 preterm infants born at <28 weeks' gestation, and admitted between 1996 and 2001. RESULTS: In 122 AGA infants (mean gestational age: 26.18 weeks, mean birth weight: 837 g), BPD was associated with gestational age-related birth weights below the 50(th) centile. Intrauterine growth deceleration started between 25 and 26 weeks' gestation. Chorioamnionitis was not related to BPD. CONCLUSIONS: AGA infants of 26-28 weeks' gestation with birth weights below the median showed an increased risk of developing BPD.     

High incidence of respiratory distress syndrome (RDS) in infants born to mothers with placenta previa

OBJECTIVE: To evaluate the incidence of respiratory distress syndrome (RDS) in infants born to mothers with placenta previa and to assess the risk factors for RDS. METHODS: Ninety-nine pregnant women with placenta previa who delivered by cesarean section at 30-35 weeks of gestation were compared retrospectively with 102 pregnant women matched for week of gestation and birth year, who underwent elective cesarean section. Maternal characteristics, neonatal outcome, and incidence of RDS were analyzed. Umbilical cord blood samples were collected at delivery and were used to determine cortisol, epinephrine, and norepinephrine levels. Student's t-test, the chi-square test, and Fisher's exact test were used for statistical comparisons. P < 0.05 was considered significant. The Mann-Whitney U test was used for comparison of continuous variables. RESULTS: Preeclampsia, histological chorioamnionitis, and premature rupture of membranes were significantly lower in the placenta previa group (placenta previa: 2.0% vs. control: 14.7%, P < 0.01; 14.1% vs. 30.1%, P < 0.01; 7.1% vs. 17.6%, P < 0.05, respectively). The incidence of RDS was significantly higher in the placenta previa group than in the control group (29.3% vs. 6.9%, P < 0.0001). The cortisol level in umbilical cord blood in the placenta previa group was lower than in the control group (median 7.3, range 4.4-14.9 microg/dl vs. median 10.6, range 4.9-30.3 microg/dl, P < 0.05). There were no significant differences in epinephrine or norepinephrine levels between the two groups. CONCLUSIONS: The incidence of RDS in infants delivered at 30-35 weeks' gestation by cesarean section was significantly higher in mothers with placenta previa than in women without placenta previa. This may reflect decreased fetal stress since the cord blood cortisol levels were found to be lower in women with placenta previa.