Systemic tocolysis for premature labor is associated with an increased incidence of pulmonary edema in the presence of maternal infection

Our hypothesis is that systemic tocolysis of patients in premature labor is associated with a higher incidence of pulmonary edema in the presence of maternal infection. Over a 64-month period, medical records of all patients with a diagnosis at discharge of pulmonary edema or congestive heart failure were reviewed. There were 27 cases of pulmonary edema, 16 of which (59.3%) were associated with treatment of preterm labor. The incidence of pulmonary edema in patients receiving systemic tocolysis for treatment of preterm labor was significantly higher than that in our general obstetric population (3.04% versus 0.05%). Of the 527 patients receiving tocolysis, there was evidence of maternal infection in 52. The incidence of pulmonary edema was higher in the presence of maternal infection than in its absence (11/52 or 21% versus 5/475 or 1%, p = 0.0000). We conclude that there is a very strong association between the development of pulmonary edema and the presence of maternal infection in patients being treated for premature labor with systemic tocolysis.     

A Review of Eclampsia in Melbourne: 1978–1992

Summary: A retrospective review of all cases of eclampsia diagnosed at 3 obstetric teaching hospitals in Melbourne from January, 1978 to December, 1992 was undertaken. Ninety cases were identified; there were 5 maternal deaths and 17 perinatal deaths. Severe maternal morbidity such as pulmonary oedema, acute renal failure or HELLP syndrome was found in 26%. Significant maternal thrombocytopenia (<100 × 10⁹/L) was found in 50% and 35% had abnormal maternal liver function tests. Forty six women received magnesium sulphate for treatment of eclampsia and of these 3 had further seizures compared to 4 of 18 who received phenytoin (odds ratio 0.24 (0.04-1.52) X², p=0.09). Eclampsia remains a significant complication of pregnancy with high maternal and perinatal mortality and morbidity. Results of this study show a trend that is in agreement with recent randomized controlled trials which demonstrate a reduced incidence of seizures and maternal and fetal complications with tbe use of magnesium sulphate. The results of these recent trials suggest that magnesium sulphate should be the drug of choice in the prevention and treatment of eclampsia.     

Severe Preeclampsia-Maternal and Fetal Outcome

Ninety patients with severe preeclampsia were reviewed. There was one maternal mortality and two patients who developed pulmonary edema. The corrected perinatal mortality rate was 143/1000. Epidural anesthesia did not adversely affect fetal outcome. Perinatal morbidity and mortality was mainly related to the development of neonatal respiratory distress syndrome (RDS).

Twenty-three neonates developed respiratory distress syndrome (RDS). RDS was strongly associated (p <. 001) with gestational age. RDS was not associated with mode of delivery, sex or perinatal asphyxia.     

Maternal and fetal outcome in eclamptic patients in Benin City, Nigeria.

Eclampsia is a well-recognised major cause of maternal death and perinatal morbidity and mortality. The incidence of eclampsia, its presentation patterns, maternal and perinatal outcomes were investigated in a retrospective study conducted at the University of Benin Teaching Hospital, Nigeria over an 8-year period, 1995 - 2002. There were 103 cases of eclampsia of 7835 deliveries, giving an incidence of one in 76 (1.32%). The mean age of the women was 27.1 +/- 5.6 years. Eclampsia significantly (P < 0.001) occurred in nulliparous and unbooked mothers. Eighty-nine (86.4%) of the patients developed fits in the predelivery stage; 85 (83%) of the patients had at least one premonitory symptom including headache (82.4%) visual disturbance (10.6%) and epigastric pain (7%). There were nine stillbirths and 16 early neonatal deaths for a perinatal mortality rate of 214/1000. The major causes of perinatal mortality were prematurity and birth asphyxia. Eleven maternal deaths occurred with a maternal case fatality rate of 10.7% and a maternal mortality ratio from eclampsia of 140/100 000. The clinical causes of deaths were cardiopulmonary failure, acute renal failure, haemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome and cerebrovascular accident. Timely referral of high-risk patients coupled with availability of emergency obstetric and neonatal care services would reduce the incidence eclampsia associated mortality and morbidity in our facility.     

Obstetric admissions to the intensive care unit: a 12-year review

Objective The objective was to ascertain the prevalence, causes and outcome of critically ill obstetric patients admitted to the intensive care unit (ICU). Design The design was a retrospective collection of data. Settings The setting was a multidisciplinary ICU in a University hospital. Patients All obstetric patients admitted to the ICU over a 12-year period from May 1992 to April 2004 were reviewed. Results The incidence of obstetric admissions to the ICU represented 0.22% of all deliveries during the study period. The majority (84.4%) of patients were admitted to the ICU postpartum. Obstetric haemorrhage (32.8%) and pregnancy-induced hypertension (17.2%) were the two main obstetrical reasons for admission. The remainder included medical disorders (37.5%) and other causes (6.2%). Associated major complications included adult respiratory distress syndrome (ARDS) and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome. The perinatal mortality rate was 20% and the maternal mortality rate 9.4%. Conclusions A team approach consisting treatment by obstetricians, intensive care specialists and anaesthesiologists provided optimal care for the patients. Improved management strategies for obstetric haemorrhage and hypertension may significantly reduce maternal morbidity.     

HELLP综合征14例临床分析

目的 探讨产科并发症HELLP综合征的母儿预后。方法 回顾性分析研究14例HELLP综合征的患者妊娠结局和围产儿预后。结果 14例中12例发生在产前，2例发生在产后，平均孕龄为32．5周，孕妇的严重并发症包括：急性肾衰、DIC、肺水肿、严重腹水和胎盘早剥等。其中8例需要输血或血液制品，12例采用剖宫产结束分娩。围产儿死亡5例，主要与胎盘早剥有关，另外胎儿宫内窘迫及早产也是重要原因。结论 HELLP综合征是一种严重的产科并发症，其高的母婴并发症和病死率要求我们对有妊娠高血压疾病的患者进行密切随访和治疗，一旦确诊为HELLP综合征应转入中心级以上医院进行治疗，尽快终止妊娠。     

Eight years' experience of uterine rupture cases.

Ruptured uterus is a serious obstetric emergency with a high maternal and perinatal mortality. It is a preventable and common obstetric problem in developing countries. The objective of this study was to review the incidence, methods of diagnosis and maternal and perinatal morbidity and mortality associated with uterine rupture. Case notes were reviewed for all patients with a ruptured uterus at Yüzüncü Yil University Medical Faculty Department of Obstetrics and Gynaecology from January 1995 to August 2003. Relevant data relating to the clinical characteristics of labour, operative procedures, maternal and perinatal outcome were assessed. There were 20 cases of ruptured uteri. The incidence was 0.40%. When patients referred from other hospitals were excluded, the revised ratio was 0.12%. There were 13 (65%) complete and seven (35%) incomplete ruptures. Nine (45%) cases occurred in patients with scarred uteri. Ten (50%) cases were grand multiparous. Subtotal abdominal hysterectomy was performed in five (25%) cases, total abdominal hysterectomy was performed in two (10%) cases and the remaining 13 (65%) cases had uterine rupture repair. There were two (10%) maternal deaths. Both of them were referred from other hospitals. There were seven (35%) perinatal deaths attributable to uterine rupture. Occurrence of uterine rupture is significantly associated with grand multiparity, scarred uterus, lack of antenatal care, unsupervised labour at home and low socioeconomic status of the patients. These factors are largely preventable.     

Outpatient obstetric management of women with type I diabetes

Conventional obstetric management of diabetic women has frequently incurred extensive hospitalization. Although this approach improved perinatal results for these women and their infants, it is costly and cumbersome. The 3-year experience of an outpatient diabetic obstetric clinic is compared with the results obtained at the same facility during 5 previous years when hospitalization was used more extensively. Perinatal mortality and morbidity were not different in 51 type I diabetic women managed almost entirely as outpatients when compared with 58 similarly complicated diabetic patients receiving more conventional management. Mean prenatal admissions (1 vs 2, p = less than 0.01), mean prenatal hospital days (6 vs 12, p = 0.05), and prolonged delivery admissions of greater than 7 days (31% vs 69%, p = less than 0.01) were significantly less. Outpatient obstetric management of diabetic women efficiently decreases maternal morbidity without increasing infant morbidity and mortality.     

Eclampsia. VI. Maternal-perinatal outcome in 254 consecutive cases

During a 12-year period, 254 cases of eclampsia were managed at this center. Eighty patients (32%) did not have edema, 58 (23%) had "relative hypertension," and 49 (19%) did not have proteinuria at the time of convulsions. Eclampsia developed at less than or equal to 20 weeks in 6 patients and beyond 48 hours post partum in 40 (16%). Convulsions developed in 33 while they were receiving standard doses of magnesium sulfate for preeclampsia during or after birth, and subsequent seizures developed in 36 (14%) after magnesium sulfate therapy was started. There was one maternal death (0.4%) and morbidity was frequent (acute renal failure, 4.7%; pulmonary edema, 4.3%; cardiorespiratory arrest, 3.1%; and aspiration, 2%. The use of multiple drug therapy was associated with significant maternal and neonatal complications. The total perinatal mortality was 11.8%, with the majority of them related to either abruptio placentae or extreme prematurity. These findings emphasize the need for intensive monitoring of women with preeclampsia throughout hospitalization and underscore the importance of maternal stabilization before and during transfer.     

Uterine rupture

Uterine rupture is an uncommon obstetric event. It is important because it continues to be associated with maternal mortality, especially in developing countries, and with major maternal morbidity, particularly peripartum hysterectomy. It is also associated with a high incidence of perinatal mortality and morbidity worldwide. This chapter examines the incidence, aetiology, clinical presentation, complications and prevention of uterine rupture. The key factor in the cause of rupture is whether or not the uterus is scarred. Rupture of an unscarred uterus is rare, usually traumatic, and its incidence decreases with improvement in obstetric practice. Rupture of the scarred uterus is more common, and usually occurs after a trial of labour in a patient with a previous Caesarean section. This chapter also explores how the incidence and complications of uterine rupture may be minimized, and yet the incidence of vaginal birth after Caesarean section (VBAC) optimized, in clinical practice.     

Course of pregnancy and delivery in patients with pregestational diabetes mellitus

INTRODUCTION: Pregnancy in a woman with pregestational diabetes mellitus (PGDM) is associated with increased risk of complications in both the mother and the fetus. A close surveillance is strongly recommended in these pregnancies. OBJECTIVES: The aim of the study was to assess perinatal outcome in pregnancies complicated by PGDM. Study design: The study covered 127 pregnancies with PGDM. Apart from perinatal outcome the patient's age, past obstetric history, the duration of perinatal diabetic care and the course of pregnancy were taken into consideration. Diabetes mellitus was classified according to White. RESULTS: 37.8% of patients were diagnosed PGDM B class, 38.6%--C class, 15.7%--D class, 1.6%--F class and 6.3%--RF class. Less than half of women (45.5%) remained under medical care since the first trimester. The arterial hypertension was the most common complication of pregnancy and occurred in over 18% of studied pregnancies. The incidence of preterm delivery was 41.7%. Cesarean section was performed in 55.9% of patients. 16.6% of the neonates had a birth weight below 2500 g. 4 neonates were stillborn (2.4%) and the next 3 ones (2.4%) died within the first month following the delivery. Congenital heart defects were found in 8.7% of offsprings. CONCLUSIONS: Despite the progress in perinatal care pregestational diabetes mellitus is still associated with increased risk of maternal and fetal mortality and morbidity.     

Placenta accreta: a surgical alternative that can save lives

The placenta accreta is the second leading cause of obstetric hemorrhage, which often require the implementation of emergency obstetric hysterectomy increased morbidity and mortality. We present a surgical alternative to hysterectomy obstetric allowed us to reduce to zero until our rate of maternal deaths from obstetric hemorrhage. Improving surgical times, associated morbidity, without altering perinatal outcomes.     

The outcome of triplet, quadruplet, and quintuplet pregnancies managed in a perinatal unit: obstetric, neonatal, and follow-up data

Multifetal gestation is associated with increased frequency of maternal complications and higher perinatal morbidity and mortality. The need for contemporary data on the outcome of multifetal gestations is further underscored when selective reduction is considered. The present study details the obstetric management, neonatal outcome, and follow-up data of 24 triplet, five quadruplet, and one quintuplet pregnancies delivered in a perinatal center. The early neonatal mortality rate was 31.6, the late neonatal mortality rate was 21, and the perinatal mortality rate was 51.5. Survival to discharge was 93%. The incidence of respiratory distress syndrome was 43%, bronchopulmonary dysplasia 6%, retinopathy of prematurity 3%, intraventricular hemorrhage 4%, and cerebral palsy 2%. Follow-up from 1 to 10 years shows that only one child is moderately handicapped, whereas 99% have no significant medical problem. Early diagnosis by ultrasonography, meticulous antenatal care, early hospitalization, delivery by cesarean section, and on-site availability of a neonatologist for each baby at the time of delivery are the probable major determinants of improved outcome.     

A surgical alternative for placenta accreta

The placenta accreta is the second leading cause of obstetric hemorrhage in the world. In many occasions it is necessary to make an obstetric hysterectomy, a circumstance that increases morbidity, and maternal mortality. Communicates a surgical alternative to hysterectomy obstetric that has enabled us to reduce until the time to zero our rate of maternal deaths by obstetric hemorrhage, in addition to reducing the surgical time and the associated morbidity, without changing the perinatal outcome.     

Pulmonary edema in preeclampsia: an Indonesian case–control study

Objective: To analyze risk factors, obstetric outcome and the need for mechanical ventilation in preeclampsia complicated by pulmonary edema.

Materials and methods: Case–control study using medical record on preeclampsia complicated by pulmonary edema patients in East Java tertiary referral hospital over 2?years. A simple scoring system was developed to predict the need for mechanical ventilation, using logistic regression.

Results: 1106 cases of preeclampsia were admitted, with 62 cases (5.6%) had pulmonary edema. Postpartum (p?p?=?.001) proportions were higher in the preeclampsia with pulmonary edema group. Of the 62 cases with pulmonary edema, 81% required intensive care admission and 60% needed mechanical ventilation support. Mechanical ventilation used was associated with eclampsia (p?=?.04), hypertensive crisis (p?=?.02), lower serum albumin (p?=?.05) and higher creatinine (p?=?.01). A simple scoring model developed could predict a 46%–99% probability of need for mechanical ventilation (AUC (ROC): 0.856, 95%CI 0.763–0.95).

Conclusions: Pulmonary edema is a common complication of preeclampsia in Indonesian referral hospitals. This severe complication increased maternal and perinatal morbidity and mortality. The developed scoring model in this study can be used as a triage tool to predict the probability of mechanical ventilation use due to this complication.     

The wider perinatal significance of the Australian in vitro fertilization data collection program

The most recent report (1986) from the Australian Register of In Vitro Fertilization pregnancies comprises 2242 in vitro fertilization (IVF) pregnancies and 261 gamete intrafallopian transfer (GIFT) pregnancies. A review of this data base indicated that this population had a relatively high incidence of both obstetric and perinatal morbidity and perinatal mortality. About 58% of the IVF pregnancies resulted in live births and 36.4% of the infants weighted less than 2500 gm at birth. These high rates could be partially accounted for by maternal prepregnancy risk factors, such as age, and by risk factors associated with the infertility management, such as multiple pregnancy (22% of all pregnancies more than 20 weeks), which accounted for approximately 50% of the preterm births (less than 37 weeks). Singleton pregnancies also had a higher incidence of preterm birth (17.8% at gestational age 24 to 36 weeks), low-birthweight babies (15.9% less than 2500 g) and perinatal mortality rates (35.4% per 1000 live births) than the Australian population at large. This warrants these patients being regarded as high risk. It is reassuring that the incidence of major malformations in IVF births (2.2%) is similar to that in the general population (1.4%).     

Pregnancy outcome in medically complicated and uncomplicated patients aged 40 years or older

Patients (183) who were delivered at age greater than or equal to 40 years were studied to ascertain the nature and frequency of maternal and fetal complications at a single institution in a recent time period. These patients were further grouped into those of low parity, those who began pregnancy without underlying disease, and those who began pregnancy with underlying medical disorders. For the entire group preeclampsia, premature labor, precipitate labor, and malpresentation were significantly more common. The rate of vaginal delivery was substantially decreased, and serious postpartum morbidity was relatively common. The incidence of stillbirth, perinatal mortality, and abnormal birth weight was significantly increased. There were some differences in the nature and frequency of complications encountered among the subgroups, but no subgroup had a complication rate comparable to our general obstetric population.     

Has improved health care provision impacted on the obstetric outcome in teenage women?

Objective: To determine the obstetric outcome in teenage women managed in the recent decade with easily accessible health care provision. Methods: In a retrospective cohort study, maternal demographics, underlying medical conditions, obstetric complications, preterm birth, type of labor, mode of delivery, and perinatal mortality were compared between 1505 women aged ≤19 years (study group) with 10,320 women aged 20–24 years (comparison group), who were carrying singleton pregnancies beyond 24 weeks of gestation and managed in our hospital between January 1998 and June 2008. Results: The study and comparison groups accounted for 2.2% and 15.1% respectively of the total deliveries. Despite comparable health status and rates of other obstetric complications, teenage women was associated with birth <34 weeks (aOR 2.45, 95% CI 1.67–3.60), birth at 34–36 weeks (aOR 2.13, 95% CI 1.71–2.65), and reduced instrumental vaginal (aOR 0.62, 95% CI 0.50–0.77) and caesarean (aOR 0.79, 95% CI 0.64–0.97) delivery, without increase in perinatal mortality. Conclusions: Teenage women had increased preterm birth, despite improved health care provision, nutrition, and similar incidence of other obstetric complications, but the obstetric and perinatal outcome remained favorable.     

Reassessment of White's classification and Pedersen's prognostically bad signs of diabetic pregnancies in insulin-dependent diabetic pregnancies

The classification systems developed over 20 years ago by White and Pedersen identified diabetic pregnancies at increased risk for perinatal mortality. To assess whether these same criteria would currently be valid, 199 diabetic pregnancies with deliveries from 1977 to 1983 were reviewed. Perinatal mortality rates for White's Classes B gestational (n = 72), B (n = 27), C (n = 67), and D + F + R (n = 33) were 2.9%, 11.1%, 14.9%, and 21.1%, respectively (p less than 0.05). White's classes were also predictive of pulmonary morbidity (12.5%, 18.5%, 22.4%, and 42.4%, respectively). The presence of one or more of the prognostically bad signs of pregnancy (n = 76) increased the perinatal mortality rate to 17.1% versus 7.3% among insulin-dependent diabetic pregnancies without prognostically bad signs (p less than 0.05). The presence of any prognostically bad signs of pregnancy was also predictive of pulmonary morbidity in general (31.6% versus 16.3%, respectively) and hyaline membrane disease in particular (13.2% versus 4.1%, respectively). Thus with use of modern obstetric management and medical care of the pregnant diabetic patient, both White's classification and Pedersen's prognostically bad signs of pregnancy continue to be predictive of perinatal mortality.