Pregnancy outcomes in women with heart disease

Background As the Shanghai Obstetrical Cardiology Intensive Care Center, our hospital has accumulated a large number of clinical data of pregnant women with heart disease. This paper is a retrospective analysis of 1142 pregnancies in women with heart disease so as to evaluate the maternal and fetal outcomes of these patients.Methods A retrospective analysis was carried out for pregnancies in 1142 women with heart disease who delivered in Shanghai Obstetrical Cardiology Intensive Care Center between 1993 and 2007.Results In this study, main heart diseases in pregnancy were arrhythmia （n=359, 31.4%）, congenital heart disease （CHD; n=291,25.5%）, and myocarditis and its sequelae （n=284, 24.9%）; based on the functional classification criteria of New York Heart Association （NYHA）, more than half （n=678, 59.4%） of patients were classified NYHA Class Ⅰ; pregnant women in NHYA Class Ⅰ-Ⅱ （n=951, 83.3%） commonly had arrhythmia, myocarditis and its sequelae, while those in NHYA Class Ⅲ-Ⅳ （n=191, 16.7%） mainly had CHD, rheumatic heart disease （RHD）, cardiopathy induced by hypertensive disorders complicating pregnancy, and peripartum cardiomyopathy （PPCM）. Cardiac failure occurred in 97 （8.5%）patients, and 8 （0.7%） maternal deaths and 12 （1.1%） perinatal deaths were reported in this study. Compared with those in NHYA Class Ⅰ-Ⅱ, women in NHYA Class Ⅲ-Ⅳ had a significantly lower gestational age at birth （P 〈0.05）, lower birth weight （P 〈0.01）, and higher incidence of preterm delivery, small for gestational age and perinatal death （P 〈0.01）. The incidence of cardiac failure in pregnant women with cardiopathy induced by hypertensive disorders complicating pregnancy and PPCM was relatively high, with a rate of 80% and 52.2%, respectively. After cardiac operation, 131（90.3%） women were in classified NHYA Class Ⅰ-Ⅱ and 14 （9.7%） in NHYA Class Ⅲ-Ⅳ.Conclusions Arrhythmia is the type of heart disease that has a highest incidence in patients with heart disease in pregnancy, while main types of heart disease that impair cardiac function are CHD and RHD; cardiac failure is more frequently caused by cardiopathy induced by hypertensive disorders complicating pregnancy and PPCM; impaired cardiac function increases perinatal morbidity; cardiac surgery before pregnancy could improve the cardiac function.     

妊娠合并心脏病85例临床分析

目的　探讨妊娠合并心脏病对母亲和围产儿的影响。方法　对我院 1990年 3月～ 2 0 0 3年 3月妊娠合并心脏病患者 85例的临床资料进行回顾性分析。结果　妊娠合并心脏病发生率为0 .72 % ,孕产妇病死率为 0 ,围产儿死亡率为 0 .6 0‰ ,剖宫产率 6 5 .0 6 %。心功能I～II级与III～IV级比较 ,妊娠孕周、新生儿平均体重、围产儿患病率及死亡率差异显著 (P <0 .0 1或P <0 .0 5 )。结论　孕周、新生儿体重与妊娠合并心脏病的心功能级别密切相关 ;加强妊娠合并心脏病孕产妇的监护 ,选择正确方式适时终止妊娠 ,可获得良好的结局     

Caesarean section and perinatal outcomes in a sub-urban tertiary hospital in North-West Nigeria

Objectives:

This study was undertaken to review the caesarean section rate and perinatal mortality in Federal Medical Centre, Birnin Kudu from 1^st January 2010 to 31st December, 2012.

Materials and Methods:

This was a retrospective study involving review of 580 case files. Ethical clearance was obtained. The records of labour ward, neonatal intensive care unit (ICU) and operating theatre were use. Information extracted includes age, parity, booking status, total deliveries, indications for caesarean section and perinatal outcome from 1^st January 2010 to 31^st December 2012 at Federal Medical Centre, Birnin Kudu. The data obtained was analysed using SPSS version 17.0 statistical software (Chicago, Il, USA). Absolute numbers and simple percentages were used to describe categorical variables. Association between caesarean section and perinatal mortality was determined using Pearson''s Coefficient of correlation and student t- test. P - value < 0.05 was considered statistically significant.

Result:

This study reported a caesarean section rate of 17.69 % and a perinatal mortality rate of 165.6 per 1000. Majority of the babies (78.2%) were within normal weight. The mean age of the women was 25.9 ± 6.2 years and mean parity was 4 ± 3. Majority of them were uneducated and unemployed. Obstructed labour was the commonest indication for emergency caesarean section accounting for 31.7% of caesarean sections and foetal distress was the least at 2.6 %. Two or more previous caesarean section was the commonest indication for elective caesarean section (17.1%) and bad obstetrics history the least indication (1.4%). There is a weak positive correlation (r = 0.35) between caesarean section rate and perinatal mortality and this association was not statistically significant (P = 0.12).

Conclusion:

Caesarean section and perinatal mortality rates in the present study are comparatively high. Absence of significant correlation means that a high caesarean section rate is not likely to improve perinatal outcomes in babies of normal weight; therefore the caesarean section rate in this centre should be reduced. Measures to reduce perinatal mortality such as skilled attendant in labour and training of medical staff in neonatal resuscitation should be adopted.     

妊娠合并心脏病60例临床分析

目的探讨妊娠合并心脏病分娩时机和分娩方式对母儿的影响。方法对60例妊娠合并心脏病患者的临床资料进行回顾性分析。结果妊娠合并心脏病主要以妊娠合并风湿性心脏病为主。分娩孕妇中,平均分娩孕周是37.94±1.97周。剖宫产分娩是阴道分娩的1.89倍,随着心功能级别的下降,剖宫产率增高。孕妇心功能级别下降,平均妊娠时间减少,心衰发生时间提前,新生儿体重减轻。孕周延长,新生儿窒息率和围生儿死亡率降低。在剖宫产组产妇心衰发生率低于阴道分娩组。结论定期产前检查有利于妊娠合并心脏病孕妇顺利渡过妊娠期及分娩期。对妊娠结局的影响主要取决于心功能状态。终止妊娠时机需根据合并心脏病的类型、心功能状态决定,适时终止妊娠,可有效降低孕产妇和围生儿并发症的发生率和死亡率。选择性剖宫产是妊娠合并心脏病较为安全的分娩方式。     

Rotational delivery with Kielland's forceps

A retrospective study over 15 months showed that 10.7% of primigravid women and 1.6% of multigravid women were delivered by Kielland's forceps: a total of 145 babies. The successful vaginal delivery rate for attempted Kielland's forceps was 96.7%. The neonatal outcome was good and there were no perinatal deaths. Traumatic injuries were present in 7.6% of babies and were minor. The data show that even in the presence of fetal distress, Kielland's forceps can be safely employed for rotational delivery from the mid-pelvic cavity. This approach can avoid some caesarean sections without undue risk to the baby, the caesarean rate being 9.5%. As 10.7% of primigravid women required rotational delivery with Kielland's forceps, it is desirable that primigravid women should be cared for by obstetricians who are skilled in the use of the instrument, in order to maintain a low caesarean section rate in this group, with a good neonatal outcome.     

重度妊娠高血压综合征剖宫产有关问题的探讨

收治重度妊娠高血压综合征（简称妊高征）１１６例，其中８８例行剖宫产术，剖宫产率７６．５２％，剖宫产的第一指征前４位顺序为：重度妊高征５７例，头盆不称８例，胎儿宫内窘迫６例，宫颈扩张活跃期停滞４例。本组病例产褥病率１４例占１５．９％。产后出血７例占８％。并发ＨＥＬＬＰ综合征２例，其中１例母亲死亡。非剖宫产直接原因围产儿死亡２例。分析了重度妊高征剖宫产率上升的趋势和原因，认为重度妊高征剖宫产可降低母婴死亡率。结合病例分析了重度妊高征剖宫产指征。     

高龄孕妇的妊娠结局

【目的】了解高龄孕妇的妊娠结局,为提高该高危人群的围产期预后提供指导。【方法】回顾性分析2006年2月11日至2006年10月7日在我院分娩的156例年龄介于35～48岁高龄孕妇的妊娠结局,并随机选择同期分娩的年龄介于21～34岁的孕妇156例作为对照。【结果】高龄组剖宫产率及辅助生育受孕率均显著高于对照组,妊娠期糖尿病及糖耐量异常、胎儿窘迫、早产的发生率高于对照组,而HSV及CMV感染显著低于对照组,两组新生儿畸形率及围产儿死亡率差异无显著性。【结论】高龄与早产、胎儿窘迫、妊娠期糖尿病、剖宫产率升高等不良妊娠结局密切相关。在妊娠期应加强对高龄孕妇糖尿病和早产等高危因素的筛查,分娩过程中密切监护,及早发现胎儿窘迫的征兆,改善妊娠结局。     

Pregnancy following eclampsia: a longitudinal study at korle-bu teaching hospital

Summary OBJECTIVE: To find out the reproductive performance of patients in the immediate pregnancy following an eclampsia. DESIGN: Longitudinal survey. SETTING: Obstetrics Unit of Department of Obstetrics and Gynaecology in a teaching hospital. SUBJECTS AND METHODS: Three hundred and ninety seven women whose previous pregnancies were complicated by eclampsia were followed up based on a schedule of antenatal care from 14-16 weeks gestation till delivery. The occurrence of hypertensive complications, timing of delivery, fetal outcome and birth weight were noted. RESULTS: There were no cases of recurrent eclampsia and no maternal death. Pregnancy-induced hypertension and pre-eclampia recurred in 15.8% of the women. These recurrencies were more significant among those who had changed their male partners (p = 0.0005). The caesarean section rate was 65.9%. The mean ponderal indices in those who developed hypertensive complications were significantly lower than the normotensives (P<0.03 However, the overall perinatal mortality rate of 23.3 per 1000 deliveries was lower than the 62.8 per 1000 in the general obstetric population. CONCLUSION: Previous episode of eclampsia does not necessarily affect perinatal and maternal outcome adversely in subsequent pregnancy, provided adequate antenatal surveillance and timely delivery are offered to the patients.     

Vaginal birth after one caesarean section: analysis of indicators of success

A study was carried out among 81 women with previous one caesarean section (CS) done for non-recurrent indications to confirm the efficacy and safety of trial of labour (TOL) and to examine the effect of various factors on the mode of delivery. Singleton term pregnancy, vertex presentation and adequate pelvic capacity were the pre-requisites for case selection. Careful monitoring was done during labour and effect of various factors on the outcome was analysed statistically. Success rate of TOL was 73%. A non-recurrent indication for previous CS, such as malpresentation and foetal distress is associated with higher success rate of vaginal birth after caesarean (VBAC) compared to recurrent indications, such as cephalopelvic disproportion (CPD) and failure to progress (FTP). Prior vaginal birth improves the success rate (87%) of VBAC. Factors like premature rupture of membranes, hypertensive disorders of pregnancy, and post-date pregnancy did not affect the outcome adversely. Rate of emergency CS was 44% in women with floating head foetus, 39% in induction/augmentation group and 43% when birth weight of the foetus was > 3000 g. No maternal/perinatal mortality observed. Maternal/perinatal morbidity was low in cases with successful TOL. Uterine rupture occurred in one woman. There are few absolute contra-indications to attempted VBAC. Though the success rate does vary with different pre-existing factors, the clinician may anticipate greater than 50% chance for success in any individual labour.     

Pregnancy outcomes in primigravid women aged 35 years and over in South Australia, 1986-1988

The South Australian perinatal data collection for 1986-1988 was used to compare the characteristics and outcomes of singleton pregnancies in 515 primigravid women aged 35 years and over with those in 4175 younger primigravid women aged 20-29 years. Notable differences observed were a higher prevalence of medical, obstetric and labour complications and assisted deliveries in the older group. Breech presentations were almost twice as common in the older women, as were caesarean sections. Only 27% achieved a spontaneous vaginal delivery. The mean duration of hospital stay for the older women was longer for both vaginal and caesarean deliveries. However, although their babies were more likely to be premature or of low birthweight, the perinatal mortality rate was not significantly increased and the great majority of older primigravid women managed by modern obstetric methods can expect a good pregnancy outcome.     

Caesarean section in Malawi: preventable factors in maternal and perinatal mortality

Objectives

To examine factors that may influence maternal and perinatal mortality associated with caesarean section in an African country.

Design

A prospective observational study, conducted between January 1998 and June 2000, of 8070 caesarean sections.

Setting

25 district and 2 central hospitals in Malawi.Main outcome measures. Association between hospital type, ward or operative care, training of surgical and anaesthesia personnel, preoperative complications, method of anaesthesia, blood loss and anaesthetic technique on maternal and perinatal mortality.

Results

Questionnaires were returned for 5236 caesarean sections in district and 2834 in central hospitals. 95% were emergencies, 65% for obstructed labour. Pre-operative haemorrhagic shock was present in 7.6% of women, anaemia in 6.2% and ruptured uterus in 4.1%. Previous caesarean section did not appear to predispose to ruptured uterus. There were 85 maternal deaths (1.05% mortality), 65 of which occurred postoperatively on the wards. Maternal mortality was increased with ruptured uterus (adjusted odds ratio 3.9, 95% CI 2.3–6.5), little anaesthetic training (2.3, 1.3 to 4.1) and blood loss requiring transfusion (19.3, 9–41). In mothers without preoperative haemorrhage spinal anaesthesia was associated with lower maternal mortality than general anaesthesia (0.23, 0.1–0.7). Perinatal mortality was 11.2% overall, and was significantly associated with ruptured uterus, halothane and ketamine anaesthesia.

Conclusion

Maternal and perinatal mortality rates among women undergoing caesarean section in Malawi are high. Improving resuscitation in postoperative wards might reduce maternal mortality. Blood loss and pre-operative complications are both strongly associated with mortality. Spinal anaesthesia was associated with good outcome.     

A five year appraisal of caesarean section in a northern Nigeria university teaching hospital

A retrospective analysis of cases of caesarean section performed in Jos University Teaching Hospital between January 1994 and December 1998 was undertaken to determine the incidence, indications, perinatal and maternal outcome. There were 11,571 deliveries with 2083 caesarean sections done giving an incidence of 18%. 62.2% of the patients who had caesarean section were booked for antenatal care and delivered in the hospital, while 37.8% were unbooked seen as emergency. 90% of the operations were done as an emergency while only 10% was electively performed. There was a high caesarean section rate in all the age groups as well as the various parity distributions. The main indications for the elective section were repeat caesarean section, placenta praevia, precious baby, severe pregnancy induced hypertension and bad obstetric history while those for emergency section were cephalo-pelvic disproportion foetal distress, repeat caesarean section, antepartum haemorrhage, severe pregnancy induced hypertension/eclampsia, obstructed labour and breech presentation. The maternal mortality rate was 624.1/100,000 due mainly to haemorrhage, eclampsia and sepsis and there was one anaesthetic death amongst the booked patients. The perinatal mortality rate was 81.6/1000. The clinical causes of deaths were birth asphyxia, ante-partum haemorrhage, obstructed labour and prematurity.     

妊娠晚期羊水过少对围生期结局的影响

目的分析妊娠晚期羊水过少者对产妇及围生儿的影响。方法应用B型超声测定羊水指数（AFI）,对245例妊娠晚期羊水过少孕妇（观察组）进行分析,同时选择200例羊水量正常者作为对照,比较2组分娩方式及其对产妇及围生儿的影响。结果除新生儿死亡外,羊水过少组中羊水污染率（≥Ⅱ度）、胎儿窘迫发生率、新生儿窒息发生率、剖宫产率、产后出血发生率及平均总产程均高于羊水正常组（P〈0.01）,在羊水过少组中,羊水量越少,羊水污染率（≥Ⅱ度）、胎儿窘迫发生率、新生儿窒息发生率、剖宫产率、产后出血发生率越高（P〈0.05）。结论羊水过少严重威胁围生儿生命,应适时终止妊娠,以选择剖宫产为宜。     

Risk of complications in a second pregnancy following caesarean section in the first pregnancy: a population-based study

OBJECTIVE: To estimate the risks of maternal and perinatal morbidity and mortality in a second pregnancy, attributable to caesarean section in a first pregnancy. DESIGN AND SETTING: Cross-sectional analytic study of hospital births in New South Wales, based on linked population databases. PARTICIPANTS: 136 101 women with one previous birth who gave birth to a singleton infant in NSW in 1998-2002. MAIN OUTCOME MEASURES: Crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) for maternal and perinatal morbidity and mortality. RESULTS: 19% of mothers had a caesarean section in their first pregnancy. Compared with mothers who had had primary vaginal births, mothers who had had primary caesarean section and underwent labour in the second birth were at increased risk of uterine rupture (aOR, 12.3; 95% CI, 5.0-30.1; P < 0.0001), hysterectomy (3.5; 1.5-8.4; P < 0.01), postpartum haemorrhage (PPH) following vaginal delivery (1.6; 1.4-1.7; P < 0.0001), manual removal of placenta (1.3; 1.1-1.6; P < 0.01), infection (6.2; 4.7-8.2; P < 0.0001) and intensive care unit (ICU) admission (3.1; 2.1-4.7; P < 0.0001); among mothers who did not undergo labour (ie, had an elective caesarean section), there was a lower risk of PPH (0.6; 0.5-0.7; P < 0.0001) and ICU admission (0.4; 0.3-0.5; P < 0.0001). For infants there was increased risk of preterm delivery (1.2; 1.1-1.3; P < 0.0001) and neonatal intensive care unit admission following labour (1.6; 1.4-1.9; P < 0.0001) in the birth after primary caesarean section. The occurrence of stillbirth was not modified by labour. CONCLUSIONS: Caesarean section in a first pregnancy confers additional risks on the second pregnancy, primarily associated with labour. These should be considered at the time caesarean section in the first pregnancy is being considered, particularly for elective caesarean section for non-medical reasons.     

妊娠合并心脏病79例临床预后分析

目的探讨妊娠合并心脏病对母婴预后影响的因素。方法对79例妊娠合并心脏病患者（包括双胎妊娠3例）的临床资料进行回顾性分析。结果妊娠合并心脏病患者中以心律失常、先天性心脏病和风湿性心瓣膜病为主,分娩方式与妊娠结局：剖宫产占78％;围生儿82例中低体质量儿23例,新生儿苍白窒息1例,围生儿死亡2例,孕产妇死亡1例。结论妊娠合并心脏病患者的母婴预后与心功能级别和抗心力衰竭处理密切相关。剖宫产为比较安全的分娩方式。     

Use of interventions for reducing mother-to-child transmission of HIV in Australia

OBJECTIVE: To describe the extent and outcome of use of interventions for reducing the risk of HIV transmission from mother to child in Australia. DESIGN: National surveillance for perinatal exposure to HIV. PARTICIPANTS AND SETTING: Notified cases of HIV infection in women in Australia and their perinatally exposed children, 1982-1999. OUTCOME MEASURES: Trends over time in use of interventions (antiretroviral therapy in pregnancy, elective caesarean delivery and avoidance of breastfeeding) and perinatally acquired HIV infection. RESULTS: By 31 March 2000, 204 children were reported as having been born in 1982-1999 to 162 women whose HIV infection had been diagnosed by 31 December 1999. The child's HIV infection status was established for 182 (89.2%); the mother's HIV infection was diagnosed antenatally in 91 of these cases (50%). Among women diagnosed antenatally, use of elective caesarean delivery and antiretroviral therapy in pregnancy increased significantly, from 3% and 14% by women whose children were born in 1982-1993, to 21% (P=0.01) and 88% (P<0.001), respectively, by women whose children were born in 1994-1999. Most women (95%) diagnosed antenatally avoided breastfeeding their children. The percentage of infected children born to women diagnosed antenatally declined from 26% among children born in 1982-1993 to 19% among those born in 1994-1999. The percentage of infected children was significantly lower among those whose mothers used antiretroviral therapy in pregnancy (11% versus 36%; P=0.03). CONCLUSION: Antiretroviral use in pregnancy, elective caesarean delivery and avoidance of breastfeeding have been effective interventions for reducing the risk of mother-to-child HIV transmission in Australia. While the rate of perinatal HIV transmission has declined, it remains high in comparison with rates reported from other industrialised countries.     

Undiagnosed case of term heterotopic pregnancy with ectopic abdominal pregnancy

Heterotopic pregnancy involves coexisting intra-uterine and extra-uterine gestations. The incidence for natural uninduced pregnancy is 1 in 30,000 pregnancies. However the incidence is increasing with ovulation induction and artificial reproductive techniques. In more than 90% heterotopic pregnancies, the ectopic implantation is in the fallopian tube. A case of undiagnosed term heterotopic pregnancy in a 26-year-old primigravida is reported. She was referred from a practising obstetrician as a case of term twin pregnancy. Her regular antenatal records suggested intra-uterine growth restriction in one foetus of the twin. After confirmation of findings with ultrasound she was taken for emergency caesarean section. Heterotopic pregnancy was diagnosed on opening the abdomen. The term abdominal pregnancy was managed successfully. Although remained undiagnosed till term, good maternal and perinatal outcome was noted with survival of both the babies.     

Planned homebirths in South Australia 1976-1987

Homebirths booked with a group of general practitioners and midwives in South Australia in 1976-1987 are described using data obtained from midwives' and hospital records. The births represented 84.7% of all births occurring at home in South Australia in 1984-1987, as assessed by official birth registrations. Of the 799 women intending to deliver at home, 136 (17.0%) required transfer to hospital before or during labour. A further 38 mothers or babies (4.8%) required transfer after delivery. The women tended to be of a relatively high socioeconomic status and older age distribution when compared with women who had hospital births as identified from the State perinatal data collection. Some had recognised pregnancy risk factors. They had lower frequencies of ultrasound examination, induced labour, epidural analgesia, episiotomy, forceps delivery and caesarean section, and a low frequency of use of oxytocics for the third stage. Their rates of postpartum haemorrhage and, in particular, perinatal mortality were higher. Potential sources of risk and difficulty in homebirth care and evaluation of this care are identified and an approach to providing an effective homebirth service is proposed.     

过期妊娠分娩时机和方式的选择对母婴的影响

目的: 探讨过期妊娠对母体及围生儿的影响及适时终止妊娠的意义。方法: 对4 383例分娩产妇作一回顾性分析。结果: 过期妊娠组手术产、产后出血、羊水过少、巨大胎儿、胎儿宫内窘迫、新生儿窒息、围生儿死亡率等均高于足月妊娠组(P<0.01~P=0.000)。结论: 过期妊娠对母婴的危害极大,应尽力避免过期妊娠的发生,适时终止妊娠,选择适当的分娩方式,改善母儿预后。     

Is grand multiparity an independent predictor of pregnancy risk? A retrospective observational study

OBJECTIVE: To determine whether high maternal parity has any effect on pregnancy outcome independent of other maternal characteristics. DESIGN AND SETTING: Retrospective observational study using the database of a referral obstetric unit in a 280-bed regional hospital in far north Queensland. PARTICIPANTS: All 15 908 women who had singleton births between 1992 and 2001, comprising 653 women with grand multiparity (>or= 5 previous births at gestation >or= 20 weeks) and 15 255 women with lower parity. MAIN OUTCOME MEASURES: Spontaneous vaginal birth, postpartum haemorrhage (estimated blood loss > 500 mL), placental retention requiring manual removal, blood transfusion associated with the birth, and perinatal death. RESULTS: Women with grand multiparity were significantly older than those with lower parity, more likely to be Indigenous, not to have had antenatal care, to have smoked during pregnancy and to have had one or more previous caesarean sections. On univariate analysis, women with grand multiparity were more likely to have a postpartum haemorrhage (9.2% v 5.3%) and blood transfusion (2.8% v 1.5%). However, multivariate logistic regression analysis of women who began labour (ie, did not have an elective caesarean section) showed that grand multiparity was not significantly associated with postpartum haemorrhage or blood transfusion when other maternal characteristics were included in the model (regression coefficients [95% CI], 1.36 [0.99-1.87] and 1.09 [0.59-2.02], respectively). However, they remained more likely to have a spontaneous vaginal birth (regression coefficient [95% CI], 2.10 [1.56-2.74]). CONCLUSIONS: Women with grand multiparity do not have an increased likelihood of poor pregnancy outcomes. Birth-suite protocols which dictate extra interventions as routine during labour in these women should be revised.