Outpatient triplet management: a contemporary review

The antepartum management of 198 women who were delivered of triplets between 1985 and 1988 is reviewed. Women were managed with the assistance of ambulatory perinatal nursing to provide outpatient surveillance. Modified bed rest, prophylactic tocolysis, and betamethasone were liberally used and patients were hospitalized only when obstetrically indicated. The most common antepartum complication was preterm labor (66.2%) and the success of therapy with tocolytic agents is described. The mean gestational age and birth weight at delivery were 33.6 +/- 3 weeks (mean +/- SD) and 1871 +/- 555 gm, respectively. Comparison of the gestational age distribution at delivery with previous reviews demonstrates fewer deliveries less than 29 weeks' gestation and significantly more deliveries between 32 and 37 weeks' gestation. Cesarean delivery occurred in 94% of the triplets, which eliminated birth order as a factor that affects survival. The corrected perinatal survival rate was 95% in this contemporary review of outpatient triplet management and represents a major improvement in the expected outcome for triplets.     

How small is too small and how early is too early? A survey of American obstetricians specializing in high-risk pregnancies.

Four hundred and five Maternal-Fetal Medicine specialists were surveyed to determine their clinical opinions regarding intrapartum management of the severely preterm fetus requiring delivery. Intrapartum fetal heart rate monitoring was initiated at 23, 24, and 25 weeks' gestation by 10%, 43%, and 66% of respondents, respectively. Cesarean section was not performed at less than 24 weeks' gestation or less than 500 gm fetal weight. Ninety percent of respondents were willing to perform cesarean section for fetal distress or breech presentation at 26 weeks' gestation or 750 gm fetal weight. Delivery management prior to 26 weeks' gestation or for fetuses smaller than 750 gm was variable and appeared to be individualized. Due to inherent uncertainty regarding appropriate management and observed variability of response, we conclude that studies be performed to assess objectively safety and efficacy of cesarean section for fetal indications at less than 26 weeks' gestation or less than 750 gm estimated fetal weight.     

Expectant management after sonographic diagnosis of placental abruption.

Forty cases of placental abruption were diagnosed by sonography after 20 weeks' gestation and managed expectantly. Tocolytics were used in 18 patients and were successful in delaying delivery for 34 +/- 24 days in 10. One-third of the patients delivered at term, after delays of 12.3 +/- 5.7 weeks. The majority of the patients who delivered before term (63%) had at least one other risk factor for preterm delivery, such as twins, ruptured membranes, or cervical dilation at presentation. Preterm delivery was not correlated with any of several clinical indicators of the severity of the abruption. Although the perinatal mortality rate was 22%, all perinatal deaths except one were attributable to extreme prematurity. It concluded that mild placental abruption is often a self-limited event and can safely be managed expectantly. Most of the perinatal morbidity and mortality is associated with premature delivery and, thus, in the absence of fetal distress or maternal compromise, delivery may often be delayed until fetal maturity is attained.     

Cervical change and uterine activity as predictors of preterm delivery

Premature uterine activity and early cervical change have both been shown to be useful in predicting preterm delivery. Prospective studies evaluating weekly uterine activity and cervical change were performed in 20 women, 17 of whom were at risk for preterm delivery, starting at 20 to 25 weeks' gestation. Patients were followed weekly until either 36 weeks' gestation or until the onset of premature labor or delivery. Seven women delivered before 37 weeks' gestation (preterm group). Thirteen women did not require tocolysis and delivered after 37 weeks' gestation (term group). A Bishop score was assessed weekly and the score added to the prior values in order to obtain a cumulative cervical score. A similar process was used to assess uterine activity. The cumulative values of Bishop score and uterine activity were plotted against gestational age in both groups. There was no observed increase in cumulative uterine activity in the preterm group before delivery. However, there was a progressive increase in cumulative cervical change weeks before delivery in the preterm group (p less than 0.05). Despite the small sample size, we conclude that progressive cervical change precedes the onset of labor and may be a better predictor of preterm delivery than is weekly monitoring of uterine activity.     

The use of betamethasone and timed delivery in management of premature rupture of the membranes in the preterm pregnancy.

Of 43 women admitted with premature rupture of the membranes between 27 and 32 weeks' gestation, 27 received antepartum glucocorticoid with delivery timed to occur approximately 24 hours after the first dose of steriod. Sixteen patients did not receive glucocorticoid and were managed expectantly. Neonatal mortality was significantly less in the steroid group (15% vs. 50%, p less than .01), and this difference was explained by a reduction in deaths from respiratory distress syndrome. Rates of infectious morbidity for both mothers and infants were similar between the steroid-treated group and the group managed expectantly.     

Management of preterm prematurely ruptured membranes: a retrospective comparison of observation versus use of steroids and timed delivery

A retrospective study of 38 women with preterm prematurely ruptured membranes was performed. Twenty were treated with intravenous hydrocortisone followed by timed delivery between 48 and 72 hours after initiation of steroid therapy. Eighteen were managed expectantly, with observation for labor and infection. There were no significant differences between steroid-treated patients and observed patients in the incidence of neonatal respiratory distress syndrome, perinatal mortality, or maternal or neonatal infections.     

Short cervical length by ultrasound and cerclage.

OBJECTIVE: To determine whether gravidas with short cervical length on endovaginal ultrasound examination, not in preterm labor, who underwent cervical cerclage have better outcomes compared with those with no cerclage. METHODS: This is an observational study in which data were collected prospectively on women who had ultrasound endovaginal cervical length measurement and were not in preterm labor. The subgroup of women who were < or = 26 weeks' at cervical measurement was analyzed separately. Short cervix was defined as < or = 30 mm. After delivery, charts were reviewed for management and outcomes, performed at the discretion of the attending obstetrician. Two study groups were defined: those with cerclage and those with no cerclage. Predictor variables were cerclage and cervical lengths. Outcome variables were birth weight, gestational age at delivery, and neonatal outcomes. Data were analyzed using the chi-squared, Fisher's exact, and Student's t-tests, a p value of < 0.05 was considered to be significant. RESULTS: A total of 85 patients with cervical lengths of < or = 30 mm were identified; of these 43 had cerclage, and 42 did not. The latter had bedrest, tocolytics, or no intervention. Indications for cervical length measurement were similar in both groups, as were age, insurance status, cervical measurements, preterm premature rupture of membranes, and mode of delivery. The mean gestational age at delivery and birth weight in the cerclage group (34.0 +/- 5.4 weeks'; 2530 +/- 905 gm) were greater than in the no cerclage group (32.0 +/- 6.0 weeks', 2084 +/- 1085 gm, p values of < 0.04 and < 0.04, respectively). Analysis for the subgroup of women who were < or = 26 weeks at first measurement revealed similar results. The relative risk for delivering at < 30 weeks' gestation, for incrementally shorter cervices, was less in the cerclage group. CONCLUSION: Cerclage in gravidas with short cervix measured by endovaginal ultrasound, not in preterm labor, may be associated with neonates of greater gestational age and birth weight, with fewer of these parturients delivering before 30 weeks' gestation. A prospective randomized trial of treatment modalities for asymptomatic shortened cervix is needed.     

Antimicrobial therapy in preterm premature rupture of membranes: results of a prospective, double-blind, placebo-controlled trial of erythromycin

This study was conducted to evaluate the effectiveness of oral erythromycin treatment in safely prolonging pregnancy among women experiencing preterm premature rupture of membranes. Sixty-five women were randomly assigned to receive double-blind treatment with either erythromycin base or an identical-appearing placebo three times daily for 7 days. Only women between 23 and 34 completed weeks' gestation who did not have an indication for delivery were enrolled in the study. Pretreatment microbiologic tests were obtained and women were followed expectantly. Fifty-five women and their newborns completed the protocol and were fully evaluated. Overall, time from rupture of membranes to onset of labor and to delivery was longer, although not significantly, for erythromycin-treated women. Similarly, there was a trend for reduced neonatal intensive care (level II, p = 0.07). When gestational age at enrollment was controlled, erythromycin treatment of women between 28 to 32 weeks' gestation was associated with a prolonged interval from enrollment to delivery [erythromycin: 292 hours (5 to 679); placebo: 54 (12 to 323); p less than 0.044]. Fifty percent of erythromycin-treated women between 28 to 32 weeks' gestation continued their pregnancies at least 13 days after premature rupture of membranes, whereas 50% of placebo-treated women were delivered of infants within 4 days (p = 0.02). Erythromycin treatment among women less than 28 and between 33 to 34 weeks' gestation was not associated with prolonged latency or other changes. There were no differences between erythromycin- and placebo-treated women in the occurrence of clinically recognized chorioamnionitis, postpartum endometritis, or neonatal infectious morbidity. In this double-blind, placebo-controlled trial, erythromycin treatment was well tolerated, safe, and associated with prolongation of pregnancy and reduced intensive neonatal care requirements for selected mother-newborn pairs with preterm premature rupture of membranes.     

Prolongation of pregnancy and survival of twin B after loss of twin A at 21 weeks' gestation

At 21 weeks' gestation premature rupture of the membranes led to unavoidable delivery of an immature first twin (390 gm) who died shortly after birth. The placenta was left undisturbed. Twin B was confirmed to be alive within an intact second sac. Directly after delivery of twin A tocolysis was begun and cervical cerclage was undertaken. Pregnancy was successfully prolonged, which enabled the second fetus to remain in utero and grow for another 12 weeks. Onset of active labor resulted in delivery of a healthy 1750 gm female infant at the beginning of 33 weeks' gestation. The neonatal care was benign and the infant left the hospital in excellent condition after 4 weeks. The case is presented in detail and discussed with respect to the aggressive approach undertaken to prolong gestation.     

Cervical dimensions and risk of preterm birth: a prospective cohort study

OBJECTIVE: To examine the relation between cervical dilatation and length and the risk of spontaneous preterm birth, including its subtypes preterm labor and preterm premature rupture of membranes (PROM). METHODS: Cervical dimensions assessed by clinical examination were recorded prospectively at 24-29 weeks' gestation in 871 subjects with singleton pregnancies who were followed to delivery. Relative risks (RRs) of preterm birth, preterm labor, and preterm PROM were calculated for clinically distinguishable categories of cervical dilatation and length and for cervical score (length minus dilatation). Regression analysis was used to adjust for confounding. Time to delivery from baseline examination was summarized using survival analysis. RESULTS: There were 73 spontaneous preterm births (8.3%), 46 preterm labors and 27 cases of preterm PROM. All cervical measurements were associated with increased risks of preterm birth, with increasing abnormality more strongly predictive of risk. The adjusted RR for preterm birth with dilatation of at least 0.5 cm was 2.9 (95% confidence interval [CI] 1.2, 7.3); for length of 1.5 cm or less, the RR was 2.1 (95% CI 1.0, 4.5), and for cervical score less than 2.0, the RR was 2.8 (95% CI 1.4, 5.6). The association with cervical measurements was stronger for preterm PROM than for preterm labor, although precision was limited. These measurements had high specificity (93-99%) and low sensitivity (8-20%) for predicting preterm birth. CONCLUSION: In asymptomatic women at 24-29 weeks' gestation, greater cervical dilatation and shorter length were associated with increased risk of spontaneous preterm delivery, particularly preterm PROM.     

Ampicillin prophylaxis in preterm premature rupture of the membranes: a prospective randomized study

It is hypothesized that ampicillin may treat subclinical deciduitis and prolong the "effective" latent period in patients with preterm premature rupture of the membranes. We studied 82 patients with preterm rupture of membranes who were managed expectantly and were randomly assigned either to receive ampicillin prophylaxis (n = 43) or not to receive ampicillin prophylaxis (n = 39). Patients were excluded from study entry on admission if they had suspected or frank chorioamnionitis, active preterm labor, a history of penicillin allergy, multiple gestation, or cervical cerclage. There were no significant differences between the groups in duration of membrane rupture prior to admission, gestational age at membrane rupture, use of steroids and tocolysis, and demographic factors. Life-table analysis showed that the risk of delivery was significantly lower for the group of patients receiving prophylactic ampicillin. The incidence of neonatal infection was significantly lower in the ampicillin group, 1 (2%) versus 6 (17%), p less than 0.04.     

A randomized comparison of home uterine activity monitoring in the outpatient management of women treated for preterm labor

OBJECTIVE: The aim of the study was to evaluate home uterine activity monitoring as an intervention in reducing the rate of preterm birth among women treated for preterm labor. STUDY DESIGN: A total of 186 women were treated in the hospital with magnesium sulfate for preterm labor and were prospectively randomly assigned to study groups; among these, 162 were ultimately eligible for comparison. Eighty-two of these women were assigned to the monitored group and 80 were assigned to an unmonitored control group. Other than monitoring, all women received identical prenatal follow-up, including daily perinatal telephone contact and oral terbutaline therapy. Outcome comparisons were primarily directed toward evaluation of preterm birth at <35 weeks' gestation. Readmissions for recurrent preterm labor and observations lasting <24 hours were evaluated in monitored and unmonitored groups. Compliance with monitoring was also evaluated in the monitored group. RESULTS: The monitored and control groups were demographically similar. According to a multivariate logistic regression model, women with cervical dilatation of >/=2 cm were 4 times more likely to be delivered at <35 weeks' gestation (P <.05). Gestational ages at delivery were similar in the monitored and control groups. There was no significant difference in the overall rate of preterm delivery at <35 weeks' gestation between the monitored group (10.9%) and the control group (15.0%). The overall rates of delivery at <37 weeks' gestation were high (48.8% and 60.0% for monitored and control groups, respectively), and the difference was not significant. The numbers of women with >/=1 instance of readmission and treatment for recurrent preterm labor were equal in the monitored and control groups. The numbers of women with >/=1 hospital observation lasting <24 hours were not different between the groups. Compliance with monitoring did not significantly differ for women who were delivered at <35 weeks' gestation, women with >/=2 cm cervical dilatation at enrollment, or for African American women. CONCLUSION: A reduction in the likelihood of preterm delivery at <35 weeks' gestation was not further enhanced by the addition of home uterine monitoring to the outpatient management regimens of women treated for preterm labor.     

Oral tocolysis with magnesium chloride: a randomized controlled prospective clinical trial

A prospective randomized clinical trial was conducted to assess the efficacy and safety of enteric-coated magnesium chloride (SLOW MAG) as an oral tocolytic agent. Seventy-five patients between 24 and 34 weeks' gestation who were treated with intravenous magnesium sulfate for a first episode of preterm labor were enrolled. After a 12-hour contraction-free period on intravenous therapy, patients were randomized by sealed envelope to one of three groups: group 1, SLOW MAG (535 mg every 4 hours); group 2, oral ritodrine (20 mg every 4 hours); or group 3, no therapy (control). Patients receiving oral therapy were treated until delivery or completion of 36 weeks' gestation. No difference was found between groups with respect to time gained with the use of oral therapy or number completing 36 weeks' gestation. Therapy with enteric-coated magnesium chloride was associated with significantly fewer side effects (20%) as compared with ritodrine (48%) (p less than 0.01). Our results suggest that compared with ritodrine, enteric-coated magnesium chloride is as effective in prolonging pregnancy and preventing recurrent preterm labor. However, neither enteric-coated magnesium chloride nor ritodrine appeared to be any more effective in the prevention of preterm delivery than observation alone.     

Candida chorioamnionitis after serial therapeutic amniocenteses: a possible association.

BACKGROUND: Reduction amniocentesis is used in cases of severe polyhydramnios to decrease maternal discomfort and the risk of preterm labor. In a MEDLINE search (1966 to present, English language, keywords: amniocentesis, chorioamnionitis), no report of Candida chorioamnionitis after serial reduction amniocentesis exists. CASE: A 29-year-old primigravida with a history of four therapeutic amniocenteses for idiopathic polyhydramnios developed preterm labor at 30 and 5/7 weeks' gestation, rupture of membranes, and Candida albicans chorioamnionitis. Despite aggressive therapy with amphotericin B, the neonate succumbed to overwhelming systemic candidiasis. CONCLUSION: Serial amniocentesis may place patients at elevated risk for Candida chorioamnionitis and subsequent preterm delivery. Clinicians should consider early diagnostic amniocentesis in patients in preterm labor with a history of prior amniocentesis, and the routine Gram stain and culture of amniotic fluid.     

Association between colonization with group B streptococci during pregnancy and preterm delivery among Danish women

OBJECTIVE: We studied the relationship between group B streptococcal colonization and preterm delivery. STUDY DESIGN: In this prospective study at a single hospital in Odense, Denmark, cervicovaginal cultures were obtained at < or = 24 weeks' gestation from all the women, at delivery from women with preterm deliveries, and from a random sample of women delivering at term. RESULTS: In 2846 singleton births, there was no significant association between group B streptococcal colonization at 相似文献   

Should intravenous tocolysis be considered beyond 34 weeks' gestation?

OBJECTIVE: Our purpose was to assess the incidence of respiratory distress syndrome in nonindigent women with uncomplicated preterm labor between 34 and 36 weeks' gestation. STUDY DESIGN: All women seen between June 1, 1992, and April 15, 1999, with uncomplicated preterm labor and intact membranes and delivering between 34 and 36 weeks' gestation were analyzed. Rates of respiratory distress syndrome after delivery were calculated. A chi(2) analysis was performed, and a P value of <.05 was considered statistically significant. RESULTS: Respiratory distress syndrome was noted in 8 (17.4%) of 46 infants delivered at 34 weeks' gestation, in comparison with 5 (6.3%) of 80 infants and 7 (4.2%) of 165 infants delivered at 35 and 36 weeks' gestation, respectively (P =.008). The rate of respiratory distress syndrome after delivery at 34 weeks was significantly higher than at 35 weeks (P =.048). CONCLUSION: The rate of respiratory distress syndrome after delivery at 34 weeks is significantly higher than at either 35 or 36 weeks' gestation in our population.     

Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial.

OBJECTIVE: To determine if elective induction (IND) increases the risk of cesarean delivery compared to expectant management (EM). METHODS: A randomized clinical trial involving women 39 weeks' gestation, according to strict dating criteria, with a Bishop score of 5 or more in nulliparous patients and 4 or more in multiparous patients. The control group was expectantly managed and delivered for obstetric indications, but not later than 42 weeks' gestation. The study had 80% power to detect a three-fold increase in cesarean delivery. RESULTS: One-hundred-and-sixteen patients (45 nulliparous) were randomized to IND and 110 (58 nulliparous) to EM. Demographic characteristics were no different between the groups. The cesarean delivery rate in the IND group was 6.9% (8/116) compared to 7.3% (8/110) in the EM group (p = NS). Rates of cesarean delivery for nulliparous patients randomized to IND compared to EM were also not significantly different: 13.3% (6/45) versus 10.3% (6/58) respectively (p = NS). Neonates delivered of IND patients weighed less than those of the EM group (3459 +/- 347 versus 3604 +/- 438, p = 0.006). CONCLUSION: In women with favorable Bishop scores, elective induction of labor resulted in no increase in cesarean delivery compared to expectant management.     

Expectant management of preterm premature rupture of membranes complicated by active recurrent genital herpes

OBJECTIVE: The study objective was to examine the neonatal outcome in pregnancies with early preterm premature rupture of the membranes (PPROM) who were managed expectantly despite the development of recurrent active genital herpes. STUDY DESIGN: Pregnancies complicated by PPROM at < or =14;31 weeks' gestation that developed an active recurrent genital herpes lesion were collected. The latency time from herpes lesion development to delivery and the neonatal outcome were analyzed. A control group of patients with PPROM at < or =14;31 weeks' gestation with no herpes infection was also obtained. RESULTS: A total of 29 patients were identified during the study period. The mean gestational age at herpes lesion development after PPROM was 28.7 weeks (range 24.6-31.0 weeks). The mean latency period from herpes development to delivery was 13.2 days (range 1-35 days). No cases of neonatal herpes developed in the delivered newborn infants and all neonatal cultures were negative (0 of 29 cases, 95% CI 0%-10.4%). Twelve newborn infants (41%) had major morbidity caused by prematurity and 3 of these (10.3%) died. There were no differences seen between the study cases and the control group. In the study, 15 of the 29 pregnancies were delivered beyond 30 weeks' gestation. If delivery had occurred on the day the herpes lesion developed, only 5 pregnancies would have been delivered beyond 30 weeks' gestation. CONCLUSION: On the basis of the 95% CI of these data, the maximum risk for development of a neonatal herpes infection in the face of PPROM and active recurrent genital herpes was 10.4%. This was equal to the mortality rate and was 75% lower than the major morbidity rate caused by prematurity. If delivery had occurred on the day the herpes lesions developed, on average, the neonates would have been nearly 2 weeks more premature, thereby potentially increasing the morbidity and mortality related to prematurity. These data concur with the American College of Obstetricians and Gynecologists consensus and expert opinion and would suggest that expectant management of PPROM at 相似文献   

Management of prolonged pregnancy: induction of labor versus antepartum fetal testing

Three hundred two low-risk obstetric patients with an unfavorable cervical examination and well-established gestational age of at least 287 days were randomly selected for management by either antepartum fetal testing or prostaglandin gel cervical ripening followed by aggressive induction of labor and delivery. The patients managed by induction of labor had a lower incidence of meconium-stained amniotic fluid, meconium aspiration, low Apgar scores, postmaturity syndrome, fetal distress, and cesarean delivery than did patients managed with antepartum fetal testing. Our data suggest that prostaglandin gel cervical ripening and induction of labor and delivery by 42 weeks' gestation may be the most appropriate management for patients with well-established gestational age and an unfavorable cervical examination.     

Differing fetal growth patterns in pregnancies complicated by preterm labor

Previous studies have demonstrated diminished ultrasonic fetal growth parameters in women delivering preterm. In this study, we tested the following hypothesis: In pregnancies complicated by spontaneous preterm labor, 1) unsuccessful tocolysis is likely to be associated with diminished fetal growth, and 2) successful tocolysis is likely to occur when fetal growth is normal. Ultrasound examinations were performed in 78 pregnancies complicated by preterm labor before 35 weeks' gestation. Tocolysis was attempted unless contraindicated or unless cervical dilatation was advanced (4 cm or greater). Pregnancies delivering before 36 weeks' gestation were compared with those delivering after this gestational age. Among the 48 pregnancies delivered before 36 weeks' gestation, a significantly greater proportion had ultrasonic growth parameters lower than normal values at corresponding gestational ages. In contrast, those pregnancies that had successful tocolysis and delivered near term demonstrated a normal distribution of ultrasound growth parameters. In pregnancies complicated by preterm labor, ultrasonic documentation of diminished fetal growth may identify the subgroup at increased risk for preterm delivery.