Volume 30, Issue 5

The odds of an indivdual triplet pregenancy to end with neonates weighing < 1000 g (extremely low birth weight [ELBW]) are unknown. We analyzed a nationwide perinatal database collected by Matria Healthcare, Inc. (Marietta, GA) to select from 3288 triplets those weighing 500–1000 g, delivered during the period 1988–2000 in the United States. We counted the number of sets with one, two, and three ELBW neonates and compared the incidence of ELBW infants between the subsets of nulliparas and multiparas. The odds of delivering at least one ELBW infant was significantly higher among nulliparas (1:8) than among multiparas (1:14), Odds Ratio (OR) 1.9, 95% Confidence Interval (CI) 1.9, 2.5. The odds of having at least two ELBW sibs in nulliparas (1:16) is twice higher than in multiparas (1:31), OR 2.0, 95% CI 1.3, 2.9. Nulliparas and multiparas had similar odds of delivering three ELBW infants (1:29 versus 1:40, OR 1.3, 95% CI 0.9, 2.1). Nulliparas are at significantly increased risk of delivering one or two ELBW triplets. This observation is no less than alarming and highlighted by the exceptionally high risk of major neurological deficits reported among ELBW infants.

A new device in assessment of cervical consistency by means of resistance to electrical current was compared to observations made by traditional clinical assessment of the cervix. The cervix of 50 specimens obtained consecutively at a series of total abdominal hysterectomies done for benign disease was evaluated for cervical consistency first by palpation preoperatively and then by the new device, using 5 prototypes, after the specimen was removed. Obtained results showed that intra-observer error for all five prototypes averaged 1.28 ± 2.5% (mean ± standard deviation), whereas inter-observer error was 8.44 ± 7.9%. Stratified by clinical cervical consistency as soft, moderate and firm, there was a statistically significant difference in the resistance to electrical current (f = 29.0, r 2 = 0.19, p < 0.0001). Resistance to electrical current was highest for firm cervices, less for those of moderate consistency, and least for soft ones (21.8 ± 2.73, 19.6 ± 2.91 and 15.6 ± 4.09 ohms, respectively). In conclusion, measurements of cervical resistance obtained objectively by a new device reliably correlated with traditional clinical assessment of cervical consistency.

Thromboembolic events are among the leading causes of maternal mortality. Mutations in the genes for clotting factors are known, but anamnestic factors can be found in a proportion of women with deep venous thromboses (DVT) during pregnancy and the puerperium. We here describe the clinical factors and pregnancy outcomes of such a group of 70 women who were all operated on for DVT. Highest risk is conferred by a familial history of clotting disease and by known mutations of the clotting factors. This might be used to target a high risk group for preventive treatment.

Objectives: The Frauenfeld Clinic for Obstetrics and Gynecology introduced waterbirths in 1991. This work examines whether guidelines for water temperature and bathing are actually necessary. Methods: This 8-year prospective clinical study follows 10,775 births in a regional women's hospital (non-selected population). Neonatal and maternal body temperature and morbidity parameters were compared between land and waterbirths. A smaller study (n = 47) selectively focused on body temperature differences as influenced by bathing time and water temperature in waterbirths as compared to land births. Results: Neonatal and maternal birth and perinatal parameters, and body temperatures do not differ between water and land births, except at birth, when waterbearing temperatures were 36.9 °C vs. 36.3 °C on land. Neonatal rectal temperatures did not differ significantly between the two groups. Water temperature increased from the beginning of the bath (35.2 °C) to 35.7 °C, and fell at the end of the bath to 32.9 °C. Water temperature range: 23 °C to 38.9 °C. Bathing duration: 28 min. to 364 min. Conclusions: Waterbirths pose no thermal risk. The parturient, with her “inborn code of body temperature regulation,” regulates water temperature and bathing duration to ensure body temperatures of mother and child remain within the physiological range. Cumbersome guidelines for water temperature and bathing duration are therefore superfluous.

Aims: Fear of damage to the pelvic floor from vaginal delivery and long-term sequelae (urinary and anal incontinence) sometimes being cited as an indication for cesarean section on request. The aim of the present study was to compare the effects of vaginal delivery versus elective cesarean section on anal sphincter function. Material and methods: We studied 71 consecutive women six weeks before delivery, 52 of them 4–6 weeks after delivery, and all patients with occult sphincter lesions 3months after delivery. A bowel function questionnaire was completed, and anal endosonography, manometry, and measurement of the pudendal-nerve terminal motor latency were performed. Results: Forty-two (80,8 percent) patients were delivered vaginally, ten (19,2 percent) by elective cesarean section at term. Clinically recognized anal sphincter injuries occurred in 9.5 percent (4) of patients, two of them developed incontinence for gas. The overall incidence of anal incontinence after vaginal delivery was 4.8 percent. Occult sphincter defects were identified endosonographically in 19 percent (8) of women, there was no reported case of any anal incontinence 3 months after delivery. No woman delivered by cesarean section had altered anal continence or any significant change in anal pressures, rectal sensibility, and PNTML. Conclusion: Severe sphincter tear is the single most important factor leading to anal incontinence in women, whereas occult sphincter defects are rarely associated with short-term sequelae, but may predispose to the development of anal incontinence later on in life. Elective cesarean section should be recommended for women at increased risk for anal incontinence.

Objective: To assess the diagnostic value of Doppler sonography of the uterine arteries (DSUA) at 20–23 gestational weeks as screening procedure in a low risk population Patients and methods: The study group consisted of 7508 singleton low-risk pregnancies. Doppler sonography of both uterine arteries was performed as routine part of anomaly scan. Impedance of both uterine arteries was registered using the mean PI of the two uterine arteries. In case of notch,“Notch-Index” was defined as (C-D)/C with D = post-systolic nadir and C = following zenith of the waveform. Outcome variables were placental abruption, pre-eclampsia, intrauterine growth retardation, intrauterine/neonatal death and preterm delivery before 32 completed gestational weeks. To discriminate normal and pathological waveform, incidence of adverse pregnancy outcome was related to four different definitions of pathological waveform. To describe the severity of impairment of perfusion, the frequency of adverse pregnancy outcome was related to different classes of impedance. Results: To find a simple discrimination between normal and pathological uterine perfusion, best diagnostic performance was reached by a definition using a combination of high impedance and notch (no notch and mean PI > P'95 or unilateral notch and mean PI > P'90 or bilateral notch and mean PI > P'50). The prevalence of notch in nulliparae (8.5%) was higher than in parae (4.7%) and decreased with increasing gestational age (20 weeks: 8.6%–23 weeks: 5.4%). We found a clear relation between elevation of impedance, depth of notch and frequency of adverse pregnancy outcome with a frequency of complications varying from 3.2% (mean PI =?0.8, mean NI = 0.1) to 38.4% (mean PI > 2.0, mean NI > 0.1 Conclusion: Doppler sonography of the uterine arteries at 20–23 weeks has the capacity to predict at least a part of severe forms of adverse pregnancy outcome and to assess the probability of complications by quantification of the impairment of the uterine blood

The aim of our study was to measure, at delivery, maternal and cord blood cadmium levels (by means of atomic absorption spectrometry) in 45 healthy non-smoking pregnant women exposed to a low cadmium challenge, and to evaluate the relationship between these cadmium levels and the birth weight of the infants. Our results showed fairly low cadmium levels in maternal blood, in accordance with the fact that all women enrolled in this study lived in areas with low toxic metal contamination and that they did not smoke during their pregnancy. Furthermore, a highly significant direct correlation was found between maternal and cord blood cadmium concentrations. Since cadmium concentration appeared of the same order of magnitudine both in cord and maternal serum, one could speculate that cadmium is transferred easily from the mother to the fetus through the placenta. Finally, we found that birth weight is inversely correlated with maternal and cord blood cadmium concentrations; thus birth weight might be negatively influenced by cadmium levels as a result of the toxic effects of the metal on the placenta. Although preliminary, our data show that (also not-predictable) prenatal exposure to even low cadmium levels might be a risk factor for developmental impairment in infants.

Aims: Little evidence-based data are available on the effects of eating and drinking during labor. Intravenous glucose administration has been related to fetal metabolic acidosis. The question is, whether oral intake of carbohydrates effects the fetal acid-base balance. Methods: In a double blind, prospective placebo controlled study 100 nulliparous women were randomized at 8–10 cm of cervical dilatation. All women were asked to drink 200 cc of either a carbohydrate solution (containing 25 grams carbohydrates) or placebo. In all women, both arterial and venous umbilical cord pH, pCO2, pO2, HCO3- and base excess/deficit were assessed. In a subgroup of women, whose deliveries were complicated by mild signs of fetal distress, clinical outcome and acid-base status was described separately. Results: Fetal arterial umbilical cord pH were identical: 7.20 +/− 0.07 in the placebo group and 7.20 +/− 0.08 in the carbohydrate group and the base excess −6.6 +/− 2.8 versus 6.6 +/− 3.7. In the women with mild signs of fetal distress, no differences were observed as well. Conclusions: Oral carbohydrate intake during labor seems to be safe regarding the fetal acid-base balance. Further study on the maternal and fetal metabolic parameters is essential to give a more complete picture.

Background. Oxytocin and various prostaglandin preparations are commonly used for pharmacological induction of labor at term. Some prostaglandin preparations appear to be associated with more fetal meconium passage and maternal gastrointestinal side effects than is oxytocin. These adverse effects may be caused by stimulation of bowel smooth muscle in the mother and in the fetus. Aim. To determine whether the in vitro ileal contractile activities of dinoprostone, misoprostol and oxytocin are in keeping with the variation in rates of meconium staining observed during labor induction with these substances. Methods. The contractile activity of the drugs was tested on isolated rat uterus and ileum mounted in Tyrode's solution. Results. Uterine contractions were stimulated by all three drugs, whereas ileal contractions were only stimulated by dinoprostone and misoprostol. Oxytocin had no contractile activity on the ileum. Dinoprostone and misoprostol stimulated significantly (p < 0.05) larger uterine contractions than ileal contractions. Conclusion. These results provide a pharmacological basis for the increased rate of maternal gastrointestinal complaints and meconium passage with labor induction using dinoprostone and misoprostol compared to oxytocin. Based on the above findings, we postulate that the difference in the rates of meconium passage following misoprostol and dinoprostone administration is caused by pharmacokinetic rather than pharmacodynamic differences between the two drugs.

Aim: The aim of this study is to show that the Clinical Assessment of Nutritional Status (CANS) score is an effective method to diagnose fetal malnutrition (FM) in term newborns and to monitor the catch-up growth of fetal malnourished newborns. Methods: A group of infants have been screened at birth for fetal malnutrition status using the CANS score (malnutrition was defined by a CANS sore cut-off value). The study group (consisting of fetal malnourished and nonmalnourished infants) has been monitored after birth by two follow-up exams at 3 rd and 6 th months. Results: The study showed that the FM group, which is similar to non-FM group in terms of gender and gestational age but different in nutritional status (CANS, weight, length, head circumference) at birth, showed partial catch-up growth, more so in head circumference than in others (weight, length). Conclusion: The study used CANS score to determine malnutrition in term infants and showed that malnourished infants (as defined by this CANS score cut-off value) caught-up partly with respect to the non-malnourished group. Furthermore, our experience showed that CANS score is an easy and effective way to identify fetal malnourished infants, and the scores can be obtained readily by following the established clinical assessment steps.

Aim. In vitro studies and animal experiments have provided evidence that albumin, bilirubin, meconium and inflammatory mediators act as surfactant inhibitors. The aim of this research was to establish whether their elevated concentrations in gastric aspirates, as representative samples of amniotic fluid, could contribute to the development of respiratory distress syndrome (RDS) in preterm infants. Methods. Infants born before the 35 th week of gestation between 1 March 1996 and 1 April 1997 were included. They were divided into two groups: the RDS and non RDS group. Gastric aspirates, taken immediately after birth, were used for biochemical measurements of albumin, bilirubin, meconium and E-α1-PI concentrations. Results. Sixty-one preterm infants were enrolled: 23 in the RDS group. The concentrations of albumin, bilirubin and meconium in gastric aspirates were higher in the RDS group (p < 0.01, p = 0.01 and p = 0.02, respectively). The E-α1-PI concentration showed no significant difference between the two groups. Logistic regression analysis showed that a markedly increased risk of RDS was only represented by albumin concentrations of over 1.6 mmol/l and gestational age of under 31 weeks. Conclusion. Our observations indicate that increased levels of albumin in the gastric aspirate, taken immediately after birth, may contribute to the development of RDS in preterm infants. Despite the established inhibitory effects of bilirubin, meconium and inflammatory mediators in vitro , we could not confirm their influence on the development of RDS.

A female term neonate with congenital tuberculosis presented with clinical manifestations of cough, respiratory distress and bilateral reticulonodular infiltration on chest radiograph. Her Indonesian mother had extrapulmonary tuberculosis. The neonate's tuberculosis symptoms were characterized by multi-organ involvement including lung, liver, gall bladder and kidneys, suggesting a spreading hematogenous transmission. Pathology of the liver biopsy revealed scattered miliary granuloma. After anti-tuberculosis treatment, significant improvement was seen on chest radiogram and in her clinical condition. Congenital tuberculosis should be suspected in infants who are unresponsive to empirical antibiotics. Transcutaneous liver biopsy may help confirm its prenatal origin.

Peripartum cardiomyopathy (PPCM) is an unusual heart failure of unknown etiology that occurs during pregnancy or postpartum. Mirror syndrome is a characteristic of maternal edema subsequent to fetal and/or placental edema. We report a case of PPCM with a transient increase of interleukin-6 concentration occurring in the postpartum period of mirror syndrome.

Congenital cystic adenomatoid lung malformation (CCAM) is a rare disorder characterized by replacement of normal pulmonary tissue with cysts of variable size and distribution. Only sporadic cases of CCAM type III have been described that were stillborn or died in the early neonatal period. To our best knowledge we report the first infant with bilateral CCAM type III that was not ventilator-dependent for the first 10 weeks of life and survived until the age of 5 months. Postnatally the newborn presented with signs of only mild respiratory distress and chest radiograph did not show evidence of cystic lesions. In the following weeks the major clinical symptom was persistent pulmonary hypertension with severe tachypnea, O 2 requirement and CO 2 retention. Pulmonary hypertension did not respond to HFOV ventilation, NO ventilation or prostacyclin inhalations. Conclusions: (1) Persistent pulmonary hypertension can be a major clinical feature in neonates with bilateral CCAM type III. (2) A normal chest X-ray does not exclude the possibility of bilateral type III CCAM. (3) Computerized tomography appears to be superior to conventional chest X-ray imaging in detection of small cystic lesions in infants with CCAM type III. (4) In cases of prenatally suspected CCAM type III, parents should be informed that short-term survival is possible.