Volume 32, Issue 6

Cesarean section is commonly perceived as a simple and safe alternative to difficult vaginal birth. However, several trends in obstetrical practice may act in concert to cause impaction of the fetal head during the second stage of labor or, more commonly, following failed instrumental delivery. Subsequently, difficult and potentially traumatic disengagement of the deeply wedged head during cesarean section occurs. The maneuvers to disengage the wedged head include pushing (bimanual or by an assistant) the head through the vagina or, alternatively, pulling the infant’s feet through the uterine incision. Although both methods may cause serious maternal and neonatal complications, available data seem to favor the pulling method and better outcome seems to depend on adequate uterine relaxation, the patient’s position during operation, and special attention to the uterine incision. More data are needed to establish the frequency and extent of intraoperative disengagement dystocia and to determine the management protocol that carries the lowest risk in such circumstances.

The aim of our study was to compare the neonatal outcome of vaginally delivered breech-presenting twins (VD) to those delivered by cesarean (CS). Maternal and neonatal charts of all live, non-anomalous twins delivered at ≥25 weeks of gestation, in a single tertiary care center, over an 11-year period were reviewed. Of 517 twins delivered, 130 breech-presenting twins were analyzed. Thirty-five (26.9%) were delivered vaginally and 95 (73.1%) by cesarean. More patients presented in labor with advanced cervical dilation in the VD compared to the CS group. There was no difference in the incidence of respiratory distress syndrome, intraventricular hemorrhage, need for mechanical ventilation, length of nursery stay or neonatal mortality rate when twin A was compared in the two groups. However, one breech-presenting twin in the VD group had a traumatic delivery at 32 weeks of gestation that caused a spine fracture followed by immediate neonatal death. Although there seems to be no compromise in the immediate neonatal outcome of breech-presenting twins delivered vaginally compared to those delivered by cesarean, the case of head entrapment that led to intrapartum death is quite alarming. Based on our study, we cannot advocate normal vaginal delivery when twin A is non-vertex: cesarean seems to be a safer route of delivery.

Aims: To measure maternal serum interleukins (IL) in pregnancy, delivery and early puerperium, and to identify their potential determinants. Methods: Prospective longitudinal measures of serum IL-1β, IL-6 and IL-8 in 38 healthy pregnant women at antenatal visits, through labor and delivery, with clinical correlates (infection, vaginal hemorrhage and anemia) recorded by questionnaire. Results: Pregnancy IL levels remained consistently low. IL-1β increased shortly before delivery, then returned to pregnant levels, except where blood loss exceeded 500 ml. IL-6 and IL-8 rose at labor onset and exceeded pregnancy levels through postpartum day three. Postpartum IL-6 was higher after non-elective cesarean section than after spontaneous delivery (P < 0.0001), and where blood loss exceeded 500 ml. IL-6 and IL-8 were higher with systemic infection during delivery (P < 0.0001) and on postpartum day one (P < 0.05); IL-8 was higher in anemia (delivery: P < 0.005; postpartum day 1: P < 0.05). Differences due to delivery mode and systemic infection remained significant after correction for other conditions. Conclusions: Labor-dependent inflammation increases all IL levels at delivery. Further studies with larger sample sizes are required to establish reference values differentiating physiology from pathology as an aid to peripartum management.

Aim: To compare perinatal outcome of patients with HELLP syndrome to that of patients with chronic hypertension and superimposed preeclampsia on chronic hypertension without HELLP syndrome. Methods: We retrospectively evaluated the perinatal outcome of 147 pregnancies complicated by the HELLP syndrome, chronic hypertension, and superimposed preeclampsia on chronic hypertension without HELLP syndrome. Results: Gestational age at delivery and birthweights were lower among women with HELLP syndrome than among women with superimposed preeclampsia and chronic hypertension (P < 0.05). There were no statistically significant differences among the three groups with respect to intrauterine growth retardation, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, Apgar score, admission to neonatal intensive care unit, overall rate of cesarean delivery and cesarean delivery rate for fetal distress. The total perinatal mortality rate was 17% (28/147) and was more frequent in the HELLP group (27%). Multivariate logistic regression analysis showed that gestational age at delivery (RR 0.45) and birthweight (RR 0.99) were risk factors for adverse outcome. Conclusions: Perinatal outcome is primarily influenced by gestational age at delivery and birthweight independent of the severity of the hypertensive status of pregnant women.

Objective: To evaluate the relationships between scalp-pH and CTG plus ST waveform analysis of the fetal ECG (STAN) clinical guidelines as indicators of intrapartum hypoxia in term fetuses born with cord artery acidemia. Study design: Data from 6999 term deliveries monitored by the STAN ® S 21 as part of an EU multi-center study on clinical implementation of the STAN methodology for intrapartum fetal surveillance were analyzed. We identified 911 cases where a scalp-pH was obtained, including 53 cases with cord artery acidemia (pH < 7.06). Lag times between ST events and scalp-pH and time to delivery were related to cord artery metabolic and respiratory acidosis and neonatal outcome. Results: 43 fetuses were identified by CTG plus ST as being in need of intervention 31 (25–46) minutes before delivery (median, 95% Cl). In five, no indications were given and in another five there were inadequate data. Fifteen cases with metabolic acidosis required special neonatal care, all 14 cases adequately monitored on STAN had indications to intervene for 19 minutes or more. In 30 adequately recorded cases, fetal blood sampling (FBS) was obtained within the last hour of labor. In 22 cases, FBS was obtained 13 (7–24) minutes after STAN guidelines had indicated abnormality and in eight no ST changes had occurred at time of FBS. The corresponding FBS data were pH 7.10 (7.01–7.15) and pH 7.21 (7.08–7.31), respectively, P = 0.01. In cases of metabolic acidosis, scalp-pH fell 0.01 units per minute after a baseline T/QRS rise was recorded during the second stage of labor. Apart from one newborn that died at 2 h from E. Coli septicemia, none of the neonates were affected neurologically. Conclusion: Cardiotocography plus ST analysis provides accurate information about intrapartum hypoxia similar to that obtained by scalp-pH.

Aims: To measure plasma concentrations of endothelin (ET)-1, NO metabolites (nitrate/nitrite; NO x ) and 6-keto PGF 1α (PGF 1α ) in maternal and fetal sheep blood, and to evaluate the effects of big ET-1 on hemodynamic response, blood gases and NO and 6-keto PGF 1α production in near term fetal sheep. Methods: Hemodynamic parameters were measured during infusion of big ET-1 into the carotid vein in chronically catheterized fetal sheep on day 125 of gestation. Fetal arterial blood samples were obtained for ET-1, PGF 1α ) and nitrate/nitrite (NO x ) measurements. Results: ET-1, NO x and PGF 1α plasma concentrations were all significantly higher in fetal compared with the maternal plasma. Big ET-1 significantly decreased fetal systolic and diastolic blood pressure and significantly increased fetal heart rate. Big ET-1 stimulated plasma PGF 1α ), but not NO x , concentration. Conclusions: Circulatory regulating factors in the fetus were up-regulated. The effects of ET-1 on fetal hemodynamic respnse may be mediated via prostacyclin, but not via the NO pathway.

Background: Cervical teratomas are extremely rare tumors with high perinatal mortality and morbidity rates. Objective: To compare our experience and outcome in newborns with cervical teratoma with similar reports from the literature, in order to propose a structured approach. Methods: A retrospective review of seven patients treated between 1986 and 2000 was performed. The results of these seven patients were compared with and added to a series of 44 well-documented patients retrieved from the literature. Results: In four of the seven patients, the diagnosis was not suspected antenatally. Three of the patients survived, one died. In the other three, the diagnosis was made antenatally. Two were born using the ex-utero intrapartum treatment (EXIT) procedure, one by planned cesarean section. Only one of these three survived. Mortality in the total series of 51 patients was 33% overall, and 46% in the group in which the diagnosis had been made antenatally. Peri- and post-operative complications were reported in 27%. Although larger tumors caused polyhydramnios more frequently than smaller tumors, and were associated with more severe respiratory distress, the relationship between tumor volume at birth and final outcome could not be established. This makes difficult the identification of fetuses with a disastrous prognosis. Conclusion: Although mostly benign, cervical teratomas are still associated with high mortality rates. Timely antenatal diagnosis is indispensable in reducing morbidity and mortality caused by upper airway obstruction. A structured approach to the management of cervical teratoma is proposed.

Aims: To compare birthweight (BW), body mass index (BMI) and ponderal index (PI) as predictors of selected short-term (ST) outcomes, namely Neonatal Intensive Care Unit (NICU) admission and prolonged hospitalization (PH), among newborn (NB) infants. Methods: Data was collected prospectively on 9,226 infants born during one year at nine tertiary care hospitals in Greater Beirut, Lebanon. The predictive abilities of BW, BMI and PI were compared using the area under the receiver operator characteristic (ROC) curves and sensitivity analysis was performed at the optimal cut-off points for the best anthropometric measurement. Results: The area under the ROC curve suggested superior discriminative power for BW as compared to BMI or PI, as a predictor of NICU admission (ROC area = 0.73) and PH (ROC area = 0.74). The optimal BW cut-off point was 2750 g (sensitivity: 0.49; specificity: 0.89) and 2950 g (sensitivity: 0.62; specificity: 0.78) for NICU admission and PH, respectively. Conclusion: In our population of NB infants, BW – a crude measure of fetal growth – is a better predictor than either BMI – a measure of adiposity in adults and children – or PI – a measure of thinness at birth – for selected ST outcomes in NB infants.

Nearly the same expression of CD 62P antigen was found on the platelets of neonates in the vein as in the artery, in both females and males. SP-selectin concentrations in sera were elevated in the vein in comparison to the artery, higher values being noted in females than in males. The activation of platelets occurs at the time of birth. The platelets of female neonates are more activated than those of male neonates.

Aims: Maternal infections with parvovirus B19, cytomegalovirus (CMV) and enterovirus have been associated with intrauterine fetal death (IUFD), but the incidence of these infections is not clear. This prospective study was conducted to estimate this incidence. Methods: A prospective study of 38 months was conducted on cases of IUFD referred to Huddinge University Hospital, Stockholm, Sweden. Placental biopsies, fetal blood and amniotic fluid were collected from cases of IUFD (n=52). Placental biopsies from normal pregnancies at term (n=53) were used as controls. These tissues were examined for parvovirus B19 DNA, CMV DNA and enterovirus RNA using polymerase chain reaction (PCR). Maternal viral serology was measured in 46 cases and virus isolation for enterovirus in maternal stool samples was performed in 31 cases. Results: Viral nucleic acid was recovered in at least one tissue sample from six cases of fetal death (parvovirus B19 in two cases, CMV in three and enterovirus in one), while all placental biopsies from controls were found negative. Serological signs of primary maternal infection were found in two of the cases, and virus isolation for enterovirus was negative in all samples examined. Conclusion: Parvovirus B19, CMV and enterovirus may be considered as etiologic agents in cases of fetal death. PCR on placental and/or fetal tissue improves diagnostic accuracy for these infections.

Aim: To determine whether plasma endothelin-1 (ET-1) relates to clinical manifestations of sepsis in the newborn, especially with systemic hypotension, acidosis, severe hypoxemia (which may represent pulmonary hypertension) and oliguria. Methods: Prospective study of 35 consecutive newborns with clinical sepsis: 22 with hemoculture-positive (HC+) sepsis and 13 hemoculture-negative (HC–). Plasma ET-1 concentrations were measured within 2 days of the diagnosis of sepsis. SNAP-II severity score was performed at the time of highest clinical severity. Results: Newborns with HC+ sepsis had higher plasma ET-1 concentrations and SNAP-II scores (especially PO 2 /FiO 2 ratio) than HC– septic children. Plasma ET-1 concentrations increased linearly with each item of the SNAP-II score, but only reached significant differences in lowest mean blood pressure (P=0.030), lowest pH (P=0.048), multiple seizures (P=0.010) and lowest urine output (P=0.013). Leukocyte count, immature/total neutrophil ratio and C-reactive protein value were not different. Each item of the SNAP-II score was independently related only to ET-1 level. Oliguria, acidosis and systemic hypotension were more correlated (R 2 >0.5). Conclusions: Plasma ET-1 levels in neonatal sepsis are related to the severity of clinical manifestations, especially oliguria, acidosis and systemic hypotension.

Noncompaction of the left ventricular myocardium (NCLV) is an uncommon congenital cardiomyopathy with poor prognosis. We describe a case of NCLV that developed in a pregnant woman and her neonate. A nulliparous woman was referred at 24 weeks’ gestation due to dyspnea and fetal hydrops. Maternal echocardiography demonstrated NCLV with characteristic findings of prominent and excessive ventricular trabeculations and deep intertrabecular recesses in the left ventricle. An M-mode echocardiography suggested depressed left ventricular systolic function. A fetal echocardiography at 24 weeks’ gestation demonstrated cardiomegaly, but morphologic findings were not definitive for NCLV. An emergency cesarean section was performed due to maternal heart failure. A neonatal echocardiography diagnosed NCLV with depressed left ventricular systolic function. The neonate died of cardiac failure on the second day of life. Autopsy confirmed the echocardiographic findings. Since patients with NCLV may develop heart failure, multidisciplinary management is mandatory. In addition, awareness of familial occurrence of NCLV should be kept in mind for early diagnosis in the fetus and neonate.

We document the value of non-invasive fetal electrocardiography (fECG) in a case of fetal arrhythmia in which an unnecessary cesarean section was almost performed. The fetal heart rate (fHR) was 60–70 beats per minute (bpm) on the cardiotocography (CTG), with occasional, sudden fluctuations to 130 bpm. This was probably a result of the technical limitations of the CTG.

Group B Streptococcus remains a leading infectious cause of neonatal morbidity and mortality. We report a case of a 37 weeks’ gestation infant with severe birth asphyxia, status epilepticus and GBS chorioamnionitis, in which a prolonged fetal bradycardia was the only prenatal clinical sign.

In order to evaluate blood pressure- and heart rate variability as a potent diagnostic tool for different hypertensive pregnancy disorders we started a clinical trial recording these variables in early pregnancies predisposed for preeclampsia. During routine measurements one of the patients experienced a grand mal epileptic seizure. Since the parameters of both heart rate and blood pressure variability were sequentially altered immediately before the seizure, this case report provides an interesting insight into autonomic cardiovascular control in a developing convulsive fit and the pathophysiological generation of a grand mal seizure in pregnancy.

Acute myocardial infarction (AMI) during pregnancy is usually transmural and occurs in late pregnancy with a peak incidence during the peripartum or postpartum periods. We report a pregnancy-related AMI, which occurring as early as the first trimester, was treated conservatively with antithrombotic and anti-ischemic drugs both acutely and through the rest of the ultimately successful pregnancy.