Volume 37, Issue 2

Aims: Recent advances in prenatal screening, including first and second trimester genetic screening as well as targeted sonography, have significantly improved the detection of trisomy 21. Therefore, several investigators have questioned the validity of recommending genetic amniocentesis to all women who are 35 years or older at delivery. Thus, we sought to investigate the risks and benefits associated with performing genetic amniocentesis in women whose sole indication for testing was advanced maternal age (AMA). Methods : A retrospective review of a Genzyme Genetics amniocentesis database (January 2006–December 2006) was performed. All specimens obtained from women of AMA as the sole indication were eligible for analysis. The amniocentesis-related potential fetal loss was calculated based on the traditional fetal loss rate of 1/200 as well as the recently published loss rate of 1/1600 procedures. Risk-benefit analysis was performed by comparing the number of trisomy 21 fetuses identified within the AMA group to the potential number of amniocentesis-related fetal losses within this group. Results : A total of 87,241 amniocentesis specimens were processed during the study period. AMA was the sole indication for genetic amniocentesis in 43,303 cases which formed the study group. In 399 (0.92%) of these cases, a trisomy 21 was identified. Assuming an amniocentesis related fetal loss rates of 1/200 or 1/1600; 217 or 27 fetal losses would have been expected, respectively. Conclusions : Our analysis suggests that the benefit of genetic amniocentesis for the sole indication of AMA far outweighs the potential amniocentesis-related fetal loss rate, regardless of the actual rate one considers.

Aims: To identify associations between reactive airway disease (RAD), eczema, and gastroesophageal reflux (GERD) and antenatal/neonatal variables. Methods: This is a retrospective observational cohort analysis of former preterm (PT) infants evaluated at the Regional Neonatal Follow-up Program in the Lower Hudson Valley Region of New York. Subjects <2 years evaluated between January 2005 and December 2007 were included. Patient demographics, antenatal factors and co-morbidities of prematurity were correlated with each medical condition. Results: A total of 727 subjects were analyzed: 12.8% had RAD, 10.5% had eczema; and 26.7% had GERD. RAD and GERD correlated inversely with gestational age. RAD was more prevalent in singletons and African Americans; GERD in Caucasians; and eczema in singletons and males. Respiratory disease in the newborn period increased the incidence of RAD and GERD. Toddlers who had RAD were likely to have eczema or GERD; no association between GERD and eczema existed. Conclusions: These three medical conditions were strongly associated. Their association may be the result of a common element developing each condition, or due to one condition exacerbating another. Respiratory problems in the newborn were strong predictors of GERD and RAD.

Objective : Chinese women have been shown to have a higher incidence of severe perineal laceration compared to other ethnic groups. We sought to test the hypothesis that this risk is related to body mass index (BMI) or to a relative fetal-maternal size disproportion as measured by the ratio of the newborn birthweight to maternal BMI (BW:BMI). Methods : A retrospective cohort study was performed using a pre-existing obstetric database. Third- and fourth-degree perineal lacerations served as the primary outcome of interest. Logistic regression was used to compare Chinese women to other ethnic groups and adjust for confounders. Results : Three thousand and eighty-five singleton vaginal deliveries were identified, with BMI data available for 2281. Chinese women had a greater risk for severe perineal laceration compared to Caucasian (OR: 3.22; 95% CI: 0.73–14.32) and Hispanic women (OR: 2.88; 95% CI: 1.92–4.30). Multivariate analysis found that newborn birth weight plays a role (OR: 1.0012; 95% CI: 1.0007–1.0016), but BMI alone did not explain the discrepancy (P=0.89). However, the BW:BMI ratio appears to be a stronger predictor of laceration rate than either variable alone (OR: 1.011; 95% CI: 1.003–1.020). Conclusion : The higher risk of severe perineal laceration in Chinese women compared to other ethnicities can be attributed, in part, to a relative fetal-maternal size disproportion.

Objective: Women with risk factors for diabetes are screened early in pregnancy. At our institution we obtain a GCT (glucose challenge test) at first prenatal visit. We sought to compare pregnancy outcomes in women who were diagnosed with GDM early in pregnancy with those diagnosed at the standard 24–28 weeks' gestation. Methods: An inner city population receiving prenatal care from August 2003 to May 2007 participated in the study. Patients were screened during the first trimester when able (group 1) or during the standard 24–28 weeks' gestation (group 2). Patient demographics, maternal and neonatal outcome data were collected and analyzed. Results: Of 340 GDM patients identified, 99 were diagnosed early and 241 at the standard time. Eighty per cent of group 2 were treated with diet alone and 20% required pharmacological therapy. Fifty per cent of group 1 were treated with diet and 45% with pharmacological therapy (P<0.001). Comparison between the early and late diagnosis groups for preterm delivery and hypertensive disorders were statistically non-significant. Cesarean delivery was 45% in group 1 and 24% in group 2. Both macrosomia (13% vs. 6%) and large-for-gestational-age (18% vs. 6%) was statistically higher in the early GTT group. Conclusion: The adverse perinatal outcome is significantly higher in the early diagnosis group despite early identification and management implying greater severity of GDM.

Aim: To examine the maternal and neonatal characteristics related to labor outcome following induction for prelabor rupture of membranes (PROM) after 37 weeks' gestation. Method: All singleton pregnancies delivered following spontaneous or induced labor after 37 weeks in four years were analyzed. Patients with labor induction for PROM comprised the study group. Outcome of labor was analyzed according to gestational age at delivery. Results: Among the 13,505 patients in the entire cohort, 1710 (12.7%) had labor induction for PROM. These women were older and heavier, were more nulliparas and had more large-for-gestational age (LGA) infants, higher rates of instrumental and cesarean deliveries, and a shorter mean gestation, but no difference in height, mean birth weight, or incidence of male infants. Multiple logistic regression analysis confirmed that labor induction was a weak but significant independent factor for cesarean delivery (aOR 1.18, 95% CI: 1.01–1.38). The rates of cesarean delivery significantly correlated with gestational age at delivery for both LGA (P<0.001) and non-LGA (P<0.001) infants, together with significantly increased birth weight. Conclusion: The results suggest that a likely explanation for the cesarean delivery following labor induction for PROM at term in our population is underlying cephalopelvic disproportion.

Early onset neonatal sepsis due to Group B streptococci (GBS) is responsible for severe morbidity and mortality of newborns. While different preventive strategies to identify women at risk are being recommended, the optimal strategy depends on the incidence of GBS-sepsis and on the prevalence of anogenital GBS colonization. We therefore aimed to assess the Group B streptococci prevalence and its consequences on different prevention strategies. We analyzed 1316 pregnant women between March 2005 and September 2006 at our institution. The prevalence of GBS colonization was determined by selective cultures of anogenital smears. The presence of risk factors was analyzed. In addition, the direct costs of screening and intrapartum antibiotic prophylaxis were estimated for different preventive strategies. The prevalence of GBS colonization was 21%. Any maternal intrapartum risk factor was present in 37%. The direct costs of different prevention strategies have been estimated as follows: risk-based: 18,500 CHF/1000 live births, screening-based: 50,110 CHF/1000 live births, combined screening- and risk-based: 43,495/1000 live births. Strategies to prevent GBS-sepsis in newborn are necessary. With our colonization prevalence of 21%, and the intrapartum risk profile of women, the screening-based approach seems to be superior as compared to a risk-based approach.

Aims: Bacterial vaginosis (BV) affects millions of women, is extremely prevalent and is frequently chronic. We recognize numerous microbiologic variations among women with BV and this variability may explain the limited effectiveness of metronidazole in curing BV and/or reducing the risk of spontaneous preterm birth (SPTB) among BV-positive pregnant women. We assessed the independent role of seven common BV-associated bacteria on the risk of spontaneous preterm birth (SPTB) among urban pregnant women. Methods: This prospective cohort study was conducted within an urban obstetrics practice at Temple University Hospital in Philadelphia, PA. Fifty pregnant women with documented singleton pregnancies between 25–36 weeks' gestation from February 2007 through June 2007 who presented to the Labor and Delivery Unit for evaluation of uterine contractions/preterm labor were enrolled. Results: We found that high median levels of Gardnerella vaginalis and low median levels of Lactobacillus crispatus were significantly predictive of SPTB. Slightly higher levels of Megasphaera-like species were also found among the group of women experiencing a SPTB during the follow-up period. Conclusions: Further identification of the individual attributable risk for separate BV-associated bacteria may be most useful in developing successful treatments to prevent SPTB among BV positive women.

Aims: To investigate whether lipopolysaccharide binding protein (LBP) level is an early marker of intraamniotic infection in pregnant women with premature rupture of the membranes (PROM) and compare it to C-reactive protein (CRP). Methods: Seventy-two pregnant women with PROM were included in the study if remained undelivered for more than 24 h. CRP and LBP concentrations were determined in 12-h-intervals and the last value before delivery was correlated with obstetrical data and placenta histology. Results: LBP concentrations ranged from 1.6 to 48.7 μg/mL (median of 16 μg/mL) and CRP concentrations from 0.02 to 6.8 mg/dL (0.64 mg/dL). CRP was significantly elevated when full blown chorioamnionitis was proven by histology (P<0.01) and when the neonates had to be admitted to the intensive care unit because of suspected infection (P<0.05 mg/dL). There were significantly higher LBP levels when fetal tachycardia occurred (20.3 vs. 14.5 μg/mL, P<0.05) and when intraamniotic infection was diagnosed by histology (22.8 vs. 14.1 μg/mL, P<0.005), but the differences were too little to provide prognostic cut-off values. Conclusion: Increase of LBP and CRP levels after PROM seem to reflect intramniotic infection, but no cut-off values could be defined for the prediction of intraamniotic infection.

Objective: Symptomatic fetal viral infection can affect placental and fetal development and may lead to non-immune hydrops or fetal death. All infections are not detectable by clinical history or ultrasound and a background positivity rate exists in asymptomatic patients. We investigated if intraamniotic presence of viral genome at the time of genetic amniocentesis in asypmtomatic patients affects perinatal outcome. Study design: Six-hundred and eighty-six pregnancies referred for second trimester genetic amniocentesis with a normal ultrasound and fetal karyotype had amniotic fluid multiplex polymerase chain reaction for adeno-, cytomegalo-, Ebstein-Barr-, entero- and parvovirus. Forty asymptomatic patients that were positive for viral genome were matched 2:1 with negative controls. Perinatal outcomes were compared between these groups. Results: Pregnancy complications and perinatal outcomes were similar in the two groups. Conclusion: Asymptomatic fetal viral infection at the time of second trimester amniocentesis does not increase the risk for adverse perinatal outcome.

Objective: To determine whether a history of terminations of pregnancy influences subsequent pregnancies in terms of pregnancy risks, prematurity and neonatal biometrics. Patients and methods: Based on the perinatal statistics of eight German federal states, data of 247,593 primiparous women with singleton pregnancies born between 1998 and 2000 were analyzed. The control group consisted of primiparous women without previous induced abortions. Maternal age was adjusted for. Results: There was an overall trend towards an increased rate of preterm delivery at ≤36 weeks' gestation and early preterm delivery at ≤31 weeks' gestation in women who had previous pregnancy terminations. For the cohort of 28–30 years, the observed rates of prematurity in women with one and with ≥2 previous induced abortions were 7.8% and 8.5%, respectively, compared to 6.5% in the control population (P=0.015). Preceding terminations of pregnancy did not alter the rate of small-for-gestational-age newborns. Psychosocial stress and symptoms associated with prematurity such as cervical incompetence and vaginal bleeding before and after 28 weeks of gestation occurred more frequently in women with previous induced abortion compared to the control group (P<0.0001). Conclusion: The rate of preterm births increases with the number of preceding abortions. Similarly, symptoms associated with prematurity are more common. The rate of small-for-gestational-age newborns was not affected by preceding terminations of pregnancy.

We devised a method to predict risk of neonatal Erb palsy using variables ascertainable before delivery. Multiple logistic regression modeling was used to construct an Erb palsy risk score from a case-control study of 45 consecutive Erb palsy cases and 90 controls. Receiver-operator characteristics identified a range of scores for which likelihood ratios were determined for calculation of predictive values across a range of prior probabilities. In the final model, large estimated fetal weight, gestational diabetes, large maternal body mass index, large weight gain, and black race were associated with 2.3–4.8 times greater odds of Erb palsy. A long second stage had a modest effect on the odds (OR=2.7, P=0.13), unless preceded by a long deceleration phase, which combination increased the odds of Erb palsy to 20.1 (P=0.001). A risk score of 0.72 had a sensitivity of 36% and a specificity of 99%. In a theoretical population with a birth prevalence of brachial plexus palsy of 2.5/1000, application of the risk score would prevent 36% of cases and result in about 14 cesareans for every nerve injury prevented. We conclude that risk scoring using multiple logistic regression coefficients of variables that can be known in time to affect decision-making about mode of delivery has the potential to guide intervention to prevent some Erb palsies.

Aims: Whether or not women with a previous cesarean section should be considered for an external cephalic version remains unclear. In our study, we sought to examine the relationship between a history of previous cesarean section and outcomes of external cephalic version for pregnancies at 36 completed weeks of gestation or more. Methods: Data on obstetrical history and on external cephalic version outcomes was obtained from the C.H.U. Sainte-Justine External Cephalic Version Database. Baseline clinical characteristics were compared among women with and without a history of previous cesarean section. We used logistic regression analysis to evaluate the effect of previous cesarean section on success of external cephalic version while adjusting for parity, maternal body mass index, gestational age, estimated fetal weight, and amniotic fluid index. Results: Over a 15-year period, 1425 external cephalic versions were attempted of which 36 (2.5%) were performed on women with a previous cesarean section. Although women with a history of previous cesarean section were more likely to be older and para >2 (38.93% vs. 15.0%), there were no difference in gestational age, estimated fetal weight, and amniotic fluid index. Women with a prior cesarean section had a success rate similar to women without [50.0% vs. 51.6%, adjusted OR: 1.31 (0.48–3.59)]. Conclusion: Women with a previous cesarean section who undergo an external cephalic version have similar success rates than do women without. Concern about procedural success in women with a previous cesarean section is unwarranted and should not deter attempting an external cephalic version.

Aim: To determine reference ranges for fetal lung volume by 3-dimensional ultrasonography using the VOCAL (Virtual Organ Computed-aided Analysis) method. Methods: A longitudinal prospective study was conducted with 61 uncomplicated pregnancies between 24 and 32 weeks of gestation. A separate measurement of both lungs volume was conducted by VOCAL with 30° rotation angle. For each gestational age, an average, standard deviation and maximal and minimal values were established in addition to the percentiles 5, 10, 25, 50, 75 and 90 for right and left lung volume. To evaluate the correlation between lung volume and gestational age, and estimated fetal weight, a polynomial regression with determination coefficient adjustment (R 2 ) was used. The intra-observer reproducibility was evaluated by the intraclass correlation coefficient (ICC), whereas the inter-observer reproducibility was evaluated by Cronbach alpha statistic test. Results: The average right lung volume varied from 12.5±0.7 cm 3 at the 24 th week to 31.8 cm 3 ±1.8 cm 3 at the 32 nd week. The average left lung volume varied from 9.2±0.9 cm 3 at the 24 th week to 22.0 cm 3 ±1.6 cm 3 at the 32 nd week. We observed a strong correlation between right lung volume and gestational age (R 2 =0.975) and estimated fetal weight (R 2 =0.905), as well as between the left lung volume with gestational age (R 2 =0.970) and estimated fetal weight (R 2 =0.908). We observed a good intra-observer reproducibility for the right lung volume (ICC=0.990) and for the left lung volume (ICC=0.986). Similarly, we observed good inter-observer reproducibility for right lung volume (0.975) and left lung volume (0.962). Conclusion: Reference range of fetal lung volume by 3D-ultrasonography using the VOCAL method was determined.

Aim: To assess linear and complex heart rate dynamics in relation to fetal gender in normal and acidemic fetuses during the minutes preceding delivery. Methods : Linear and non-linear fetal heart rate indices, namely mean FHR, long-term irregularity index, short-term variability, low and high frequency spectral indices, approximate and sample entropy, were assessed in 36 female and 30 male fetuses, adjusted for gestational age and weight, during the minutes preceding delivery. Analysis was performed in the initial and final minutes of each tracing in fetuses with umbilical artery blood pH at delivery ≥7.20, 7.11–7.19 and ≤7.10. Results: Progression of labor was associated with a significant decrease in non-linear indices and an increase in almost all linear indices, both in female and male fetuses, but changes were more marked in female fetuses. Non-acidemic females showed higher mean FHR in the final minutes of labor, compared with males. Acidemic females had higher linear indices when compared to similar male fetuses. Conclusions: During the minutes preceding delivery, female fetuses express higher linear indices than male fetuses, suggesting greater activation of the autonomic nervous system, while maintaining similar complexity indices, which suggests different reaction and adaptation capabilities to stress and distress.

Background: The 2 nd born in twin delivery is at higher risk of fetal asphyxia. We tested the hypothesis that inadequate, fetal heart rate (FHR) monitoring has contributed to an inadvertent outcome. Study design: A database was reviewed consisting of 41 twin deliveries with a pH in the umbilical artery of the 2 nd twin below 7.05. Cardiotocograms were examined for possible signs of a maternal instead of a fetal origin of the heart rate pattern. Results: In four of the reviewed cases, a good outcome had been anticipated by the attending physician based on the cardiotocogram, whereas the 2 nd twin was born with low Apgar scores and a low pH of the umbilical artery. In retrospect it was concluded that the recorded heart rate pattern was of maternal origin. In all four cases the heart rate tracings had characteristics typical for a maternal origin. Conclusion: Misidentifying the maternal for the fetal heart rate increases the risk that a compromised fetal condition is missed. This occurrence may contribute to the increased incidence of fetal asphyxia in 2 nd twins.

Background : Hypothermia is a major contributor to early neonatal deaths especially in the developing world. Factors which predispose babies to hypothermia need to be identified for intervention purposes. Objectives : To determine the prevalence and risk factors for neonatal hypothermia at admission in the first 72 h of life. Methods : Babies hospitalized within the first 72 h of life in a Nigerian Neonatal Unit were surveyed. Data collected included age, sex, weight, place of delivery, history of breastfeeding, recent bath, oil cleansing of the skin and presence of asphyxia. Babies with skin (axillary) temperature <36.5°C were considered hypothermic. Results : Of the 111 babies, 75 (67.6%) were hypothermic. The prevalence of hypothermia was high among babies aged <6 h (80.6%), preterm infants (88.9%), low-birth-weight babies (89.1%), babies with birth asphyxia (76.3%), babies without recent oiling of the skin (90.6%) and babies who had not been breastfed (79.2%). Using logistic regression, significant risk factors for early neonatal hypothermia at admission included low-birth-weight (P=0.000) and lack of breastfeeding (P=0.028). Conclusion : Most of the identified risk factors are preventable. The warm chain should be strictly applied in-hospital and be taught to mothers and community health workers.

Aim: Duration of breastfeeding, socio-demographic and psychosocial characteristics of the mothers attending breastfeeding support groups were investigated. Methods: All examined mothers were cared for according to the Baby Friendly Hospital Initiative (BFHI) of the World Health Organization (WHO) and UNICEF. The investigated group of mothers attended a breastfeeding support group (BSG) led by a community nurse and women experienced in breastfeeding without additional training. Data on breastfeeding duration were collected retrospectively by self-reported questionnaire. Results: Of 980 eligible, 393 mothers were included to the study: 210 attended BSG, while 183 did not. The following differences between the two groups were found: time when the decision to breastfeed was made, smoking during lactation and social support while breastfeeding. More mothers in the investigated group continued breastfeeding at least six months postnatal (83.8% vs. 48.1%, P<0.001), with exclusive breastfeeding until the age of three months (56% vs. 23.5%, P<0.001). After logistic regression analysis, the following factors were found to be positively associated with the duration of breastfeeding for at least six months: time when the decision to breastfeed was made, intended duration of breastfeeding and household income. Maternal smoking during pregnancy affected duration of breastfeeding inversely. Conclusion: Characteristics which positively influenced the duration of breastfeeding are the time when the decision to breastfeed was made, intended duration of breastfeeding, household income, and smoking during pregnancy. Mothers who attended BSG more often continued breastfeeding for at least six months if they decided to breastfeed after birth, intended to breastfeed for longer than six months, had higher monthly household income and did not smoke during pregnancy.

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No Abstract available