Band 46, Heft 3 - Highlight: Obstetrics

Objective: To compare perinatal outcomes in different advanced maternal age groups. Patients and methods: We used a population-based data set to compare perinatal outcomes in three maternal age groups: 30–34.9, 35–39.9, and in women over 40 years. Results: Over a 10-year period there were 23,422 (25.2%) births in the 35–39.9 years group, 3987 (4.3%) in the over 40 years group, and 65,492 births (70.5%) in our reference group (30–34.9 years). A direct significant relationship was found between maternal age and BMI and between pregnancy complications such as diabetes and hypertensive disorders, whereas an inverse relationship was found between older age and nuliparity and spontaneous conceptions. Also, older mothers had a higher incidence of both types of cesareans, and more early as well as late preterm births. Perinatal mortality was similar in all groups. Conclusions: Advanced maternal age is associated with higher, gradually increasing, incidence, of adverse perinatal outcomes.

Introduction: The incidence of venous thromboembolism (VTE) after cesarean section is up to 0.6%, and the widespread use of cesarean section draws attention to this group. The dosage and duration of low-molecular-weight heparin (LMWH) prophylaxis after delivery is estimated by anamnestic risk-scales; however, the predictive potency for an individual patient’s risk can be low. Laboratory hemostasis assays are expected to solve this problem. The aim of this study was to estimate the potency of tests to reflect the coagulation state of patients receiving LMWH in the early postpartum period. Materials and methods: We conducted an observational study on 97 women undergoing cesarean section. Standard coagulation tests (Fg, APTT, prothrombin, D-dimer), an anti-Xa assay, rotation thromboelastometry and thrombodynamics/thrombodynamics-4D were performed. Coagulation assay parameters were compared in groups formed in the presence or absence of LMWH to estimate the laboratory assays’ sensitivity to anticoagulation. Results: Coagulation assays revealed hypercoagulation after delivery and a tendency toward normalization of coagulation during early postpartum. The thromboprophylaxis results revealed a higher percentage of coagulation parameters within the normal range in the LMWH group. Conclusion: This research is potentially beneficial for the application of thrombodynamics and thrombodynamics-4D in monitoring coagulation among patients with high VTE risk who receive thromboprophylaxis with heparin.

Introduction: Epidural analgesia has been considered a risk factor for labor dystocia at trial of labor after cesarean (TOLAC) and uterine rupture. We evaluated the association between exposure to epidural during TOLAC and mode of delivery and maternal-neonatal outcomes. Materials and methods: A single center retrospective study of women that consented to TOLAC within a strict protocol between 2006 and 2013. Epidural “users” were compared to “non-users”. Primary outcome was the mode of delivery: repeat in-labor cesarean or vaginal birth after cesarean (VBAC). Secondary outcomes were maternal/neonatal morbidities. Univariate/multivariate analyses for associations between epidural and mode of delivery were adjusted for significant covariates/mediators. Results: Of a total of 105,471 births registered, 9464 (9.0%) were eligible for TOLAC; 7149 (75.5%) women consented to TOLAC, among which 4081 (57.1%) had epidural analgesia. The in labor cesarean rate was significantly lower for the epidural “users” 8.7% vs. “non-users” 11.8%, P<0.0001, with a parallel increased rate of instrumental delivery. Uterine rupture rates were comparable: 0.4% and 0.29%, respectively (P=0.31). The adjusted multivariate model showed that epidural “users” were more likely to experience a VBAC, odds ratio (OR) 4.58 [3.67; 5.70]; P<0.0001 with a similar rate of adverse maternal-neonatal outcomes. Conclusion: Epidural analgesia at TOLAC may emerge as a safe and significant adjunct for VBAC.

The purpose was to evaluate the association between maternal characteristics, obstetrical interventions/complications and postpartum wound infections (WI), urinary tract infection (UTI) and endometritis. Furthermore, this study aimed to determine the time from delivery to onset of infections after discharge from the hospital. Three large Swedish Medical Health Registers were scrutinized for the period 2005–2012. A total of 582,576 women had 795,072 deliveries. Women with diagnosis codes for WIs, UTIs or endometritis, from delivery to 8 weeks postpartum, were compared to non-infected women. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated. Increasing age and body mass index (BMI) were both associated with increasing prevalence of postpartum infections. WIs were most strongly associated with cesarean section (CS) (OR 17.2; 95%CI 16.1–18.3), 3 rd and 4 th degree tears (OR 10.7%; 95%CI 9.80–11.9) and episiotomy (OR 10.2; 95%CI 8.94–11.5). Endometritis was associated with anemia (OR 3.16; 95%CI 3.01–3.31) and manual placental removal (OR 2.72; 95%CI 2.51–2.95). UTI was associated with emergency CS (OR 3.46; 95%CI 3.07–3.89) and instrumental delivery (OR 3.70; 95%CI 3.29–4.16). For women discharged from the delivery hospital the peak occurrence of UTI was 6 days postpartum, while for WIs and endometritis it was 7 days postpartum.

Objective: To describe an innovative electronically-controlled vacuum extractor (VE) in detail and to illustrate its performance characteristics, as observed in a laboratory study. Design: Thirty simulated, vacuum-assisted deliveries. Main outcome measure(s): (1) The ability to measure in real-time of the pull applied and to sound an alert, when the traction approaches the negative pressure under the cup, to prevent its detachment. (2) The recording and printing of a graphic representation of the pull applied (vacuum delivery graph). (3) The emission of a warning signal when the 15-min time limit of continuous cup application on the fetal scalp, is reached. Results: No cup detachment occurred in any of the 15 vacuum-assisted deliveries, in which traction was kept below the adhesive force of the cup [44 lb (20 kg)], except in three cases, due to loss of negative pressure. In the remaining 15 tests, in which traction was greater than the adhesive force of the cup, “pull-offs” inevitably occurred. Furthermore, upon reaching the 15-min time limit of continuous cup application on the fetal cephalic model, a warning signal was emitted, as programmed. Conclusions We demonstrated that the electronically-controlled VE, with its distinctive pull-sensing handle, performs suitably for its intended purposes. The ability of the modernized device to decrease the incidence of cup detachment, secondary to the inadvertent application of excessive traction, may result in considerable safety, medico-legal and didactic advantages.

Introduction: The aim, of this study is to describe our approach and outcomes in an outpatient anesthesia/analgesia antepartum clinic among ambulatory high-risk obstetric patients. Methods: This was a retrospective evaluation of the activity of the anesthesiology antenatal clinic from its inception in 2010 until 2016 (a 5-year period). The clinic works in collaboration with the Department of Obstetrics and Gynecology. The catchment area of the study University Affiliated Hospital attends a multiethnic population characterized by high parity. Results: There were 241 referrals over the 5 years, each of whom was discharged with a consult and a delivery management plan and 228 (95%) of which were performed as planned. Mean gestational age at consultation was 34.4 weeks (range: 20–37). There were no preconceptional consultation. No limitations regarding mode of anesthesia/analgesia was considered for 47% of the referrals. Nulliparous women accounted for 50% of the referrals and 17% were in their second pregnancy. The greatest number of referrals (30%) was for musculoskeletal conditions. No maternal death encountered. The mode of delivery was vaginal in 139 (65%) women; elective cesarean section in 44 (21%) women; and emergent cesarean section in 30 (14%) women. The neonatal outcomes were unremarkable; 210 (87%) in hospital births, 97.1% had an a 5′ Apgar score of 9. Conclusion: Our findings reveal the need for high-risk obstetric patients consult with a dedicated obstetric anesthesiologist to devise a management plan for labor and delivery that is tailored to their comorbidity and obstetric status, to ensure an optimum outcome for mother and child.

Aim: To evaluate the pregnancy outcomes of women with heart disease. Materials and methods: In this retrospective study, 383 pregnant women with cardiac diseases were examined. The cases were classified according to the World Health Organization (WHO) classification. The distribution of the cases according to class, congenital heart diseases, mean birthweight, mean gestational week at delivery, type of delivery [cesarean section (CS) or vaginal delivery], and cardivascular events (during pregnancy and puerperium) were evaluated. Results: Of the 383 patients, 25 were in Class I; 39, Class II; 255, Class II or III; 31, Class III; and 33, Class IV cardiac diseases. The neonatal birth weights were significantly lower in Class III than in Classes II, and II or III. The preterm delivery rate was higher in Class III than in the other classes. Delivery was performed by CS due to cardiac indications in the high-risk classes, however, only obstetric indications were considered in the low-risk classes. Only one case of maternal death occurred during the postpartum period, in a patient with Eisenmenger’s syndrome. Discussion: Cardiovascular diseases are an important cause of mortality and morbidity in pregnancy. The adverse impact of cardiovascular disorders on pregnancy outcomes should be the main concern during the management of these women.

Background: Trial of labor after cesarean (TOLAC) is a viable option for safe delivery. In some cases cervical ripening and subsequent labor induction is necessary. However, the commonly used prostaglandins are not licensed in this subgroup of patients and are associated with an increased risk of uterine rupture. Methods: This cohort study compares maternal and neonatal outcomes of TOLAC in women (n=82) requiring cervical ripening agents (osmotic dilator vs. prostaglandins). The initial Bishop scores (BSs) were 2 (0–5) and 3 (0–5) (osmotic dilator and prostaglandin group, respectively). In this retrospective analysis, Fisher’s exact test, the Kruskal-Wallis rank sum test and Pearson’s chi-squared test were utilized. Results: Vaginal birth rate (including operative delivery) was 55% (18/33) in the osmotic dilator group vs. 51% (25/49) in the dinoprostone group (P 0.886). Between 97% and 92% (32/33 and 45/49) (100%, 100%) of neonates had an Apgar score of >8 after 1 min (5, 10 min, respectively). The time between administration of the agent and onset of labor was 36 and 17.1 h (mean, Dilapan-S ® group, dinoprostone group, respectively). Time from onset of labor to delivery was similar in both groups with 4.4 and 4.9 h (mean, Dilapan-S ® group, dinoprostone group, respectively). Patients receiving cervical ripening with Dilapan-S ® required oxytocin in 97% (32/33) of cases. Some patients presented with spontaneous onset of labor, mostly in the dinoprostone group (24/49, 49%). Amniotomy was performed in 64% and 49% (21/33 and 24/49) of cases (Dilapan-S ® group and dinoprostone group, respectively). Conclusions: This pilot study examines the application of an osmotic dilator for cervical ripening to promote vaginal delivery in women who previously delivered via cesarean section. In our experience, the osmotic dilator gives obstetricians a chance to perform induction of labor in these women.

Aim: To compare the efficacy and safety of the misoprostol vaginal insert (MVI) with an off-label use of oral misoprostol (OM). Methods: Pair-matched case-control study comparing the induction of labor with a retrievable MVI to OM. The primary outcomes were the time from induction to delivery and the cesarean section rate. Secondary outcomes included uterine tachysystole, tocolysis, fetal scalp blood testing, meconium-stained amniotic fluid, umbilical arterial pH, and Apgar score. Results: One hundred and thirty eight women ≥37/0 weeks pregnant undergoing labor induction with misoprostol were included. The mean time from application to delivery was significantly shorter and the caesarean section rate significantly higher in the MVI group (P<0.01) with an odds ratio of 2.75 (95% CI: 1.21–6.25) in favor of vaginal delivery in the OM group. The mean 5-min Apgar scores and arterial cord pH values were significantly lower in the MVI group. An arterial pH value of 7.10–7.19 was found in 26.1% and 15.9%, and a value <7.10 was found in 4.3% and 0% of MVI and OM cases, respectively. Conclusion: The MVI compared with OM significantly shortened the time from application to delivery at the expense of a higher cesarean section rate and negative effects on neonatal outcomes.

Objective: Factors influencing intraamniotic adiponectin levels and their functional significance remain incompletely elucidated. We prospectively measured adiponectin in amniotic fluid and identified its associations with maternal parameters, mediators in amniotic fluid and pregnancy outcomes. Study design: Mid-trimester amniotic fluid from 571 women was tested for adiponectin, interleukin (IL)-6, IL-8 and α-amylase by enzyme-linked immunosorbant assay (ELISA), after which clinical data were obtained. Correlations between adiponectin and clinical or laboratory variables were analyzed by the Kruskal-Wallis, Mann-Whitney and Spearman rank correlation tests. Results: As compared to median levels in 462 women with a term delivery (7.8 ng/mL), adiponectin was elevated in 14 women who subsequently developed preterm premature rupture of membranes (pPROM) (17.3 ng/mL) and 24 women with an iatrogenic preterm birth (IPTB) (13.9 ng/mL) (P=0.0003), but not in 30 women who subsequently had a spontaneous preterm birth with intact membranes (8.1 ng/mL) (P>0.05). Median adiponectin was also elevated in 13 women whose babies developed fetal growth restriction (FGR) (20.6 ng/mL) (P=0.0055) and in 22 women whose babies had respiratory distress syndrome (RDS) (23.0 ng/mL) (P<0.0001). The adiponectin concentration was positively correlated with amylase (P=0.0089) and inversely correlated with maternal body mass index (P=0.0045). Conclusion: Adiponectin is a component of mid-trimester amniotic fluid and its concentration varies with maternal body mass index and subsequent development of pPROM, IPTB, FGR and RDS.

Aim: To retrospectively statistically compare clinical and placental phenotypes of nonmacerated fetuses and live-born perinatal deaths in 3 rd trimester pregnancies. Methods: Twenty-five clinical and 47 placental phenotypes were statistically compared among 93 cases of nonmacerated (intrapartum, or recent antepartum death) 3 rd trimester fetal deaths (Group 1), 118 3 rd trimester neonatal deaths (Group 2) and 4285 cases without perinatal mortality (Group 3). Results: Sixteen clinical and placental phenotypes were statistically significantly different between Group 3 and the two groups of perinatal deaths, which included eight placental phenotypes of fetal vascular malperfusion and eight other placental phenotypes of various etiology (amnion nodosum, 2-vessel umbilical cord, villous edema, increased extracellular matrix of chorionic villi, erythroblasts in fetal blood and trophoblastic lesions of shallow placentation). Statistically significant differences between Groups 1 and 2 were scant (oligohydramnios, fetal malformations, cesarean sections, hypercoiled umbilical cord and amnion nodosum being more common in the latter, and retroplacental hematoma more common in the former). Conclusion: Placental examination in neonatal mortality shows thrombotic pathology related to umbilical cord compromise and features of shallow placental implantation that are similar to those in nonmacerated stillbirth; however, the features of placental abruption were more common in recent antepartum death, as were the features related to neonatal congenital malformations in neonatal deaths.

Purpose: To evaluate whether a trial of planned vaginal breech labor affects neurologic development in children. Methods: This is a nationwide, Finnish, population-based record linkage study. An odds ratio with 95% confidence intervals was used to estimate the relative risk that a child delivered by planned vaginal breech labor would be diagnosed with adverse neurodevelopmental outcome (cerebral palsy, epilepsy, intellectual disability, sensor neural developmental outcome, hyperactivity, speech and language problems) at the age of 4 years. The reference group were children born by planned cesarean section. Results: During a study period of 7 years, 8374 infants were delivered in breech position. Among them, 3907 (46.7%) had an attempted labor and 4467 (53.3%) infants were delivered by planned cesarean section. There were no differences in the neurodevelopmental outcome. In the planned vaginal labor group, 133 (3.4%) children had an abnormal neurodevelopmental outcome at the age of 4 years compared to 142 (3.2%) in the planned cesarean section group. Conclusion: The absolute risk of abnormal neurological outcome in breech deliveries at term was low, regardless of planned mode of birth. Planned vaginal breech labor did not increase the risk for abnormal neurological outcome compared to planned cesarean section.

Objectives: The umbilical coiling index (UCI) is one of cord parameters for foetal assessment with limited studies in our environment. With recent advances in its evaluation, its significance, pattern, abnormalities and correlates need to be defined in our parturients. Methods: The umbilical cords of 436 neonates were examined. Gross examination was done within 5 min of delivery. The UCI was defined as the number of complete coils per centimetre of cord. Normal UCI was defined as values between the 10 th and 90 th percentiles of the study population. Results: The mean umbilical cord length was 52.7±11.5 cm, mean number of coils was 10.8±5.1 and mean UCI was 0.21±0.099. The range was between 0.0 and 1.0. UCI values of 0.13 and 0.30 were 10 th and 90 th percentiles, respectively. Normal UCI was observed in 351 (80.5%) neonates, 44 (10.4%) and 41 (9.1%) had hypo- and hypercoiled cords, respectively. Congenital abnormalities occurred in the normocoiled and hypercoiled groups but was not demonstrated in the hypocoiled group. The mean value of UCI in neonates with congenital abnormalities was 0.29±0.12 (P=0.011). There was no significant statistical relationship between foetal outcome and degree of UCI. Conclusion: The UCI was not associated with adverse perinatal outcome in this study.