- Email: [email protected]
Clinical chorioamnionitis is not predicted by umbilical artery Doppler velocimetry in patients with premature rupture of membranes
188
Citations from the Literature
TMo*
d-e
during ~egu=~
in
womell
with
primary
llYuothmidism
C%l&JC,
De Swiet M Department of Obstetrics and Gynaecology, St. Mary’s Hospital, Praed Street, London W2 IPG, GBR BR J OBSTET GYNAECOL 1992 9915 (368-370) Objective: To assess whether pregnancy changes the thyroxine requirements of hypothyroid women. Design: A retrospective, longitudinal study. Setting: Queen Charlotte’s and Chelsea Hospital for Women. Subjects: 32 women referred for antenatal care during 35 pregnancies. Main outcome measures: Changes in thyroid stimulating hormone (TSI-I) and free thyroxine (fT4) levels as pregnancy progresses. Results: In most of the pregnancies (80%), no change in thyroxine dose was required (mean dose 129 pg). The mean TSH levels in early (1.8 mu/I) and in late pregnancy (1.5 mu/I) were unchanged (P > 0.5). In the remaining pregnancies, thyroxine dose was increased after the first antenatal clinic appointment, on the basis of thyroid function test results, from a mean of 104 cg to a mean of 172 pg (P < 0.01). These women had a mean early pregnancy TSH of 12.3 mu/I, which decreased by 95% to 1.3 mu/l (P < 0.01). Conclusions: Most of the hypothyroid patients presenting to an antenatal booking clinic are well controlled in early pregnancy and will remain so throughout pregnancy. The dose of thyroxine does not need to be changed and further assessments of thyroid function should not be necessary. It is unlikely that the patients were all ‘overtreated’ before conception, since they were referred to us by a large number of independent doctors. Women who are under-treated before the pregnancy are likely to require both increased thyroxine dose and further thyroid function assays. They can generally be easily detected, biochemically, at the first hospital visit. Pmdictioo of respiratorydistress syndromeby a ww colorimetvic -Y Almog R; Goldkrand JW; Saulsberry RA; Samsonoff C Wadnvorth Cent. for Labs/Research, New York State Department of Health, P.O. Box 509, Albany, NY 12201-0509, USA AM J OBSTET GYNECOL 1992 166/6 I (1827-1834) Objective: The purpose of this study was to evaluate the clinical performance of a new, simple and rapid calorimetric assay for predicting respiratory distress syndrome. Study Design: Ninety-four specimens obtained within 3 days of delivery were assayed with the new test. For 78 of these specimens, the lecithimsphingomyelin ratio was also detennined. Significant differences were calculated with x2 analysis. Cutoff points were selected by maximizing the corresponding sums of sensitivity and specificity and from receiver-operatorcharacteristic curves. Results: The specificity of the new colorimetric test was better than 89% and it yielded more than 86% correct diagnoses. Furthermore, the test had a significantly (P < 0.05) lower percentage of false-immature results than that obtained with the lecithin/sphingomyelin ratio. Moreover, the new test performed relatively well in analyses of patients between 27 weeks and 36 weeks’ gestation. Conclusion: We concluded that the new assay is reliable and that it can serve as a useful alternative to current methods for predicting respiratory distress syndrome. Int J Gynecol Obstet 40
Cboriomnnionitis A barbiier of dystocir Satin kl; Maberry MC; Leveno KJ; Sherman ML; Kline DM Department Obstetrics and Gynecology, Univ. Texas Southwestern Med. Center, 5323 Harry Hines Boulevard, Dallas, TX 752359032, USA OBSTET GYNECOL 1992 7916 (913-915) The impact of chorioamnionitis on the course of labor is controversial. Some clinicians believe the infection has stimulatory effects, whereas others suspect inhibitory influences. Two hundred sixty-six pregnancies with chorioamnionitis requiring labor stimulation with oxytocin were matched to uninfected women for maternal age, race, parity, gestational age, oxytocin dosage regimen, indication for labor stimulation, type of labor stimulation, cervical dilatation at initiation of oxytocin and time from rupture of membranes to initiation of labor stimulation. Chorioamnionitis diagnosed before oxytocin infusion was associated with shorter oxytocin initiation-to-delivery intervals (4.3 vs. 5.6 h; P = 0.04) and had no significant impact on the cesarean rate compared with matched controls. In contrast, pregnancies complicated by chorioamnionitis detected late in labor were associated with markedly longer oxytocin initiation-, to-delivery intervals (12.6 vs. 7.9 h; P < 0.0001) and a fourfold increase in cesarean for dystocia compared with matched controls (40 vs. 100/o,P c 0.0001). Thus, the impact of chorioamnionitis on the course of labor can be divided into two clinical presentations. That diagnosed before labor stimulation does not increase the use of cesarean, whereas that diagnosed after oxytocin stimulation may be a sign of abnormal labor, as it was associated with a marked increase in abdominal delivery for dystocia. clinical ehnrloamnionltis is not predictedby umbiical artery Doppler veloclmetry in patfents with prematureruptureof membrLe.0 MV, Skumick JH; Ganesh W; Adhate A; Apuzzio JJ Department Obstetrics and Gynecology, Univ. Medicine/Dentistry New Jersey, I85 South Orange Avenue, E506, Newark, NJ 07103-2757, USA OBSTET GYNECOL 1992 7916 (916-918) Chorioamnionitis substantially increases fetal and neonatal morbidity. Infants born to women with chorioamnionitis have a fourfold increase in neonatal morbidity. If this condition could be predicted before the clinical manifestation and thereby treated earlier, an improved perinatal outcome might reasonably be expected. Based on the in vitro model of bacteria-induced vasoconstriction and pulmonary hypertension noted in sheep and lambs after exposure to the spent medium of a bacterial culture, we theorized that infected amniotic fluid may produce vasospasm of umbilical and placental vessels, reduce fetal perfusion and increase perinatal asphyxia, morbidity and mortality. Umbilical vessel vasospasm may be detected by measuring the systolic-diastolic ratio (S/D) of the umbilical artery. Continuous Doppler flow studies of the umbilical artery SD were performed prospectively on 51 patients with premature rupture of membranes who were not in labor. The most recent test, done within 1 day of delivery, was compared with pregnancy outcome. Ten subjects developed clinical chorioamnionitis, of whom none had an abnormal S/D. Six of
Citations from the Literature
41 women without clinical chorioamnionitis had abnormal SIDs. These data do not support the use of Doppler measurement of the S/D as a predictor of clinical chorioamnionitis. EXect of mtion
of Partogram information 00 obstetric
Cartmill RSV, Thornton JG Institute of Epidemiology. Leeds University, 34 Hyde Terrace, Lee& LS2 9LN. GBR
LANCET 1992 339/8808 (1520- 1522) The way in which medical information is presented may affect doctor’s decision-making. We have assessed whether changing the appearance of the same information on the partogram affects clinical decisions during labor. Sixteen junior obstetricians were asked about how they would manage six hypothetical cases of difficult labor. Information was given by partogram, in which we varied either the relative scales of the x and y axes or whether the latent phase of labor had been included. Doctors were more likely to intervene and to intervene more actively if the progress of labor curve appeared flat and if the latent phase was included. The shape and point of origin of the partogram probably influence intervention rates in practice and may partly explain the low rates of cesarean section in some hospitals. Netmetal and matorm~Imorbidity in relation to the length of the wcoad~0fl8bor Saunders NSF, Paterson CM; Wadsworth J Imperial College of Science,
St. Mary’s
Hospital Medical
School, Norfolk Place, London W2 IPG, GBR
BR J OBSTET GYNAECOL 1992 99/5 (381-385) Objective: To investigate the relation between the duration of the second stage of labor and subsequent early neonatal and maternal morbidity. Design: Retrospective analysis of a regional obstetric database. Setting: 17 maternity units in the North West Thames Health Region. Subjects: Selected from 36 727 consecutive singleton deliveries in 1988. The analysis was confined to the 25 069 women delivered of an infant of at least 37 weeks gestation with a cephalic presentation following the spontaneous onset of labor. Main outcome measures: The relative risk of early maternal morbidity, postpartum hemorrhage (PPH) and postpartum infection, and neonatal morbidity, as judged by low Apgar scores or admission to the special care baby unit (SCBU), in relation to anthropomorphic characteristics (parity and birthweight), interventions (epidural analgesia, episiotomy and operative delivery), signs of fetal compromise (meconium staining of the amniotic fluid or abnormal cardiotocography (CTG)), maternal morbidity in labor (pyrexia) and the duration of the second stage of labor. Results: The duration of the second stage of labor had a significant independent association with the risk of both PPH and maternal infection after adjustment for other factors. However, there was a similar or greater risk of PPH in association with operative delivery or a birthweight greater than 4000 g. Both maternal pyrexia in labor and primiparity were associated with a greater risk of post partum maternal infection than was the duration of the second stage, although all these factors were statistically significant. In contrast, the duration of the second
189
stage was not significantly associated with the risk of a low Apgar score or admission to SCBU after adjustment for other factors. Conclusions: The duration of the second stage of labor has a positive independent association with early maternal morbidity. We could show no such relation between time spent in the second stage of labor and the frequency of low Apgar scores or the rate of admission to SCBU. With current management approaches, in the absence of factors suggesting fetal compromise, second stage labors of up to 3 h duration do not seem to carry undue risk to the fetus. A radomhd pmapedve sludy comparing delivery with metal aoMkooerpbberv~extractorcnpp Chenoy R; Johanson R LIudley Road Hospital, Birmingham 818 7QH. GBR BR J OBSTET GYNAECOL 1992 99/5 (360-363) Objective: To determine the relative benefits and complications of assisted vaginal delivery with metal and silicone rubber vacuum extractor cups. Design: Prospective randomized controlled study. Setting: A busy referral maternity hospital in Kathmandu, Nepal. Subjects: 101 women were assigned to delivery with the Silt-cup and 98 to delivery with the metal cup. Main outcome measures: Success rate at achieving delivery with the assigned instrument and incidence of neonatal trauma. Analysis was by ‘intention to deliver’ with women remaining in their original group regardless of the eventual mode of delivery. Results: Randomization resulted in two groups of women similar in respect of age, parity, gestation and indication for delivery. The overall success rate was similar for the two instruments (Silt-cup 85% and metal cup 87%). The Silt-cup was more likely to fail if there was excessive caput (seven failures compared with one in the metal cup group). The frequency of clinically significant maternal trauma was low in both groups. There were fewer babies with clinically significant scalp trauma in the Silt-cup group (22%), compared with the metal cup group (37%). Conclusions: The data indicate a greater tendency for the S&cup to fail when excessive caput is present but that metal cups are associated with increased scalp injuries. Braehhl pbxns palsy: An old problem revisited Jennett RJ; Tarby TJ; Kreinick CJ 2425 East Harvard St., Phoenix, AZ 85008, USA AM J OBSTET GYNECOL 1992 166/6 1(1673-1677) Objectives: It is an almost universal assumption in obstetric literature that bra&al palsy is due to extreme lateral traction on the fetal head during the last phase of delivery. In contrast, there have been reports in the neurologic literature of probable intrauterine origin of brachial plexus palsy. Data to dispute or support the latter view were sought. Study Design: With this overview in mind, our perinatal data base was searched for all instances of shoulder dystocia and independently for all diagnoses of brachial plexus impairment. Results: Seventeen instances of brachial plexus impairment associated with shoulder dystocia were found. Twenty-two instances of brachial plexus impairment without mention of shoulder dystocia were ascertained. The characteristics of the two groups were remarkably different, especially in birth weight and in maternal age and parity. Conclusions: The data are strongly suggestive that inInt J Gynecol Obstet 40
Citations from the Literature
TMo*
d-e
during ~egu=~
in
womell
with
primary
llYuothmidism
C%l&JC,
De Swiet M Department of Obstetrics and Gynaecology, St. Mary’s Hospital, Praed Street, London W2 IPG, GBR BR J OBSTET GYNAECOL 1992 9915 (368-370) Objective: To assess whether pregnancy changes the thyroxine requirements of hypothyroid women. Design: A retrospective, longitudinal study. Setting: Queen Charlotte’s and Chelsea Hospital for Women. Subjects: 32 women referred for antenatal care during 35 pregnancies. Main outcome measures: Changes in thyroid stimulating hormone (TSI-I) and free thyroxine (fT4) levels as pregnancy progresses. Results: In most of the pregnancies (80%), no change in thyroxine dose was required (mean dose 129 pg). The mean TSH levels in early (1.8 mu/I) and in late pregnancy (1.5 mu/I) were unchanged (P > 0.5). In the remaining pregnancies, thyroxine dose was increased after the first antenatal clinic appointment, on the basis of thyroid function test results, from a mean of 104 cg to a mean of 172 pg (P < 0.01). These women had a mean early pregnancy TSH of 12.3 mu/I, which decreased by 95% to 1.3 mu/l (P < 0.01). Conclusions: Most of the hypothyroid patients presenting to an antenatal booking clinic are well controlled in early pregnancy and will remain so throughout pregnancy. The dose of thyroxine does not need to be changed and further assessments of thyroid function should not be necessary. It is unlikely that the patients were all ‘overtreated’ before conception, since they were referred to us by a large number of independent doctors. Women who are under-treated before the pregnancy are likely to require both increased thyroxine dose and further thyroid function assays. They can generally be easily detected, biochemically, at the first hospital visit. Pmdictioo of respiratorydistress syndromeby a ww colorimetvic -Y Almog R; Goldkrand JW; Saulsberry RA; Samsonoff C Wadnvorth Cent. for Labs/Research, New York State Department of Health, P.O. Box 509, Albany, NY 12201-0509, USA AM J OBSTET GYNECOL 1992 166/6 I (1827-1834) Objective: The purpose of this study was to evaluate the clinical performance of a new, simple and rapid calorimetric assay for predicting respiratory distress syndrome. Study Design: Ninety-four specimens obtained within 3 days of delivery were assayed with the new test. For 78 of these specimens, the lecithimsphingomyelin ratio was also detennined. Significant differences were calculated with x2 analysis. Cutoff points were selected by maximizing the corresponding sums of sensitivity and specificity and from receiver-operatorcharacteristic curves. Results: The specificity of the new colorimetric test was better than 89% and it yielded more than 86% correct diagnoses. Furthermore, the test had a significantly (P < 0.05) lower percentage of false-immature results than that obtained with the lecithin/sphingomyelin ratio. Moreover, the new test performed relatively well in analyses of patients between 27 weeks and 36 weeks’ gestation. Conclusion: We concluded that the new assay is reliable and that it can serve as a useful alternative to current methods for predicting respiratory distress syndrome. Int J Gynecol Obstet 40
Cboriomnnionitis A barbiier of dystocir Satin kl; Maberry MC; Leveno KJ; Sherman ML; Kline DM Department Obstetrics and Gynecology, Univ. Texas Southwestern Med. Center, 5323 Harry Hines Boulevard, Dallas, TX 752359032, USA OBSTET GYNECOL 1992 7916 (913-915) The impact of chorioamnionitis on the course of labor is controversial. Some clinicians believe the infection has stimulatory effects, whereas others suspect inhibitory influences. Two hundred sixty-six pregnancies with chorioamnionitis requiring labor stimulation with oxytocin were matched to uninfected women for maternal age, race, parity, gestational age, oxytocin dosage regimen, indication for labor stimulation, type of labor stimulation, cervical dilatation at initiation of oxytocin and time from rupture of membranes to initiation of labor stimulation. Chorioamnionitis diagnosed before oxytocin infusion was associated with shorter oxytocin initiation-to-delivery intervals (4.3 vs. 5.6 h; P = 0.04) and had no significant impact on the cesarean rate compared with matched controls. In contrast, pregnancies complicated by chorioamnionitis detected late in labor were associated with markedly longer oxytocin initiation-, to-delivery intervals (12.6 vs. 7.9 h; P < 0.0001) and a fourfold increase in cesarean for dystocia compared with matched controls (40 vs. 100/o,P c 0.0001). Thus, the impact of chorioamnionitis on the course of labor can be divided into two clinical presentations. That diagnosed before labor stimulation does not increase the use of cesarean, whereas that diagnosed after oxytocin stimulation may be a sign of abnormal labor, as it was associated with a marked increase in abdominal delivery for dystocia. clinical ehnrloamnionltis is not predictedby umbiical artery Doppler veloclmetry in patfents with prematureruptureof membrLe.0 MV, Skumick JH; Ganesh W; Adhate A; Apuzzio JJ Department Obstetrics and Gynecology, Univ. Medicine/Dentistry New Jersey, I85 South Orange Avenue, E506, Newark, NJ 07103-2757, USA OBSTET GYNECOL 1992 7916 (916-918) Chorioamnionitis substantially increases fetal and neonatal morbidity. Infants born to women with chorioamnionitis have a fourfold increase in neonatal morbidity. If this condition could be predicted before the clinical manifestation and thereby treated earlier, an improved perinatal outcome might reasonably be expected. Based on the in vitro model of bacteria-induced vasoconstriction and pulmonary hypertension noted in sheep and lambs after exposure to the spent medium of a bacterial culture, we theorized that infected amniotic fluid may produce vasospasm of umbilical and placental vessels, reduce fetal perfusion and increase perinatal asphyxia, morbidity and mortality. Umbilical vessel vasospasm may be detected by measuring the systolic-diastolic ratio (S/D) of the umbilical artery. Continuous Doppler flow studies of the umbilical artery SD were performed prospectively on 51 patients with premature rupture of membranes who were not in labor. The most recent test, done within 1 day of delivery, was compared with pregnancy outcome. Ten subjects developed clinical chorioamnionitis, of whom none had an abnormal S/D. Six of
Citations from the Literature
41 women without clinical chorioamnionitis had abnormal SIDs. These data do not support the use of Doppler measurement of the S/D as a predictor of clinical chorioamnionitis. EXect of mtion
of Partogram information 00 obstetric
Cartmill RSV, Thornton JG Institute of Epidemiology. Leeds University, 34 Hyde Terrace, Lee& LS2 9LN. GBR
LANCET 1992 339/8808 (1520- 1522) The way in which medical information is presented may affect doctor’s decision-making. We have assessed whether changing the appearance of the same information on the partogram affects clinical decisions during labor. Sixteen junior obstetricians were asked about how they would manage six hypothetical cases of difficult labor. Information was given by partogram, in which we varied either the relative scales of the x and y axes or whether the latent phase of labor had been included. Doctors were more likely to intervene and to intervene more actively if the progress of labor curve appeared flat and if the latent phase was included. The shape and point of origin of the partogram probably influence intervention rates in practice and may partly explain the low rates of cesarean section in some hospitals. Netmetal and matorm~Imorbidity in relation to the length of the wcoad~0fl8bor Saunders NSF, Paterson CM; Wadsworth J Imperial College of Science,
St. Mary’s
Hospital Medical
School, Norfolk Place, London W2 IPG, GBR
BR J OBSTET GYNAECOL 1992 99/5 (381-385) Objective: To investigate the relation between the duration of the second stage of labor and subsequent early neonatal and maternal morbidity. Design: Retrospective analysis of a regional obstetric database. Setting: 17 maternity units in the North West Thames Health Region. Subjects: Selected from 36 727 consecutive singleton deliveries in 1988. The analysis was confined to the 25 069 women delivered of an infant of at least 37 weeks gestation with a cephalic presentation following the spontaneous onset of labor. Main outcome measures: The relative risk of early maternal morbidity, postpartum hemorrhage (PPH) and postpartum infection, and neonatal morbidity, as judged by low Apgar scores or admission to the special care baby unit (SCBU), in relation to anthropomorphic characteristics (parity and birthweight), interventions (epidural analgesia, episiotomy and operative delivery), signs of fetal compromise (meconium staining of the amniotic fluid or abnormal cardiotocography (CTG)), maternal morbidity in labor (pyrexia) and the duration of the second stage of labor. Results: The duration of the second stage of labor had a significant independent association with the risk of both PPH and maternal infection after adjustment for other factors. However, there was a similar or greater risk of PPH in association with operative delivery or a birthweight greater than 4000 g. Both maternal pyrexia in labor and primiparity were associated with a greater risk of post partum maternal infection than was the duration of the second stage, although all these factors were statistically significant. In contrast, the duration of the second
189
stage was not significantly associated with the risk of a low Apgar score or admission to SCBU after adjustment for other factors. Conclusions: The duration of the second stage of labor has a positive independent association with early maternal morbidity. We could show no such relation between time spent in the second stage of labor and the frequency of low Apgar scores or the rate of admission to SCBU. With current management approaches, in the absence of factors suggesting fetal compromise, second stage labors of up to 3 h duration do not seem to carry undue risk to the fetus. A radomhd pmapedve sludy comparing delivery with metal aoMkooerpbberv~extractorcnpp Chenoy R; Johanson R LIudley Road Hospital, Birmingham 818 7QH. GBR BR J OBSTET GYNAECOL 1992 99/5 (360-363) Objective: To determine the relative benefits and complications of assisted vaginal delivery with metal and silicone rubber vacuum extractor cups. Design: Prospective randomized controlled study. Setting: A busy referral maternity hospital in Kathmandu, Nepal. Subjects: 101 women were assigned to delivery with the Silt-cup and 98 to delivery with the metal cup. Main outcome measures: Success rate at achieving delivery with the assigned instrument and incidence of neonatal trauma. Analysis was by ‘intention to deliver’ with women remaining in their original group regardless of the eventual mode of delivery. Results: Randomization resulted in two groups of women similar in respect of age, parity, gestation and indication for delivery. The overall success rate was similar for the two instruments (Silt-cup 85% and metal cup 87%). The Silt-cup was more likely to fail if there was excessive caput (seven failures compared with one in the metal cup group). The frequency of clinically significant maternal trauma was low in both groups. There were fewer babies with clinically significant scalp trauma in the Silt-cup group (22%), compared with the metal cup group (37%). Conclusions: The data indicate a greater tendency for the S&cup to fail when excessive caput is present but that metal cups are associated with increased scalp injuries. Braehhl pbxns palsy: An old problem revisited Jennett RJ; Tarby TJ; Kreinick CJ 2425 East Harvard St., Phoenix, AZ 85008, USA AM J OBSTET GYNECOL 1992 166/6 1(1673-1677) Objectives: It is an almost universal assumption in obstetric literature that bra&al palsy is due to extreme lateral traction on the fetal head during the last phase of delivery. In contrast, there have been reports in the neurologic literature of probable intrauterine origin of brachial plexus palsy. Data to dispute or support the latter view were sought. Study Design: With this overview in mind, our perinatal data base was searched for all instances of shoulder dystocia and independently for all diagnoses of brachial plexus impairment. Results: Seventeen instances of brachial plexus impairment associated with shoulder dystocia were found. Twenty-two instances of brachial plexus impairment without mention of shoulder dystocia were ascertained. The characteristics of the two groups were remarkably different, especially in birth weight and in maternal age and parity. Conclusions: The data are strongly suggestive that inInt J Gynecol Obstet 40