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Home uterine activity monitoring in the care of preterm labor: a review of the evidence
Uterine Rupture: A Placentally Mediated Event? Irma Jauregui Childbirth Injury Prevention Foundation, Pasadena, CA
C. Kirkendall, M. O. Ahn, and J. Phelan Objective: After previously demonstrating that uterine activity patterns and oxytocin did not appear to be associated with uterine rupture, our objective was to determine whether the placenta plays a role in uterine rupture. Study design: From a national registry of brain-injured neonates, cases were obtained from patients with a uterine rupture sufficient to produce fetal brain injury or death. Through retrospective chart review, the placental implantation site was determined, and its relationship to the site of uterine rupture was recorded. Exclusion criteria were as follows: no record of placental location—13, the uterine rupture site—3, or the intactness of placenta—3. Results: Of 81 uterine rupture cases resulting in fetal brain injury, 62 (77%) cases met entry criteria. Of these 62, the site of the uterine rupture was at the prior incision— 42 (68%) or at a nonscar site—17 (27%), and 3 (5%) had no prior incision. Of these, the placenta was found at the rupture site in 37 (60%). In the 25 (40%) in whom the placenta was not found at the rupture site, 21 (84%) experienced a partial or complete placental abruption. Conclusions: Uterine rupture in the patient with prior cesarean delivery is not always associated with the prior uterine incision. Of those patients who experienced a uterine rupture, the placenta appears to have been at the uterine rupture site and/or partially or completely abrupted. These findings suggest that the placenta may play a role in uterine rupture.
Intrapartum Fetal Heart Rate Variability and Subsequent Neonatal Cerebral Edema Joo Oh Kim, MD Childbirth Injury Prevention Foundation, Pasadena, CA
G. Martin, C. Kirkendall, and J. Phelan Objective: To determine whether fetal heart rate variability (FHRV) in the neurologically impaired neonate is associated with cerebral edema. Study design: Through retrospective chart review, singleton term infants with neonatal encephalopathy and permanent neurologic impairment were identified in a national registry of brain-injured infants. Cerebral edema was defined as follows: (1) ultrasound-generalized increases in echodensity throughout the brain with loss of normal landmarks or slitlike ventricles, (2) computed tomography scan-low attenuation throughout the brain, or mass effect as evidenced by sulcal
VOL. 95, NO. 4 (SUPPLEMENT), APRIL 2000
effacement, displacement of the midline structures, ventricular distortion, or compression of subarachnoid spaces, and (3) low magnetic resonance imaging signal on T1-weighted images and high signal on T2-weighted images or morphologic change on T1-weighted image detected by gross enlargement of structures or by distortion of normal adjacent structures. Cases with a Hon intrapartum fetal heart rate (FHR) pattern (reactive pattern on admission followed by tachycardia and repetitive FHR decelerations) were selected. These cases were then categorized according to the FHR variability at the end of the monitor strip as follows: average ⱖ6 bpm or diminished (D) ⬍6 bpm. Exclusion criteria were as follows: (1) nonqualifying FHR pattern—183; (2) no neuroimaging studies within 7 days of birth— 48; (3) insufficient data—19; and (4) other—7. Results: Of 300 singleton term brain-injured neonates, 43 (14%) neonates met entry criteria. Prior to birth, the FHRV average was 10 (23%) or diminished (33 [77%]). Of these infants, cerebral edema was found in 18 (42%) patients. But, average FHRV was associated with significantly less cerebral edema (average 1/10 [10%] versus diminished 17/33 [52%] [P ⫽ 0.02]). Conclusions: In brain-injured neonates, cerebral edema appears to be associated with the Hon FHR pattern. Cerebral edema also appears to be associated with diminished FHRV. These findings suggest that the presence of average FHRV in the fetus with the Hon FHR pattern is associated with fetal brain injury, but not necessarily neonatal cerebral edema.
Home Uterine Activity Monitoring in the Care of Preterm Labor: A Review of the Evidence Melissa McPheeters, MPH Research Triangle Institute–University of North Carolina Evidence-Based Practice Center, Chapel Hill, NC
John M. Thorp, MD, Norma I. Gavin, PhD, Victor Hasselblad, PhD, Nancy D. Berkman, PhD, Kathleen N. Lohr, PhD, and Katherine E. Hartmann, MD, PhD Objective: Preterm labor (PTL) that results in cervical change and spontaneous preterm birth requires organized forceful uterine contractions. Home uterine activity monitoring (HUAM) detects increases in activity and facilitates intervention. We sought to summarize randomized trials comparing pregnancy outcomes of women who did and did not receive HUAM. Methods: We worked as part of the AHCPR Evidence Report on the Management of Preterm Labor and restricted our search to randomized trials of HUAM among women who had experienced PTL in the pregnancy for which they were receiving monitoring. With ACOG and an advisory group, we developed search criteria. We did an exhaustive literature search, including the gray literature, for articles in English from 1980 to 1998. The initial search identified 37 studies; after review (masked to author and journal), 4 studies met inclusion criteria.
Wednesday Posters 75S
Results: This is a systematic review of HUAM for the care of women with a history of PTL in the current pregnancy. We will report the results examining the outcomes of gestational age at delivery, infant birth weight, and term birth. Conclusions: We will present the conclusions and recommendations of the project team.
Delayed Interval Delivery in Multifetal Pregnancies in the Second Trimester: Maternal and Neonatal Outcomes Matthew Hoffman, MD, MPH Christiana Hospital, Newark, DE
S. Walker, M. Pollock, and A. Sciscione Objective: A short latency period (mean ⫽ 1.1 days) and poor neonatal outcomes make the management of multifetal pregnancies who present in the second trimester with rupture of the membranes a difficult problem. Recent reports of attempting delayed interval delivery with antibiotics or tocolysis, with or without cerclage, have been encouraging. We describe our experience over the last 7 years. Study design: We reviewed our database for all patients who had a multifetal pregnancy in the second trimester with rupture of the membranes and were offered an attempt at delayed interval delivery. All women were counseled about the potential risks and benefits of this management and offered cervical cerclage. We compared the neonatal outcomes between the delivered fetus and the remaining fetuses. We also reviewed the charts for maternal outcomes. Fisher’s exact and Mann Whitney U tests were used where appropriate. Results: There were 10 women who attempted delayed interval delivery in the second trimester. There were six twin and four triplet pregnancies. All women received aggressive tocolysis and antibiotic therapy immediately after delivery of the presenting fetus. Four women opted for cerclage placement. The mean gestational age at delivery of the presenting fetus was 23.3 weeks versus 25.5 weeks for the remaining fetuses (P ⫽ 0.14), with a birth weight of 630 g for the presenting fetus versus 885 g in the remaining fetuses (P ⫽ 0.07). The mean prolongation of pregnancy was 16 days (range, 1– 46 days; mode, 9.5 days). There was a 30% survival in the delivered fetus versus 60% in the remaining fetuses (P ⫽ 0.37). There was no difference in delay in delivery between those patients who received a cerclage and those who did not (13.8 versus 17.5 days; P ⫽ 0.83). There was significant maternal morbidity in five cases. Four cases had endomyometritis and one case had Gram-negative sepsis, adult respiratory distress syndrome, and renal failure. Conclusions: Offering women delayed interval delivery who have a multifetal pregnancy in the second trimester with rupture of the membranes continues to be a reasonable option. Nonetheless, given our experience, patients must be counseled regarding the potential for serious infectious morbidity.
76S Wednesday Posters
Oral Misoprostol Versus Intravaginal Prostaglandin E2 for Preinduction Cervical Ripening: A Randomized Trial Joseph Browning, MD Portsmouth Naval Hospital, Portsmouth, VA
Robert B. Gherman, MD Objective: To compare orally administered misoprostol with intravaginal prostaglandin E2 (dinoprostone vaginal suppository) for cervical ripening and labor induction. Methods: Patients presenting with medical or obstetric indications for labor induction whose Bishop score was 6 or less were randomly allocated to receive either 50 g of oral misoprostol or 4 mg of dinoprostone. If adequate cervical ripening or active labor did not ensue, repeat doses of each medication were administered every 4 hours. A maximum of six doses of either oral misoprostol or dinoprostone was permitted; intravenous oxytocin was subsequently administered. Results: Among the 60 enrolled patients, the mean interval from start of induction to delivery was similar between the misoprostol and dinoprostone groups (1,495 ⫾ 119 versus 1,692 ⫾ 242 minutes, P ⫽ 0.47). Vaginal delivery occurred within 24 hours in 46% of those administered oral misoprostol, compared with 37% of those who received dinoprostone (P ⫽ 0.5). A similar number of medication doses was administered in each group (2.6 ⫾ 0.3 for misoprostol, 2.9 ⫾ 0.3 for dinoprostone; P ⫽ 0.4). No statistically significant differences existed between the two groups with respect to tachysystole, uterine hyperstimulation, or fetal heart rate changes. Conclusions: Oral administration of misoprostol is an effective alternative to intravaginal prostaglandin E2 for preinduction cervical ripening.
Decreased Birth Weight/Placenta Ratio and Asymmetric Growth Restriction Mark C. Williams, MD University of South Florida, Tampa, FL
David Gore, MD, and William F. O’Brien, MD Background: Asymmetric intrauterine growth restriction (AsymIUGR) in normal birth weight (BW) infants is associated with increased perinatal morbidity, but without documented length or head circumference it cannot be assessed. Objective: To evaluate the association between decreased BW/placenta ratio and markers of AsymIUGR in normal BW, term infants. Method: There were 34,568 singleton, nonanomalous infants born at 36 – 44 weeks with BW equal to or exceeding the 10th
Obstetrics & Gynecology
C. Kirkendall, M. O. Ahn, and J. Phelan Objective: After previously demonstrating that uterine activity patterns and oxytocin did not appear to be associated with uterine rupture, our objective was to determine whether the placenta plays a role in uterine rupture. Study design: From a national registry of brain-injured neonates, cases were obtained from patients with a uterine rupture sufficient to produce fetal brain injury or death. Through retrospective chart review, the placental implantation site was determined, and its relationship to the site of uterine rupture was recorded. Exclusion criteria were as follows: no record of placental location—13, the uterine rupture site—3, or the intactness of placenta—3. Results: Of 81 uterine rupture cases resulting in fetal brain injury, 62 (77%) cases met entry criteria. Of these 62, the site of the uterine rupture was at the prior incision— 42 (68%) or at a nonscar site—17 (27%), and 3 (5%) had no prior incision. Of these, the placenta was found at the rupture site in 37 (60%). In the 25 (40%) in whom the placenta was not found at the rupture site, 21 (84%) experienced a partial or complete placental abruption. Conclusions: Uterine rupture in the patient with prior cesarean delivery is not always associated with the prior uterine incision. Of those patients who experienced a uterine rupture, the placenta appears to have been at the uterine rupture site and/or partially or completely abrupted. These findings suggest that the placenta may play a role in uterine rupture.
Intrapartum Fetal Heart Rate Variability and Subsequent Neonatal Cerebral Edema Joo Oh Kim, MD Childbirth Injury Prevention Foundation, Pasadena, CA
G. Martin, C. Kirkendall, and J. Phelan Objective: To determine whether fetal heart rate variability (FHRV) in the neurologically impaired neonate is associated with cerebral edema. Study design: Through retrospective chart review, singleton term infants with neonatal encephalopathy and permanent neurologic impairment were identified in a national registry of brain-injured infants. Cerebral edema was defined as follows: (1) ultrasound-generalized increases in echodensity throughout the brain with loss of normal landmarks or slitlike ventricles, (2) computed tomography scan-low attenuation throughout the brain, or mass effect as evidenced by sulcal
VOL. 95, NO. 4 (SUPPLEMENT), APRIL 2000
effacement, displacement of the midline structures, ventricular distortion, or compression of subarachnoid spaces, and (3) low magnetic resonance imaging signal on T1-weighted images and high signal on T2-weighted images or morphologic change on T1-weighted image detected by gross enlargement of structures or by distortion of normal adjacent structures. Cases with a Hon intrapartum fetal heart rate (FHR) pattern (reactive pattern on admission followed by tachycardia and repetitive FHR decelerations) were selected. These cases were then categorized according to the FHR variability at the end of the monitor strip as follows: average ⱖ6 bpm or diminished (D) ⬍6 bpm. Exclusion criteria were as follows: (1) nonqualifying FHR pattern—183; (2) no neuroimaging studies within 7 days of birth— 48; (3) insufficient data—19; and (4) other—7. Results: Of 300 singleton term brain-injured neonates, 43 (14%) neonates met entry criteria. Prior to birth, the FHRV average was 10 (23%) or diminished (33 [77%]). Of these infants, cerebral edema was found in 18 (42%) patients. But, average FHRV was associated with significantly less cerebral edema (average 1/10 [10%] versus diminished 17/33 [52%] [P ⫽ 0.02]). Conclusions: In brain-injured neonates, cerebral edema appears to be associated with the Hon FHR pattern. Cerebral edema also appears to be associated with diminished FHRV. These findings suggest that the presence of average FHRV in the fetus with the Hon FHR pattern is associated with fetal brain injury, but not necessarily neonatal cerebral edema.
Home Uterine Activity Monitoring in the Care of Preterm Labor: A Review of the Evidence Melissa McPheeters, MPH Research Triangle Institute–University of North Carolina Evidence-Based Practice Center, Chapel Hill, NC
John M. Thorp, MD, Norma I. Gavin, PhD, Victor Hasselblad, PhD, Nancy D. Berkman, PhD, Kathleen N. Lohr, PhD, and Katherine E. Hartmann, MD, PhD Objective: Preterm labor (PTL) that results in cervical change and spontaneous preterm birth requires organized forceful uterine contractions. Home uterine activity monitoring (HUAM) detects increases in activity and facilitates intervention. We sought to summarize randomized trials comparing pregnancy outcomes of women who did and did not receive HUAM. Methods: We worked as part of the AHCPR Evidence Report on the Management of Preterm Labor and restricted our search to randomized trials of HUAM among women who had experienced PTL in the pregnancy for which they were receiving monitoring. With ACOG and an advisory group, we developed search criteria. We did an exhaustive literature search, including the gray literature, for articles in English from 1980 to 1998. The initial search identified 37 studies; after review (masked to author and journal), 4 studies met inclusion criteria.
Wednesday Posters 75S
Results: This is a systematic review of HUAM for the care of women with a history of PTL in the current pregnancy. We will report the results examining the outcomes of gestational age at delivery, infant birth weight, and term birth. Conclusions: We will present the conclusions and recommendations of the project team.
Delayed Interval Delivery in Multifetal Pregnancies in the Second Trimester: Maternal and Neonatal Outcomes Matthew Hoffman, MD, MPH Christiana Hospital, Newark, DE
S. Walker, M. Pollock, and A. Sciscione Objective: A short latency period (mean ⫽ 1.1 days) and poor neonatal outcomes make the management of multifetal pregnancies who present in the second trimester with rupture of the membranes a difficult problem. Recent reports of attempting delayed interval delivery with antibiotics or tocolysis, with or without cerclage, have been encouraging. We describe our experience over the last 7 years. Study design: We reviewed our database for all patients who had a multifetal pregnancy in the second trimester with rupture of the membranes and were offered an attempt at delayed interval delivery. All women were counseled about the potential risks and benefits of this management and offered cervical cerclage. We compared the neonatal outcomes between the delivered fetus and the remaining fetuses. We also reviewed the charts for maternal outcomes. Fisher’s exact and Mann Whitney U tests were used where appropriate. Results: There were 10 women who attempted delayed interval delivery in the second trimester. There were six twin and four triplet pregnancies. All women received aggressive tocolysis and antibiotic therapy immediately after delivery of the presenting fetus. Four women opted for cerclage placement. The mean gestational age at delivery of the presenting fetus was 23.3 weeks versus 25.5 weeks for the remaining fetuses (P ⫽ 0.14), with a birth weight of 630 g for the presenting fetus versus 885 g in the remaining fetuses (P ⫽ 0.07). The mean prolongation of pregnancy was 16 days (range, 1– 46 days; mode, 9.5 days). There was a 30% survival in the delivered fetus versus 60% in the remaining fetuses (P ⫽ 0.37). There was no difference in delay in delivery between those patients who received a cerclage and those who did not (13.8 versus 17.5 days; P ⫽ 0.83). There was significant maternal morbidity in five cases. Four cases had endomyometritis and one case had Gram-negative sepsis, adult respiratory distress syndrome, and renal failure. Conclusions: Offering women delayed interval delivery who have a multifetal pregnancy in the second trimester with rupture of the membranes continues to be a reasonable option. Nonetheless, given our experience, patients must be counseled regarding the potential for serious infectious morbidity.
76S Wednesday Posters
Oral Misoprostol Versus Intravaginal Prostaglandin E2 for Preinduction Cervical Ripening: A Randomized Trial Joseph Browning, MD Portsmouth Naval Hospital, Portsmouth, VA
Robert B. Gherman, MD Objective: To compare orally administered misoprostol with intravaginal prostaglandin E2 (dinoprostone vaginal suppository) for cervical ripening and labor induction. Methods: Patients presenting with medical or obstetric indications for labor induction whose Bishop score was 6 or less were randomly allocated to receive either 50 g of oral misoprostol or 4 mg of dinoprostone. If adequate cervical ripening or active labor did not ensue, repeat doses of each medication were administered every 4 hours. A maximum of six doses of either oral misoprostol or dinoprostone was permitted; intravenous oxytocin was subsequently administered. Results: Among the 60 enrolled patients, the mean interval from start of induction to delivery was similar between the misoprostol and dinoprostone groups (1,495 ⫾ 119 versus 1,692 ⫾ 242 minutes, P ⫽ 0.47). Vaginal delivery occurred within 24 hours in 46% of those administered oral misoprostol, compared with 37% of those who received dinoprostone (P ⫽ 0.5). A similar number of medication doses was administered in each group (2.6 ⫾ 0.3 for misoprostol, 2.9 ⫾ 0.3 for dinoprostone; P ⫽ 0.4). No statistically significant differences existed between the two groups with respect to tachysystole, uterine hyperstimulation, or fetal heart rate changes. Conclusions: Oral administration of misoprostol is an effective alternative to intravaginal prostaglandin E2 for preinduction cervical ripening.
Decreased Birth Weight/Placenta Ratio and Asymmetric Growth Restriction Mark C. Williams, MD University of South Florida, Tampa, FL
David Gore, MD, and William F. O’Brien, MD Background: Asymmetric intrauterine growth restriction (AsymIUGR) in normal birth weight (BW) infants is associated with increased perinatal morbidity, but without documented length or head circumference it cannot be assessed. Objective: To evaluate the association between decreased BW/placenta ratio and markers of AsymIUGR in normal BW, term infants. Method: There were 34,568 singleton, nonanomalous infants born at 36 – 44 weeks with BW equal to or exceeding the 10th
Obstetrics & Gynecology