Alfred G. Robichaux

Vaginal birth after cesarean section: The impact of patient resistance to a trial of labor

In spite of the relative safety and medical advantages of vaginal birth after cesarean section, the procedure continues to be underutilized in the private practice setting. To evaluate the hypothesis that resistance by the patient often precludes a trial of labor, an observational study was conducted of all women with a history of one prior cesarean section who were delivered in 1989 at Ochsner Foundation Hospital. The choices of 167 women and the judgments of their obstetricians were longitudinally recorded during the antepartum and intrapartum course. Patients routinely received the patient guide of the American College of Obstetricians and Gynecologists for vaginal birth after cesarean section. Ultimately, 50% of patients who were encouraged by their obstetrician toward vaginal birth after cesarean section opted for an elective repeat cesarean section without a trial of labor. Reasons for patient resistance are enumerated and potential future remedial proposals are discussed.

Gastrointestinal Conditions during Pregnancy

Pregnancy causes anatomic and physiologic changes in the gastrointestinal tract. Pregnant women with intestinal disease such as Crohn disease or ulcerative colitis pose a management challenge in clinical diagnosis, radiologic evaluation, and treatment secondary to potential risk to the fetus. Heightened physician awareness on possible etiologies such as appendicitis, diverticulitis, and rarely colorectal cancer is required for rapid diagnosis and treatment to improve maternal/fetal outcome. A multidisciplinary approach to evaluation is a necessity because radiologic procedures and treatment medications commonly used in nonpregnant patients may have a potential harmful effect on the fetus. The authors review several gastrointestinal conditions encountered during pregnancy and address presentation, diagnosis, and treatment of each condition.

The MisoPROM study: A multicenter randomized comparison of oral misoprostol and oxytocin for premature rupture of membranes at term ☆

OBJECTIVE This study was undertaken to determine whether induction of labor with oral misoprostol will result in fewer cesarean deliveries than intravenous oxytocin in nulliparous women with premature rupture of membranes at term. STUDY DESIGN Three hundred five women at 10 centers were randomly assigned to receive oral misoprostol, 100 microg every 6 hours to a maximum of two doses or intravenous oxytocin. The primary outcome measure was cesarean deliveries. Secondary outcomes were time from induction to vaginal delivery and measures of maternal and neonatal safety. RESULTS The study was stopped prematurely because of recruitment difficulties. We present the results for the 305 enrolled women. There was no difference in the proportion of women who underwent cesarean delivery (20.1% in the misoprostol group, 19.9% in the oxytocin group). The time interval from induction to vaginal delivery was also similar (11.9 hours for the misoprostol group, and 11.8 hours for the oxytocin group). Maternal and neonatal safety outcomes were similar for the two treatments. More infants born to women in the misoprostol group received intravenous antibiotics in the neonatal period (16.4% vs 6.9%, P=.01), although there were no differences in chorioamnionitis or in proven neonatal infections. Women receiving misoprostol were less likely to have postpartum hemorrhage than those receiving oxytocin (1.9% vs 6.2%, P=.05). CONCLUSION Oral misoprostol does not offer any advantage in time from induction to vaginal delivery or risk of cesarean section.

Fetal Abdominal Wall Defect: A New Complication of Vesicoamniotic Shunting

Vesicoamniotic shunting for fetal obstructive uropathy is beneficial in selected cases. We report a new complication, fetal abdominal wall defect secondary to vesicoamniotic shunting. Placement of the shunt should be as low and as close to the fetal midline as possible in order to reduce the risk of this complication.

Fertility following excision of a symptomatic craniopharyngioma during pregnancy: case report.

A 27-year-old woman in the second trimester of pregnancy presented with bitemporal hemianopsia. Total resection of a craniopharyngioma restored normal vision, and she delivered a normal infant at term. Permanent hormonal replacement therapy was not needed. Subsequent spontaneous pregnancy and delivery indicate that fertility was preserved. Literature review shows this case to be unique. Even with new developments in stereotactic radiotherapy, total excision remains a potentially achievable surgical goal.

Post-Katrina Perinatal Mood and the Use of Alternative Therapies

Purpose and Design: The purpose of this cross-sectional, exploratory study is to describe perinatal moods and complementary alternative therapy (CAT) use among childbearing women living in New Orleans, post—Hurricane Katrina. How women coped with the disaster with limited access to mental health services was not known. Method: A convenience sample of 199 postpartal/expectant mothers completed two questionnaires. The Edinburgh Postnatal Depression Scale measured risk for perinatal depression (>10 for depression risk) and the Perinatal Alternative Therapy Index (PATI) obtained subjects’ self-perceived overall scores for anxiety and overall mood, frequency and type of use of alternative therapies, and health behaviors. Open-ended questions solicited qualitative data. Findings: The mean EPDS score was 8.47, yet 37% of the postpartum subjects had scores ≥10, indicating risk for depression, while 25% of the women in the prenatal group had scores ≥10. Ninety-five percent of women reported using CATs to improve their mood during pregnancy. Two themes emerged from the qualitative data: (a) Distress and Instability: The Katrina Effect and (b) Life Transitions. Conclusion: Post-Katrina, most women were proactive in seeking ways to improve their mood. Knowing that there are effective, alternative therapies to improve mood during the perinatal period, nurses and other care providers can offer more information about these nonmedical, accessible interventions.

Plasma and red blood cell β-endorphin immunoreactivity in normal and complicated pregnancies: Gestational age variation

Recent observations suggest that there may be two pools of beta-endorphin-like immunoreactivity in mammalian circulation. One of these pools is present in plasma and the other is detected in association with erythrocytes. Elucidation of an erythrocyte-associated pool may explain some of the wide variability of plasma beta-endorphin levels reported in the literature. We measured beta-endorphin immunoreactivity levels in 85 normal and 33 complicated pregnancies to delineate a possible correlation between gestational age and beta-endorphin immunoreactivity levels in plasma and in erythrocytes. Our results indicate that beta-endorphin immunoreactivity levels in both plasma and erythrocytes vary systematically throughout the gestational period, reaching a peak at 31 to 32 weeks of gestation. Amniotic fluids at midgestation were also analyzed and no correlation was observed between the levels of beta-endorphin immunoreactivity and fetal sex. Compared to normal patients, diabetic patients had significantly lower levels of beta-endorphin immunoreactivity in plasma and higher levels in erythrocytes although the total beta-endorphin immunoreactivity was not statistically different from that in normal subjects. We conclude that (1) the total beta-endorphin immunoreactivity level in whole blood is much higher than that reported in plasma, (2) both plasma- and erythrocyte-associated beta-endorphin immunoreactivity levels vary with gestational age, with a peak level at 24 to 32 weeks of gestation, (3) amniotic fluid beta-endorphin immunoreactivity levels are unrelated to fetal sex, and (4) diabetic patients may have a different distribution of beta-endorphin immunoreactivity pools than normal individuals.

Viable Pregnancies after Diagnosis of Trisomy 16 by CVS: Lethal Aneuploidy Compartmentalized to the Trophoblast

Increasing utilization of chorionic villus sampling (CVS) has lead to the discovery that the placenta can karyotypically be a very heterogeneous organ, and chromosomal mosaicism within the placental can confuse cytogenetic interpretation. Recently, confined placental mosaicism (confined regions of aneuploidy in the otherwise normal diploid placental and fetus) has been described involving a number of chromosomal abnormalities. Fetal trisomy 16 is considered uniformly lethal early in gestation. However, we present 3 cases of nonmosaic trisomy 16 confined regionally to the placenta. We discuss the possible etiology, impact on the developing fetus, and suggest an approach to the workup and evaluation of cases where the karyotype obtained on CVS is not compatible with the findings on ultrasound.

A review of the preventability of maternal mortality in one hospital system in Louisiana, USA

To determine preventability of in‐hospital maternal mortality in the Ochsner Health System (OHS) in the US state of Louisiana.

Comparison of in-hospital maternal mortality between hospital systems in Queensland, Australia and Louisiana, United States

BACKGROUND It is well documented that the American maternal mortality ratio has increased during the years 2000-2015. The Australian maternal mortality ratio, in contrast, has decreased during the same time period, a trend common among most Western countries. METHODS This study was a retrospective cohort study of cases of in-hospital maternal deaths in the Ochsner Health System (Louisiana, United States) and the Queensland Health System (Australia) from 1995 to 2013. The aim was to determine if American and Australian women have a similar rate of preventable maternal death and if the deaths were attributable to the same factors. A multidisciplinary team assessed medical records to determine preventability. RESULTS Sixteen eligible medical records were identified in the Ochsner Health System and 15 in the Queensland Health System. In the American cohort, deaths in the private insurance group (n=5) were least likely to be preventable (P=0.003). Australian maternal deaths were less likely to occur among women with late or no prenatal care than American maternal deaths; the risk difference was 44.5% for all deaths (95% confidence interval [CI]=9.7%, 79.4%; P=0.03) and 50.0% for potentially preventable deaths (95% CI=9.3%, 90.6%; P=0.04). CONCLUSION Women from Louisiana, United States and Queensland, Australia have similar rates of preventable maternal death. No statistically significant factors explained trends in Australian maternal death; American maternal mortality was significantly associated with point of entry into prenatal care, likely influenced by insurance status. Furthermore, the majority of deaths in this group were complicated by hospital systems-based factors.