April T. Bleich

Disseminated gonococcal infection in women.

OBJECTIVE: To review the clinical presentation, complications, and response to treatment of pregnant and nonpregnant women admitted for management of disseminated gonococcal infection over a 34-year period. METHODS: This was a review of all women diagnosed with disseminated gonococcal infection who were admitted to Parkland Memorial Hospital from 1975 through 2008. Medical records were reviewed and data extracted that included demographic information, clinical and laboratory findings, and response to antimicrobial treatment. In addition to determining perinatal outcomes, the clinical findings of women in the pregnant cohort were compared with those of nonpregnant women. RESULTS: Of 112 women hospitalized for treatment during the study period, 80 (71%) were nonpregnant and 32 (29%) were pregnant. In both groups, the frequency of disseminated infections declined substantively over the last 34 years. Presenting symptoms were similar for pregnant and nonpregnant women, and with one exception, all had arthritis that involved a mean of two joints, most commonly the knee and wrist. Two notable differences between the cohorts were that pregnant women sought care a mean of 2 days after symptoms began compared with that of 5 days for nonpregnant women (P=.003). Related to this, only 50% of pregnant women had a joint effusion compared with 70% of nonpregnant women (P=.05). CONCLUSION: The frequency of disseminated gonococcal infection decreased remarkably over the 34-year study period, paralleling the decreasing prevalence of mucosal Neisseria gonorrhoeae infections reported nationwide. In women with disseminated infections, prompt recognition and antimicrobial treatment will usually result in a favorable outcome. LEVEL OF EVIDENCE: II

An analysis of second-stage labor beyond 3 hours in nulliparous women

OBJECTIVE To analyze outcomes after second-stage labor beyond 3 hours and determine if prolonged second stages were intentional. STUDY DESIGN Retrospective cohort analysis of maternal and neonatal outcomes in nulliparous women based on second-stage duration. Medical records were reviewed for management decisions in women with second stages ≥4 hours; all other outcomes were accessed via computerized obstetric database. RESULTS Second stage exceeding 3 hours occurred in 1489 (7%) of 21,991 pregnancies analyzed. Of the 427 (2%) with second stages ≥4 hours, 315 (74%) reached 4 hours unintentionally, after a decision for operative delivery had been made. Only 34 (8%) women were intentionally allowed to continue second-stage labor beyond 4 hours, and half of these ultimately required cesarean. Indices of maternal and neonatal morbidity were significantly increased when second stages exceeded 3 hours. CONCLUSION Most second stages reaching 4 hours are unintentional, occurring while awaiting an previously decided upon operative delivery. Maternal and neonatal morbidities are significantly increased with second stages beyond 3 hours.

Oral Misoprostol for Labor Augmentation: A Randomized Controlled Trial

OBJECTIVE: To estimate the efficacy of oral misoprostol for labor augmentation. METHODS: We performed a randomized, controlled trial comparing intravenous oxytocin to a 75-microgram dose of oral misoprostol. Women in spontaneous labor were eligible if they had cervical dilation of 4–8 cm and required labor augmentation. Primary outcome was the incidence of uterine tachysystole, hypertonus, or both. Secondary outcomes included labor durations, presence of nonreassuring fetal heart rate, mode of delivery, and select maternal and neonatal outcomes. RESULTS: Three hundred fifty women were randomized, 176 (50%) to oral misoprostol and 174 (50%) to intravenous oxytocin. Whereas the admission to study drug interval was significantly shorter in women randomized to misoprostol (median 330 minutes [252, 408] compared with 402 minutes [330, 492]; P<.001), there was no difference in the time interval between initiation of augmentation and delivery: 306 (150, 534) minutes in the misoprostol group compared with 276 (162, 462) in the oxytocin group (P=.29). Women in the misoprostol group were more likely to experience uterine tachysystole, hypertonus, or tachysystole and hypertonus compared with those in the oxytocin group (76% compared with 64%, respectively; P=.02). This increase was secondary to uterine hypertonus as the incidence of tachysystole did not differ between groups (P=.74). Women in the misoprostol arm were no more likely to experience a nonreassuring fetal heart rate (P=.20) or require a cesarean delivery for this indication (P=.78). There were no significant differences in maternal or neonatal outcomes. CONCLUSION: Oral misoprostol is an effective agent for augmentation of labor. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00906347. LEVEL OF EVIDENCE: I

A multicenter prospective study of neonatal outcomes at less than 32 weeks associated with indications for maternal admission and delivery

BACKGROUND: Counseling for patients with impending premature delivery traditionally has been based primarily on the projected gestational age at delivery. There are limited data regarding how the indications for the preterm birth affect the neonatal outcome and whether this issue should be taken into account in decisions regarding management and patient counseling. OBJECTIVE: We performed a prospective study of pregnancies resulting in premature delivery at less than 32 weeks to determine the influence of both the indications for admission and their associated indications for delivery on neonatal mortality and complications of prematurity. STUDY DESIGN: This is a multicenter, prospective study in 10 hospitals where all data from the neonatal intensive care unit routinely was imported to a deidentified data warehouse. Maternal data were collected prospectively at or near the time of delivery. Eligible subjects included singleton deliveries in these hospitals between 23 0/7 and 31 6/7 weeks. The primary hypothesis of the study was to determine whether there was a difference in the primary outcome, which was defined as neonatal composite morbidity, between those neonates delivered after admission for premature labor vs premature rupture of membranes, because these were expected to be the 2 most frequent diagnoses leading to premature birth. The sample size was calculated based on a 10% difference in outcomes for these 2 entities. We based this hypothesis on the knowledge that premature rupture of membranes has a greater incidence of intra‐amniotic infection and inflammation than premature labor and that outcomes for premature neonates are worse when delivery is associated with intra‐amniotic infection. Additional outcomes were analyzed for all other indications for admission and delivery. Composite morbidity was defined as ≥1 of the following: respiratory distress syndrome (oxygen requirement, clinical diagnosis, and consistent chest radiograph), bronchopulmonary dysplasia (requirement for oxygen support at 28 days of life), severe intraventricular hemorrhage (grades 3 or 4), periventricular leukomalacia, blood culture‐proven sepsis present within 72 hours of birth, necrotizing enterocolitis, or neonatal death before discharge from the hospital. A secondary composite of serious neonatal morbidity also was defined prospectively. RESULTS: The study included 1089 mother/baby pairs. Composite morbidity between those with premature labor (77.2%) and premature rupture of membranes (73.2%) was not significantly different (P = .29). A few neonatal complications were associated with indications for admission and delivery, but on logistic regression adjusting for gestational age and other confounders, suspected intrauterine growth restriction was the only indication for admission or delivery associated with an increase in serious morbidity (odds ratio 4.5, [2.1 to 9.8], P < .003). Other factors not related to the indications for admission including cesarean delivery, and low 5‐minute Apgar were associated with an increase in morbidity. CONCLUSION: Studies of many single factors related to the indications for preterm delivery have been shown to be associated with adverse neonatal outcome. In this study evaluating all of the most frequent indications, however, we found only suspected intrauterine growth restriction as an indication for admission and delivery was found to be so. Thus, it seems that in almost all situations counseling patients can be based primarily on gestational age along with other factors including estimated fetal weight, sex, race, plurality, and completion of a course of antenatal corticosteroids.