Arnon Samueloff

Shoulder dystocia: Should the fetus weighing ≥4000 grams be delivered by cesarean section?

Abstract A total of 75,979 women who were delivered vaginally in the period 1970 to 1985 were stratified into diabetic and nondiabetic groups. Overall, the incidence of macrosomia (≥4000 gm) was 7.6% (5674/74390) in the nondiabetic group and 20.6% (328/1589) in the diabetic group. Patients were further subdivided by weight categories at 250 gm intervals. Eight percent of shoulder dystocia occurred in the diabetic group when fetal weight was ≥4250 gm. In contrast, 20% of shoulder dystocia in the nondiabetic group could have been prevented by elective cesarean section when the fetal weight was ≥4500 gm. Furthermore, logistic regression analysis demonstrated that birth weight, diabetes, and labor abnormalities were the principal contributors to shoulder dystocia. Elective cesarean section is strongly recommended for diabetics with fetal weights ≥4250 gm, and trial of vaginal delivery for nondiabetic fetuses with weights ≥4000 gm is recommended. In all cases the clinician must be watchful for labor abnormalities in macrosomic fetuses.

Is the obstetric outcome of in vitro fertilized singleton gestations different from natural ones? A controlled study

OBJECTIVE To determine whether singleton IVF pregnancies carry adverse maternal or fetal outcome when compared with naturally conceived gestations. DESIGN An analysis of the obstetric outcome of singleton IVF pregnancies in comparison with matched, naturally conceived singleton controls. SETTING In vitro fertilization unit and obstetric service at a tertiary medical center. PATIENT(S) Two hundred sixty consecutive singleton IVF pregnancies and 260 naturally conceived singleton controls matched 1:1 for maternal age, parity, ethnic origin, and location and date of delivery. INTERVENTION(S) In vitro fertilization-ET. MAIN OUTCOME MEASURE(S) The rate of antenatal obstetric complications, nonvertex presentation, cesarean section, preterm labor, low birth weight, small and very small for gestational age, neonatal intensive care unit admissions, and perinatal mortality. RESULT(S) The rates of most antenatal complications were similar in both groups. Urinary tract infection was the only complication diagnosed significantly more frequently after IVF (7.3% versus 1.2%); however, the rates of severe urinary tract infection necessitating hospitalization were similar. The incidence of nonvertex presentation was also similar. The cesarean section rate was significantly higher among IVF patients (41.9% versus 15.5%). The rates of preterm labor, low birth weight, small and very small for gestational age, neonatal intensive care unit admissions, and perinatal mortality were comparable. CONCLUSION(S) When controlling for maternal age, parity, ethnic origin, and location and date of delivery, singleton IVF pregnancies do not carry an increased risk for prematurity, low birth weight, or maternal or fetal complications. Still, these pregnancies are associated with a high rate of cesarean sections.

Effect of interpregnancy interval on adverse perinatal outcomes — a national study

BACKGROUND The interpregnancy interval (IPI) has been reported to influence the outcome of pregnancy and birth. We performed a national study in Israel to determine the impact of IPI on multiple adverse perinatal outcomes. STUDY DESIGN This longitudinal cohort study used birth certificates of siblings born to the same biological mother, with at least one previous birth and a subsequent singleton pregnancy. Adverse pregnancy outcomes included preterm delivery, very preterm birth, small for gestational age (SGA), very SGA (VSGA), early neonatal death and major congenital malformations. Multivariate logistic regression was performed for each outcome. RESULTS The study included 440,838 of a total of 846,845 reported live births in Israel over 5 years; excluded were primiparas (32%), multifetal births (4.9%) and those with incomplete data (10.9%). For IPIs shorter than 6 months, there were significantly increased risks for preterm birth (OR=1.23), SGA (OR=1.14), VSGA (OR=1.15), early neonatal death (OR=1.62) and congenital malformations (OR=1.14). Intervals of 60 months or longer had higher risks for preterm birth (OR=1.39) and VSGA (OR=1.16). CONCLUSION Optimal IPI recommendation of >11 months is an accessible and low-cost means to improve multiple adverse perinatal outcomes.

Urinary function during epidural analgesia with methadone and morphine in post-cesarean section patients

&NA; Urinary function was assessed in 120 women after cesarean section under epidural anesthesia. Postoperative analgesia was obtained by means of epidurally administered methadone (40 patients) or morphine (40 patients). In the remaining 40 women, no narcotic drugs were given and postoperative pain was treated with intramuscular or oral non‐opiate analgesics and sedatives. Both methadone and morphine provided potent postoperative pain relief. Following epidural methadone, mean urine volumes of the first two postoperative voidings were increased (543 ± 38n ml and 571 ± 31 ml) as compared with those after epidural morphine (219 ± 25 ml and 218 ± 18 ml) and with those of patients receiving non‐opiate analgesics (319 ± 28ml and 414 ± 30 ml). The mean time interval between the end of surgery and first voiding following methadone analgesia was shorter (336 ± 27 min) than after morphine (582 ± 18 min) or after non‐opiate (448 ± 28 min) analgesic drugs. Difficulty in micturition and the need for bladder catheterization were also decreased in the group with epidural methadone (2.5%) in comparison with the groups receiving morphine (57.5%) or non‐opiate analgesic medicaments (12.5%). The use of epidural methadone for postoperative pain relief is advocated, both in view of its analgesic potency and of the low incidence of urinary disturbances.

Expectant Management of Midtrimester Premature Rupture of Membranes: A Plea for Limits

OBJECTIVE: Our aim was to assess neonatal and maternal complications of the expectant management of pregnancies with preterm premature rupture of membranes (P-PROM) prior to 24 weeks of gestation and to delineate a patient consult strategy.STUDY DESIGN: We included all consecutive cases of early midtrimester P-PROM (16–24 weeks gestation). Information coded in our perinatal database was analyzed. Descriptive statistics, Students t-test and Mann–Whitney test, and a logistic regression model were built accordingly.RESULTS: A total of 28 women presented with P-PROM at 16–24 weeks (mean 22.7±1.0 weeks). Two patients declined conservative management and one was lost to follow-up (10.7%). In all, 25 (89.2%) were followed until the onset of labor or development of chorioamnionitis. Overall, 8/25 (32%) Of the neonates survived. Pulmonary hypoplasia accounted for three deaths (3/25, 12%). Of 10 pregnancies with P-PROM before 22 weeks gestation, two (20%) neonates survived. The amount of amniotic fluid and gestational age at the time of diagnosis were crucial independent factors determining overall survival. Pulmonary hypoplasia (12%) and skeletal deformities (0%) were infrequent. The 21-day mean maternal antenatal hospital stay was further complicated by a high cesarean rate delivery (33.7%) and by postpartum infectious morbidity (32%).CONCLUSION: In cases of early midtrimester P-PROM (<24 weeks) expectantly managed, neonatal survival is positively associated with the amount of amniotic fluid present and with the gestational age at the time of diagnosis. The mothers are at increased risk of prolonged antenatal hospitalization, cesarean delivery, preterm birth, and postpartum infection. In very early midtrimester P-PROM (<22 weeks), the maternal complication rate outweighs the poor neonatal outcome and expectant management should be reconsidered.

Is fetal heart rate variability a good predictor of fetal outcome

Objective. The purpose of this study was to investigate, in a prospective manner, whether fetal heart rate (FHR) variability serves as a reliable single predictor of fetal outcome.

The effects of the socioeconomic status on the perinatal outcome of grand multipara

Grandmultiparity has been considered as an obstetric hazard both to the mother and the fetus. Since high paritius tend to be more common in the lower socioeconomic groups, the effect of the socioeconomic status on perinatal outcome was evaluated in this study. This survey covers all the deliveries in Israel (22,815) in a 3 month period. The 1542 grand-multiparous women were divided into two groups: low socioeconomic group (947) and high socioeconomic group (595). Perinatal mortality and low birth weight were found to be in correlation with low socioeconomic status but not with grand multiparity. Maternal diseases complicating pregnancy were found to be significantly more common for grand multipara for both socioeconomic groups. This study shows that the grave association of parity and mortality found for the total population was due to the predominance of parturients of low socioeconomic class in the high birth order group.

Fryns syndrome: A predictable, lethal pattern of multiple congenital anomalies

Fryns syndrome is a unique pattern of lethal multiple congenital malformations with variable expression. A family in which all four sibs conformed to Fryns syndrome is detailed and substantiates the criteria for definition of the syndrome; perinatal mortality, hypoplastic lungs, and facial deformities should be highly suggestive of the syndrome. The addition of a strong family history, diaphragmatic hernias, distal limb deformities, and early onset of polyhydramnios with subsequent premature delivery should definitely confirm the diagnosis.

Transabdominal Sonography Before Uterine Exploration as a Predictor of Retained Placental Fragments

OBJECTIVE To evaluate the diagnostic accuracy of sonography in postpartum patients thought to have retained placental fragments. METHODS The study group consisted of 39 postpartum women in whom inspection of the placenta brought up suspicion of retained placental fragments. All these women underwent manual exploration of the uterine cavity. Before the procedure, all patients had two-dimensional sonographic imaging, after which they were divided into 2 groups. The first group comprised women who were judged to have had an empty uterus or nothing but intrauterine fluid collection. The second group consisted of those in whom sonography showed echoes of what might appear as residual trophoblastic tissue, that is, echogenic, hypoechoic, or mixed echo intracavitary patterns. The sonographic patterns were then correlated with the presence or absence of retained placental fragments as found on uterine manual exploration and pathologic examination. RESULTS In 18 patients, no suspected contents were observed on sonography. In 17 of these patients, the uterus was empty on manual uterine exploration. One of these patients had residual trophoblastic tissue, which was of minimal quantity and clinically unimportant. In 21 patients, sonography suggested retained placental tissue. In 15 of these patients, pathologic examination confirmed residual trophoblastic tissue, and in the remaining 6, the uterus contained blood clots, decidua, or both. CONCLUSIONS Sonography is an effective tool for evaluating postpartum patients thought to have retained placental fragments. Normal sonographic findings might obviate the need for manual exploration of the uterine cavity. A questionable sonographic result is not an effective tool for distinguishing between placental fragments and blood clots.

A sero-epidemiological study of herpes virus type 1 and 2 infection in Israel

In order to obtain data on the prevalence and incidence of herpes virus type 2 (HSV(2)) infection in selected populations of women and to identify groups that might benefit from routine prenatal screening, an epidemiological study was conducted during the period 1984-1990, which showed HSV(2) seroprevalence to be 2.8%. Due to the worldwide increase of over 30% of HSV(2) infection in the past two decades, a second study was performed during the period 1 January 1998-31 December 1999. Four different population groups were studied: 172 children aged 6 months to 17 years (group 1), 716 adults, men and women aged 18-95 (group 2), 200 women aged 30-67 who participated in the first survey and were re-examined in 1999 in the second survey (group 3), and a prevalence group of 155 parturient women from six different delivery rooms (group 4). Among the healthy 716 males and females HSV(2) seroprevalence was 4.5%. When analyzed by subgroup, HSV(2) seroprevalence rose from 2.3% in the 18-30 years subgroup to 6.5% in the 30-50 years subgroup and to 7.3% in the 51-70 years subgroup, and then declined to 2.4% after age 70 years. In the 200 women re-examined, HSV(2) seroprevalence was 7.7% with a 0.55% HSV(2) sero incidence per annum. In the prevalence group HSV(2) seroprevalence was 4.5%. Sera from the 1223 participants of all four groups were also screened for HSV(1) infection. HSV(1) antibody was present in 22% of children aged 6 months-1 year, in 60% at 21 years and in 87% at age 70 years. The data support the conclusion that in Israel there is no justification for routine prenatal HSV(2) screening in the healthy female population.