Catherine Greenwood

Fever in labour and neonatal encephalopathy: a prospective cohort study

Objective To determine whether the reported association of maternal fever with neonatal encephalopathy is independent of other associated intrapartum risk factors.

The relationship between intrapartum maternal fever and neonatal acidosis as risk factors for neonatal encephalopathy

OBJECTIVES This study was undertaken to investigate the relationship among maternal intrapartum fever, neonatal acidosis, and the risk of neonatal encephalopathy. STUDY DESIGN Cohort study of pregnancies at term. Logistic regression was used to estimate the effect of maternal fever and acidosis on the risk of neonatal encephalopathy. The potential interaction between maternal fever and acidosis was included in the models. RESULTS Of 8299 women, 25 neonates (0.3%) had encephalopathy develop. These were more often born acidotic (adjusted odds ratio 11.5; 95% CI, 5.0-26.5) or after a maternal intrapartum fever (adjusted odds ratio 8.1; 95% CI, 3.5-18.6). Where both risk factors coexisted, the risk was 12.5% (adjusted odds ratio 93.9; 95% CI, 28.7-307.2). Although this effect is multiplicative, there was no evidence of statistical interaction (P = .93); the effect of maternal fever on the risk of encephalopathy was similar in infants with (adjusted odds ratio 8.7; 95% CI, 2.4-31.7) and without acidosis (adjusted odds ratio 7.4; 95% CI, 2.4-21.9). CONCLUSION The combination of a maternal fever with cord acidosis greatly increases the risk of neonatal encephalopathy, but there is evidence against interaction between them, suggesting that they represent 2 separate causal pathways.

Why is there a modifying effect of gestational age on risk factors for cerebral palsy

Objective: To investigate risk factors for cerebral palsy in relation to gestational age. Design: Three case-control studies within a geographically defined cohort. Setting: The former Oxfordshire Health Authority. Participants: A total of 235 singleton children with cerebral palsy not of postnatal origin, born between 1984 and 1993, identified from the Oxford Register of Early Childhood Impairment; 646 controls matched for gestation in three bands: ⩽32 weeks; 33–36 weeks; ⩾37 weeks. Results: Markers of intrapartum hypoxia and infection were associated with an increased risk of cerebral palsy in term and preterm infants. The odds ratio (OR) for hypoxia was 12.2 (95% confidence interval 1.2 to 119) at ⩽32 weeks and 146 (7.4 to 3651) at ⩾37 weeks. Corresponding ORs for neonatal sepsis were 3.1 (1.8 to 5.4) and 10.6 (2.1 to 51.9). In contrast, pre-eclampsia carried an increased risk of cerebral palsy at ⩾37 weeks (OR 5.1 (2.2 to 12.0)) but a decreased risk at ⩽32 weeks (OR 0.4 (0.2 to 1.0)). However, all infants ⩽32 weeks with maternal pre-eclampsia were delivered electively, and their risk of cerebral palsy was no lower than that of other electively delivered ⩽32 week infants (OR 0.9 (0.3 to 2.7)). Nearly 60% of ⩽32 week controls were delivered after spontaneous preterm labour, itself an abnormal event. Conclusion: Inflammatory processes, including pre-eclampsia, are important in the aetiology of cerebral palsy. The apparent reduced risk of cerebral palsy associated with pre-eclampsia in very preterm infants is driven by the characteristics of the gestation matched control group. Use of the term “protective” in this context should be abandoned.

The relation between pre-eclampsia at term and neonatal encephalopathy

OBJECTIVES To determine whether pre-eclampsia, hypothesised to be an inflammatory condition, is associated with fever in term labour, and confirm and examine the reported association of pre-eclampsia at term with neonatal encephalopathy. DESIGN Prospective cohort study. SETTING A Dublin teaching hospital. PARTICIPANTS 6163 women in labour with singleton pregnancies at term at low risk for intrapartum hypoxia, recruited to a randomised trial examining the effect of admission cardiotocography on neonatal outcome. RESULTS Pre-eclampsia was associated with maternal fever > 37.5° in labour (odds ratio (OR) 3.39, 95% confidence interval (CI) 2.1 to 5.4); this was independent of obstetric intervention (adjusted OR 2.07, 95% CI 1.24 to 3.47). Pre-eclampsia was associated with neonatal encephalopathy (OR 25.5, 95% CI 8.4 to 74.7); this too was independent of obstetric intervention (adjusted OR 18.5, 95% CI 5.9 to 58.1). Cord arterial pH values were significantly lower in pre-eclamptics (7.20v 7.24), although severe cord acidaemia was not significantly more common (OR 2.91, 95% CI 0.7 to 9.9). The association of pre-eclampsia with encephalopathy was independent of maternal fever (adjusted OR 16.5, 95% CI 5.1 to 54) and cord acidaemia (adjusted OR 13.5, 95% CI 3.2 to 56.7). CONCLUSIONS The association of pre-eclampsia with maternal fever at term supports the hypothesis that pre-eclampsia is an inflammatory condition. The association of pre-eclampsia with neonatal encephalopathy is independent of obstetric intervention and cannot be explained by either acidaemia or maternal fever. A systemic inflammatory response in the fetus, perhaps secondary to oxidative stress, could explain the link between maternal pre-eclampsia and neonatal encephalopathy, and this may occur through cerebral vasoconstriction.

Does a first trimester dating scan using crown rump length measurement reduce the rate of induction of labour for prolonged pregnancy? An uncompleted randomised controlled trial of 463 women.

Objective  To evaluate the effect of a first trimester ultrasound dating scan on the rate of induction of labour for prolonged pregnancy.

Meconium passed in labor: How reassuring is Clear amniotic fluid?

OBJECTIVE Clear amniotic fluid is frequently considered a reassuring sign during labor. Our aim was to examine the incidence of meconium that can only have been passed intrapartum and to determine its neonatal associations and whether its absence is a useful sign. METHODS This was a prospective cohort study of 8394 “low risk” laboring women at term with clear amniotic fluid at early amniotomy. RESULTS Meconium was passed in 5.2% of labors but was not detected until delivery of the fetal head in 51.5% of these. It was associated with moderate–severe acidosis (odds ratio [OR] 4.40; 95% confidence interval [CI] 3.21, 6.03), low Apgar score at 5 minutes (OR 6.49; 95% CI 2.73, 15.44), and neonatal seizures (OR 4.33; 95% CI 3.17, 5.93). However, the sensitivity for these outcomes of the intrapartum passage of meconium and, particularly, its detection before delivery was very poor. CONCLUSION Although correlated with adverse neonatal outcomes, most affected infants had clear amniotic fluid throughout labor. The presence of clear amniotic fluid is an unreliable sign of fetal well-being.

Meningioma mimicking puerperal psychosis

BACKGROUND: Meningiomas are slow-growing benign brain tumors. They can be sensitive to sex hormones, increasing in size with pregnancy and leading to clinical presentation either before or immediately after delivery. Initial symptoms and signs can present in the antenatal as well as the postnatal period. CASE: A patient presented with confusion associated with complaints of déjà vu and auditory hallucinations on day 1 postcesarean delivery. Meningioma was diagnosed by computed tomography and treated successfully with steroids, anticonvulsant, and craniotomy. CONCLUSION: It is imperative to perform a thorough neurologic examination in a patient who presents with atypical psychiatric symptoms in the antenatal or postpartum period. Neuroimaging should be performed in the presence of any neurologic abnormality to exclude intracranial lesions such as meningioma.

The association of nuchal cord with cerebral palsy is influenced by recording bias

OBJECTIVES To determine if the association of cerebral palsy (CP) with umbilical cord around the fetal neck (nuchal cord) is the result of recording bias. STUDY DESIGN Population-based case control study. RESULTS There were 68 cases with cerebral palsy and 157 controls (singleton term infants matched for gestational age and hospital of birth). CP was associated with tight nuchal cord overall (OR=2.8, 95% CI 1.1-6.8). Where cord around the neck is recorded at the discretion of the accoucheur (37 cases, 97 controls), there was an association between tight nuchal cord and CP (OR=5.4, 95% CI 1.4-20.4) and, in controls only, between Apgar score <7 at 1 min (OR=16.9, 95% CI 1.4-456.3). In the hospital where records included a tick box for nuchal cord (31 cases, 60 controls), an association between CP and tight nuchal cord could not be demonstrated (OR=1.4, 95% CI 0.4-4.9). Nor was there an apparent association between nuchal cord and Apgar score <7 at 1 min (OR=2.6, 95% CI 0.4-15.9) in controls. CONCLUSIONS The presence of nuchal cord is subject to recording bias. In a retrospective study, this can lead to an association of CP with nuchal cord that is not evident where documentation is systematic.

Recurrent acquired sideroblastic anemia in a twin pregnancy

A woman whose sideroblastic anemia had relapsed with progestogen and combined oral contraceptive therapy suffered further relapses in a (twin) pregnancy. Previous reports exist of relapses both from progestogens and in pregnancy, and we postulate a shared etiology. Affected women considering pregnancy or sex hormone usage should be advised accordingly.

External Cephalic Version after Previous Cesarean Section: A Cohort Study of 100 Consecutive Attempts

OBJECTIVE External cephalic version is commonly not performed in women with a previous cesarean section. Fear of uterine rupture and cesarean section in labor are prominent. The risks, however, of these are unclear. This study aims to document the safety and efficacy of external cephalic version in women with a prior cesarean section in a series of 100 consecutive attempts, and to perform a literature of the existing literature. STUDY DESIGN This is a retrospective cohort study of prospectively collected data of external cephalic version attempts in women at term with a previous cesarean section, and a literature review of previously published series. External cephalic version was performed by one of 3 experienced operators, with salbutamol tocolysis if appropriate, using ultrasound to visualize the fetal heart and place of fetal parts. RESULTS 100 women with a prior cesarean section underwent external cephalic version over a 16-year period in one institution. 68% had no previous vaginal delivery. The external cephalic version success rate was 50%, and 30 (63.8%) of these subsequently delivered vaginally. There were no cases of uterine rupture or other complications. A literature review of series containing a total of 549 cases revealed no cases of uterine rupture or perinatal death. CONCLUSIONS External cephalic version in women with a prior cesarean section is safe but enables a vaginal birth in only about a third of women.