Craig V. Towers

Severity of asthma and perinatal outcome

Abstract OBJECTIVE : Our objective was to determine the impact of asthma and its severity, as determined by medication requirements, on perinatal outcome. STUDY DESIGN : A case-controlled study was conducted. Among 30,940 live births at Long Beach Memorial Medical Center Womens Hospital, 183 deliveries occurred between Jan. 1, 1985, and Dec. 31, 1990, that were coded for the diagnosis of asthma. Eighty-one that required the chronic use of medications to control their disease were identified. Thirty-one patients were steroid dependent and 50 were non-steroid-medication dependent. A control group was randomly selected (excluding maternal transports), and selected perinatal variables were compared between groups. RESULTS : When compared with controls, steroid-dependent asthmatics were at significantly increased risk for gestational (1.5% vs 12.9%) and insulin-requiring diabetes (0% vs 9.7%). Preterm delivery and preterm premature ruptured membranes occurred significantly more often in both asthmatic groups. Overall cesarean section rate was significantly increased in the non-steroid-medication-dependent asthmatic group when compared with controls (56.0% vs 30.0%). Delivery by primary cesarean section was significantly more common in the steroid-dependent group (38.7% vs 19.2%), and a strong trend was noted among the non-steroid-medication-dependent patients (34.0% vs 19.2%). Cesarean delivery for fetal distress was also more common in these two asthmatic groups. Neonates born to both groups of asthmatic pregnant women were significantly more likely to be of birth weight CONCLUSIONS : Perinatal outcome is compromised in the pregnancy complicated by chronic medication-dependent asthma. The extent is variable and is associated with disease severity, as measured by medication requirements. (Am J Obstet Gynecol 1992;167:963–7.)

Perinatal outcome in pregnancy complicated by massive obesity

OBJECTIVE: Our objective was to determine the impact of massive obesity during pregnancy, defined as maternal weight >300 pounds, on perinatal outcome. n nSTUDY DESIGN: A case-controlled study was conducted. Between Jan. 1, 1986, and Dec. 31, 1990, 111 pregnant women weighing >300 pounds who were delivered at Long Beach Memorial Womens Hospital were identified with a perinatal data base search. A control group matched for maternal age and parity was selected, and perinatal variables were compared between groups. To control for potential confounding medical complications, massively obese patients with diabetes and/or chronic hypertension antedating the index pregnancy were excluded from the obese group, and the data were reanalyzed. The Student t test x2, and Fishers exact statistical analysis were used where appropriate. n nRESULTS: Massively obese pregnant women are significantly more likely to have a multitude of adverse perinatal outcomes, including primary cesarean section (32.4% vs 14.3%, p = 0.002), macrosomia (30.2% vs 11.6%, pp = 0.0001), intrauterine growth retardation (8.1% vs 0.9%, p = 0.03), and neonatal admission to the intensive care unit (15.6% vs 4.5%, p = 0.01). They also are significantly more likely to have chronic hypertension (27.0% vs 0.9%, p < 0.0001) and insulin-dependent diabetes mellitus (19.8% vs 2.7%, p = 0.0001). However, when those massively obese pregnant women with diabetes and/or hypertension antedating pregnancy are excluded from analysis, no statistically significant differences in perinatal outcome persisted. n nCONCLUSION: Massively obese pregnant women are at high risk for adverse perinatal outcome; however, this risk appears to be related to medical complications of obesity. (Am J Obstet Gynecol 1992;167:958–62.)

Management of the nonvertex second twin: Primary cesarean section, external version, or primary breech extraction

Six hundred eighty-two consecutive twin deliveries were reviewed. Included in the study were 136 sets of vertex-nonvertex twins with birth weights greater than 1500 gm. A primary attempt at delivery of the second twin by external version was performed on 41 twins, 55 twins underwent attempted breech extraction, and 40 patients had a primary cesarean section solely because of physician preference. There were no differences in the incidence of neonatal morbidity or mortality among the modes of delivery. External version was associated with a higher failure rate than primary breech extraction (p less than 0.01). External version was associated with complications (fetal distress, cord prolapse, and compound presentation) that were not seen in the other two groups. Primary breech extraction of the second nonvertex twin weighing greater than 1500 gm appears to be a reasonable alternative to either cesarean section or external version.

Fetal gastroschisis and omphalocele: Is cesarean section the best mode of delivery?

There has always been controversy regarding the mode of delivery of fetuses with abdominal wall defects. Prior studies may have been biased in this evaluation as a result of the effects of delay in repair, transport of the fetus to level III facilities, and antenatal diagnosis compared with an unsuspected diagnosis. The purpose of this study was to evaluate mode of delivery at level III institutions with access to complete care to determine if cesarean section improved outcome. One hundred eight infants were treated in the study period for abdominal wall defects. Fifty-six infants met all criteria for admission to the study. No difference in neonatal morbidity or mortality was identified. No difference was found in infants who were born by elective cesarean section compared with infants delivered after labor ensued. In conclusion, we found no evidence that cesarean section or avoidance of labor improved outcome in fetuses with uncomplicated abdominal wall defects.

Rate of recurrence of preterm premature rupture of membranes in consecutive pregnancies

The reported incidence of preterm premature rupture of membranes ranges between 1% and 2% of all pregnancies. The rate of recurrence is poorly defined. The goal of this study was to establish the frequency of recurrence in a high-risk referral practice. Over a 5-year period we identified 121 patients with preterm premature rupture of membranes who had a minimum of two consecutive pregnancies under our care, resulting in a total of 255 pregnancies for analysis. Recurrent preterm premature rupture of membranes occurred in 39 of 121 patients, for a rate of 32.2% (95% confidence interval, 23.9 +/- 40.5). We were unable to demonstrate an association between the estimated gestational age at the time of rupture in the index pregnancy, latency period, interval between pregnancies, and the probability of repeat preterm premature rupture of membranes in the next pregnancy. We conclude that patients with preterm premature rupture of membranes should be counseled regarding the significant risk of recurrence and need to have close follow-up in their subsequent pregnancies.

Controlled trial of hydration and bed rest versus bed rest alone in the evaluation of preterm uterine contractions

Patients who are seen with uterine contractions but without documented change in cervical dilation or effacement are often treated with intravenous hydration before the initiation of intravenous tocolytic therapy. This is done with the intention of stopping uterine activity in patients with false preterm labor. A prospective randomized study was conducted to evaluate the effect of hydration on preterm uterine contractions in patients without proved preterm labor. A total of 28 patients were treated with bed rest and an intravenous bolus and subsequent continuous infusion of 5% dextrose in lactated Ringers solution. A control group of 20 patients were treated with bed rest alone. Uterine activity and arrest of uterine contractions were compared between the two groups. Contractions stopped in 54% of the patients treated with hydration, whereas contractions stopped in 40% of the patients in the control group. This difference was not statistically significant. As a crossover study, those in the control group with contractions that continued after the initial observation period were subsequently treated with intravenous fluids. Only one patient in this group stopped contracting. Of all patients whose contractions with either therapy, 18% eventually were delivered of preterm infants. This included 20% of the hydration group and 14% of the control group. The use of hydration as a pretherapy indicator to differentiate true preterm labor from false preterm labor could not be supported by this study. In addition, patients whose contractions stopped with either hydration or bed rest are at increased risk of subsequent preterm delivery.

Aplasia cutis congenita: A rare cause of elevated α-fetoprotein levels

We present a catastrophic case of aplasia cutis congenita from a pregnancy complicated by elevated maternal serum and amniotic fluid alpha-fetoprotein levels and a positive acetylcholinesterase. Delivery occurred at 27 weeks 1 day after premature rupture of membranes with chorioamnionitis. The neonate lacked > 90% of its skin and died.

Incidence of intrapartum maternal risk factors for identifying neonates at risk for early-onset group B streptococcal sepsis: A prospective study

OBJECTIVEnIn mid-1996 and early 1997, the Centers for Disease Control and Prevention, The American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics all published guidelines outlining 2 potential strategies for the purpose of preventing neonatal sepsis caused by group B Streptococcus. One of these approaches involves treating pregnant women intrapartum with antibiotics if any of the following risk factors develop: delivery at <37 weeks gestation, membrane rupture for >/=18 hours duration, or temperature during labor of >/=38 degrees C. However, to date there have been no population-based studies that have ascertained the percentage of pregnant women eligible to receive intrapartum antibiotic chemoprophylaxis if these risk factors were used. Our objective was to perform a large patient-based study at >1 institution evaluating all deliveries for the presence of maternal risk factors by using the definitions of the current guidelines.nnnSTUDY DESIGNnA prospective cohort study was initiated in 1995 at 3 private community hospitals and 1 private referral center. The study population was composed of 5410 consecutively delivered patients from the 4 different hospitals. Every pregnancy was analyzed for gestational age at delivery, duration of membrane rupture, temperature during labor, and use of intrapartum antibiotic chemoprophylaxis.nnnRESULTSnOf the 5410 patients, a total of 455 (8. 4%) were delivered of their neonates before 37 weeks gestation, 421 (7.8%) had rupture of membranes for at least 18 hours duration, and 378 (7.0%) had an intrapartum temperature of >/=38 degrees C. Overall, 1071 pregnant women (19.8% of the population studied) had >/=1 of the defined risk factors.nnnCONCLUSIONSnThese data suggest that, if the current risk factor strategy is used, 19.8% of the delivering population would potentially be candidates for intrapartum antibiotic chemoprophylaxis.

The capture rate of at-risk term newborns for early-onset group B streptococcal sepsis determined by a risk factor approach☆☆☆★★★

OBJECTIVEnCurrently, the Centers for Disease Control and Prevention, The American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend that health care providers for pregnant women implement 1 of 2 strategies for the potential prevention of early-onset neonatal group B streptococcal sepsis. Both algorithms recommend intrapartum antibiotic chemoprophylaxis for patients delivered of their neonates at <37 weeks gestation. The basic difference lies in the management of the term pregnancy. One protocol suggests treatment of all patients with term pregnancies with a positive culture for group B Streptococcus obtained at 35 to 37 weeks gestation. The second approach recommends treatment on the basis of risk factors of membrane rupture of >/=18 hours duration or intrapartum temperature of >/=38 degrees C. The capture rate of at-risk neonates determined by the risk factor strategy is quoted as being approximately 70%; however, the basis for this percentage was from studies that used slightly different definitions than the current guidelines and never separated the term from the preterm newborn. Our objective was to prospectively collect every case of blood culture-proven early-onset neonatal group B streptococcal sepsis and determine whether risk factors, as currently defined, were present that might have warranted maternal intrapartum antibiotic chemoprophylaxis.nnnSTUDY DESIGNnA prospective study was initiated on July 1, 1987, and completed on December 31, 1996. Every patient that was delivered of a neonate in whom early-onset group B streptococcal sepsis developed was analyzed in detail for possible intrapartum risk factors.nnnRESULTSnA total of 49 cases of early-onset group B streptococcal sepsis occurred in 46,959 deliveries. Of these 49 newborns, 9 (18%) were delivered at <37 weeks gestation. The remaining 40 newborns were delivered at term, and only 12 (30%) were delivered with an intrapartum risk factor of either membrane rupture of >/=18 hours duration or temperature of >/=38 degrees C or both.nnnCONCLUSIONSnOn the basis of the data from this study and the current literature, the risk factor approach with the current guideline recommendations would capture <50% of the term newborns in whom sepsis develops.

Comparison of a rapid enzyme-linked immunosorbent assay test and the Gram stain for detection of group B streptococcus in high-risk antepartum patients.

Early-onset neonatal sepsis with group B streptococci is a major problem in the management of high-risk obstetrics. Intrapartum treatment of the colonized mother reduces neonatal acquisition; however, many high-risk patients are delivered before culture results are available. This study prospectively evaluated a new enzyme-linked immunosorbent assay and the Gram stain for their accuracy in rapid detection of group B streptococci in 131 high-risk patients. Twenty positive cultures for group B streptococci were identified in the study population and were used as the control for test comparisons. The enzyme-linked immunosorbent assay test was 60% sensitive, whereas the Gram stain was 45% sensitive. The enzyme-linked immunosorbent assay showed an increase in sensitivity as the colony count increased; however, two cases of severe neonatal sepsis occurred in patients with low colony counts and both had enzyme-linked immunosorbent assay negative results. In conclusion, the need for a rapid sensitive test for group B streptococci detection still exists.