Edward R. Yeomans

Chronic Renal Disease in Pregnancy

The purpose of this review was to examine the impact of varying degrees of renal insufficiency on pregnancy outcome in women with chronic renal disease. Our search of the literature did not reveal any randomized clinical trials or meta-analyses. The available information is derived from opinion, reviews, retrospective series, and limited observational series. It appears that chronic renal disease in pregnancy is uncommon, occurring in 0.03–0.12% of all pregnancies from two U.S. population-based and registry studies. Maternal complications associated with chronic renal disease include preeclampsia, worsening renal function, preterm delivery, anemia, chronic hypertension, and cesarean delivery. The live birth rate in women with chronic renal disease ranges between 64% and 98% depending on the severity of renal insufficiency and presence of hypertension. Significant proteinuria may be an indicator of underlying renal insufficiency. Management of pregnant women with underlying renal disease should ideally entail a multidisciplinary approach at a tertiary center and include a maternal–fetal medicine specialist and a nephrologist. Such women should receive counseling regarding the pregnancy outcomes in association with maternal chronic renal disease and the effect of pregnancy on renal function, especially within the ensuing 5 years postpartum. These women will require frequent visits and monitoring of renal function during pregnancy. Women whose renal disease is further complicated by hypertension should be counseled regarding the increased risk of adverse outcome and need for blood pressure control. Some antihypertensives, especially angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers, should be avoided during pregnancy, if possible, because of the potential for both teratogenic (hypocalvaria) and fetal effects (renal failure, oliguria, and demise).

Cost-effectiveness of intrapartum screening and treatment for maternal group B streptococci colonization

Early-onset neonatal group B streptococci infection occurs in two cases per 1000 live births in the United States and is associated with a mortality rate greater than 20%. Nearly 30% of infected infants have concomitant meningitis and half suffer permanent neurologic damage. Group B streptococci also account for at least 20% of postpartum metritis. The annual cost of group B streptococci infection in the United States is conservatively estimated at nearly 2000 neonatal deaths and greater than

Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas.

500 million, excluding the costs of long-term neurologic handicaps. Intrapartum chemoprophylaxis with ampicillin is effective in curtailing transmission of group B streptococci from mother to infant. Methods have been developed to identify maternal colonization before delivery. We applied principles of decision analysis to evaluate cost-effectiveness of intrapartum screening for maternal group B streptococci colonization with various reported methods in cohorts of low- and high-risk women. In the United States intrapartum screening for group B streptococci is cost-effective and offers the potential to avert a significant number of neonatal deaths and postpartum infections.

Gestational diabetes: a field of controversy.

Puerperal hematomas, although rare, can be potentially morbid or life-threatening events. Early surgical management, including clot evacuation, layered closure, drainage, antibiotics, and fluid replacement (including blood), usually result in satisfactory outcome. Prevention is clearly preferable and often achievable with careful initial repair of episiotomies and lacerations.

A prospective study of two dosing regimens of oxytocin for the induction of labor in patients with unfavorable cervices

Many clinicians in the United States routinely screen all pregnant women in their practices for gestational diabetes. Recently, the US Preventive Services Task Force re-emphasized that such screening is not supported by rigorous scientific evidence. Recommendations for diagnosis and management are based on an even scantier scientific foundation. Although this review questions several aspects of current dogma, it, too, is based on the frequently flawed existing data. It is surprising how, in spite of an abundance of published information on the subject, we continue to be ignorant of the real benefits of the widespread practice of screening and treating for gestational diabetes. The authors hope that the results of a randomized clinical trial, now in progress, will help to resolve some of the controversies surrounding gestational diabetes. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to describe the controversy surrounding the significance of gestational diabetes, to break down the data regarding the efficacy of screening for gestational diabetes, and to outline potential treatment options for gestational diabetes.

Pregnancy in women with renal disease. Part I: general principles.

The ideal regimen for induction of labor with oxytocin with respect to the magnitude and frequency of dosage changes has not been defined. In spite of few data regarding labor induction with an unfavorable cervix, the initial dose recommended by the American College of Obstetricians and Gynecologists is lower than that of other commonly used protocols. Eighty patients with unfavorable cervices and unruptured membranes, without evidence of labor, were randomized to one of two protocols and met criteria for data analysis. Patients in both protocols were given an initial dose of oxytocin of 2 mU/min. Patients in protocol A (n = 32) then received incremental increases of oxytocin of 1 mU/min at 30-minute intervals, while those in protocol B (n = 48) received incremental increases of 2 mU/min at 15-minute intervals. Induction failures were higher among patients on protocol A (31% vs 8%, p less than 0.05). Patients on protocol B had shorter times to delivery (mean = 10 hours 57 minutes vs 8 hours 3 minutes; p less than 0.05). The number of operative deliveries were similar regardless of protocol. There were no significant differences (p = NS) among groups and protocols in maternal and fetal complications, cesarean section rate, and uterine hyperstimulation. In this population a more aggressive protocol may lead to fewer induction failures and shorter induction-to-delivery intervals.

Randomized trial of preinduction cervical ripening: misoprostol vs oxytocin

The purpose of this review is to improve the basis upon which advice on pregnancy is given to women with renal disease and to address issues of obstetric management by drawing upon the accumulated world experience. To ensure the proper rapport between the respect for patients autonomy and the ethical principle of beneficence, the review attempts to impart up-to-date, evidence-based information on the predictable outcomes and hazards of pregnancy in women with chronic renal disease. The physiology of pregnancy from the perspective of the affected kidney will be discussed as well as the principal predictors of maternal and fetal outcomes and general recommendations of management. The available evidence supports the implication that the degree of renal function impairment is the major determinant for pregnancy outcome. In addition, the presence of hypertension further compounds the risks. On the contrary, the degree of proteinuria does not demonstrate a linear correlation with obstetric outcomes. Management and outcome of pregnancies occurring in women on dialysis and after renal transplant are also discussed. Although the outcome of pregnancies under chronic dialysis has markedly improved in the past decade, the chances of achieving a viable pregnancy are much higher after transplantation. But even in renal transplant recipients, the rate of maternal and fetal complications remains high, in addition to concerns regarding possible adverse effects of immunosuppressive drugs on the developing embryo and fetus.

Monoamniotic twin pregnancy discordant for body stalk anomaly: case report with nosologic implications.

OBJECTIVE The purpose of this study was to compare the vaginal delivery rate in women who undergo labor induction with preinduction misoprostol or oxytocin alone. STUDY DESIGN Women with singleton pregnancies and Bishop scores <5 with labor induction at > or = 24 weeks of gestation were eligible; they were assigned randomly to oxytocin alone or preinduction cervical ripening with misoprostol. Labor characteristics, maternal complications, and neonatal outcomes were analyzed. RESULTS One hundred sixty-three women received oxytocin, and 164 women received misoprostol. Maternal demographics, pretreatment Bishop scores, and labor analgesia were similar between groups. Vaginal delivery rates were also similar: 87% (n = 141) for oxytocin and 81% (n = 133) for misoprostol. Mean time from treatment to delivery was shorter for the oxytocin group, compared with the misoprostol group (13.1 vs 16.3 hours; P = .005). There was no difference in maternal complications or neonatal outcomes between groups. CONCLUSION Preinduction cervical ripening with misoprostol did not improve the vaginal delivery rate and resulted in longer intervals to active labor and delivery. Preinduction cervical ripening with misoprostol may not be necessary.

Umbilical arterial and venous acid-base and blood gas values and the effect of chorioamnionitis on those values in a cohort of preterm infants

ultiple pregnancies, especially if monozygotic, are at increased risk for fetal malformations. The spectrum of fetal ventral disruption syndromes, variably described as limb-body wall complex or body stalk anomaly, appears to occur more frequently in monozygotic twins than in singletons.1 The anomaly can be detected on sonography as early as the end of the first trimester.2 When the cases diagnosed by antenatal sonography are considered, the incidence in the general obstetric population is about 1 per 7500 pregnancies.3 Because of the high rate of subsequent intrauterine death, the incidence at birth is much lower, about 0.32 per 100,000 births.4 The fetal ventral disruption syndromes are almost uniformly lethal and must therefore be distinguished from other nonlethal fetal abdominal wall defects, such as gastroschisis or omphalocele. Gastroschisis is usually an isolated right paraumbilical defect, easy to diagnose. The differential diagnosis of omphalocele may be more challenging because this midline defect is frequently associated with other anomalies and sometimes more severe midline disruptions in a cephalad direction, as in pentalogy of Cantrell, or caudal direction, as in cloacal exstrophy. The limb-body wall complex or body stalk anomaly is even more complex, usually including larger body wall defects, marked scoliosis, umbilical cord abnormalities, and evisceration of abdominal contents into the exocoelomic cavity. In multiple pregnancies, midline disruption syndromes have been reported in both monozygotic and polyzygotic cases, the typical situation being concordant monozygotic and discordant polyzygotic. The literature between 1965 and November 2004 was searched for articles dealing with fetal ventral disruption syndromes occurring in multiple pregnancies. We used the MEDLINE bibliographic database, using a combination of key words, including multiple pregnancy, twins, body stalk anomaly, and limb-body wall complex. All references in the retrieved articles were screened for further articles. The search yielded 16 cases (Table 1). There were only 4 reports of monozygotic pregnancies discordant for such malformations, 2 of them occurring in a monoamniotic pregnancy. The first reported case of monoamniotic Received June 13, 2005, from the Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences (A.C.V., J.B.S., E.R.Y.), and Department of Radiology (A.N.D.), University of Texas-Houston Medical School, Houston, Texas USA. Revision requested July 6, 2005. Revised manuscript accepted for publication August 1, 2005. Address correspondence to Alex C. Vidaeff, MD, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Texas-Houston Medical School, 6431 Fannin St, Suite 3.604, Houston, TX 77030 USA. E-mail: alex.c.vidaeff@uth.tmc.edu

Early repair of episiotomy dehiscence

Umbilical arterial and venous acid-base and blood gas values in uncomplicated premature births are similar to values that are reported in term infants and are unaffected by birth weight or gestational age. In this group of patients chorioamnionitis had no significant effects on umbilical arterial acid-base or blood gas values or on the percentage of patients that were born with acidemia. Apgar scores were significantly lower in the group with chorioamnionitis in spite of a virtual absence of acidemia, which again suggests that low Apgar scores alone do not confirm a diagnosis of birth asphyxia.