Elaine I. Haney

Mid-trimester dilation and evacuation with laminaria does not increase the risk for severe subsequent pregnancy complications

Objective: To evaluate subsequent pregnancy outcomes in women with a previous mid‐trimester (12–24 weeks) pregnancy termination by dilation and evacuation (D&E) as compared to women without a previous D&E. Method: Medical records for women who underwent a D&E between 1995 and 2003 were identified and reviewed. Women with subsequent pregnancies were compared on a 1:2 basis with women in a control group who had viable pregnancies and no previous mid‐trimester DE. Outcomes of interest included preterm labor, placental abnormalities, and a composite complication outcome. Results: Of the 317 women who underwent a D&E, 85 had viable subsequent pregnancies. These women delivered slightly earlier than the 170 controls (38.9 versus 39.5 weeks, p = 0.001), although there was no statistically significant difference between the two groups with regard to birth weights, spontaneous preterm delivery, abnormal placentation, and overall complication rate. Conclusions: Mid‐trimester termination by D&E does not increase the rate of clinically significant subsequent pregnancy complications.

Reducing high-order perineal laceration during operative vaginal delivery

OBJECTIVE This study was undertaken to assess the impact of a focused intervention on reducing high-order (third and fourth degree) perineal lacerations during operative vaginal delivery. STUDY DESIGN The following recommendations for clinical management were promulgated by departmental lectures, distribution of pertinent articles and manuals, training of physicians, and prominent display of an instructional poster: (1) increased utilization of vacuum extraction over forceps delivery; (2) conversion of occiput posterior to anterior positions before delivery; (3) performance of mediolateral episiotomy if episiotomy was deemed necessary; (4) flexion of the fetal head and maintenance of axis traction; (5) early disarticulation of forceps; and (6) reduced maternal effort at expulsion. Peer comparison was encouraged by provision of individual and departmental statistics. Clinical data were extracted from the labor and delivery database and the medical record. RESULTS One hundred fifteen operative vaginal deliveries occurred in the 3 quarters preceding the intervention, compared with 100 afterward (P = .36). High-order laceration with operative vaginal delivery declined from 41% to 26% (P = .02), coincident with increased use of vacuum (16% vs 29% of operative vaginal deliveries, P = .02); fewer high-order lacerations after episiotomy (63% vs 22%, P = .003); a nonsignificant reduction in performance of episiotomy (30% vs 23%, P = .22); and a nonsignificant increase in mediolateral episiotomy (14% vs 30% of episiotomies, P = .19). CONCLUSION Introduction of formal practice recommendations and performance review was associated with diminished high-order perineal injury with operative vaginal delivery.

Ultrasound examination of the postpartum uterus: what is normal?

Objective: To establish normal ultrasonographic findings for the postpartum uterus after vaginal delivery, and to characterize associated bleeding patterns.Methods: Postpartum women were scanned by transabdominal ultrasound within 48 h after normal vaginal delivery. Uterine length, uterine width, endometrial stripe thickness and endometrial contents were evaluated by a single sonographer. Patients maintained a daily symptom diary for 6 weeks and were interviewed by telephone at 2 weeks. Statistical analysis was performed using χ2, Fishers exact test, Students t test and Pearson correlation.Results: Mean endometrial stripe thickness was 1.1±0.6 cm, mean uterine length was 16.1±1.7 cm and mean uterine width was 8.7±1.0 cm. Postpartum bleeding requiring more than four protective pads per day for ≥10 days was associated with a thicker endometrial stripe (1.5±0.7 cm vs. 0.9±0.4 cm, p=0.006). However, no patients experienced postpartum bleeding complications requiring intervention. Of the 40 women evaluated, 16 had echogenic material in the uterine cavity (mean size 12.7±6.9 cm2). The presence of echogenic material was not associated with the amount or duration of bleeding.Conclusions: Frequent postpartum ultrasonographic findings include a thickened endometrial stripe and echogenic material in the uterine cavity. The echogenic material commonly seen in the endometrial cavity of asymptomatic patients was not associated with the development of bleeding complications.

Neonatal outcomes in triplet gestations after a trial of labor

OBJECTIVE This study aimed to compare neonatal outcomes in a cohort of triplet gestations undergoing a trial of labor with those of a similar cohort delivered by elective cesarean delivery. STUDY DESIGN Thirty-three women with triplet gestations who underwent a trial of labor were compared with a matched cohort of 33 women with triplet gestations who were delivered of their infants by elective cesarean delivery. Neonatal outcomes assessed included respiratory distress syndrome, retinopathy of prematurity, necrotizing enterocolitis, intraventricular hemorrhage, Apgar scores, and birth trauma. RESULTS Twenty-nine of 33 women (87.9%) who underwent a trial of labor had a successful vaginal delivery of all 3 neonates. One patient was delivered of her first triplet vaginally but then required a cesarean delivery for abruptio placentae; 3 other patients were delivered of their infants by cesarean section for active-phase arrest of labor. There were no differences in neonatal outcomes between the 2 groups, although triplet neonates delivered by elective cesarean section demonstrated a trend toward a greater incidence of respiratory distress syndrome (P = .09). CONCLUSION Our experience suggests that offering vaginal delivery is an acceptable management plan for triplet gestations.

Complement, fetal antigen, and shaking rigors in parturients

Objectives. To assess the relationship, if any, between complement, fetal antigen, and shaking rigors during labor and delivery. Methods. We recruited 13 volunteers for serial blood sampling during labor and childbirth. Results. Complement levels had a small but significant drop (11–15%) immediately following childbirth but had no association with fetal antigen levels or shaking rigors. Fetal antigen levels failed to show any consistent relationship with shaking rigors or the labor and delivery process. Conclusion. Shaking rigors do not appear to be associated with changes in either complement or fetal antigen levels. Complement levels remain stable during labor but drop immediately following birth.

Comparison of Active Phase Labor Between Triplet, Twin, and Singleton Gestations:

Objective: To characterize the active phase of labor in triplet pregnancies and compare it with gestational age-matched twins and singletons. Methods: Active phase rates were calculated beginning at 5 cm of dilation for women with triplet gestations longer than 24 weeks who labored and reached the second stage. Twin and singleton cohorts that also completed the first stage of labor were matched for gestational age at deliverty (± 1 week), parity, and epidural use. Intrapartum variables included oxytocin use (induction or augmentation, duration of infusion, and maximum dosage), cervical dilation at membrane rupture, and active phase dilation rate. Results: Thirty-two triplet pregnancies met inclusion criteria between January 1994 and September 1998 and were each compared with twin and singleton cases in a 1:2 ratio. Triplet and twin active phase rates, while similar (1.8 versus 1.7 cm/hour, respectively), were significantly lower than the mean singleton dilation rate (2.3 cm/hour, P = .02). No other intrapartum variables differed between the three groups. Despite controlling for gestational age of delivery, mean birth weights were significantly higher in singletons and correspondingly lower in twins and triplets (2493 versus 2112 and 1968 g, respectively; P = .001). An analysis of active phase dilation rates as a function of the cumulative birth weight per pregnancy demonstrated an inverse correlation, with slower progress in active labor associated with increasing total fetal weight (R = - .24; P = .002). Conclusions: Triplet and twin active phase dilation proceeds at a slower rate than that observed in singleton pregnancies. The rate of active phase dilation is inversely correlated to total fetal weight.

Health literacy and pregnancy preparedness in pregestational diabetes

OBJECTIVE We investigated the association between functional health literacy and markers of pregnancy preparedness in women with pregestational diabetes. RESEARCH DESIGN AND METHODS English- and Spanish-speaking pregnant women with pregestational diabetes were recruited. Women completed the Test of Functional Health Literacy in Adults (TOFHLA) short form and a questionnaire. A TOFHLA score of < or =30 was defined as low functional health literacy. RESULTS Of 74 women participating in the study, 16 (22%) were classified as having low functional health literacy. Compared with women with adequate health literacy, those with low health literacy were significantly more likely to have an unplanned pregnancy (P = 0.02) and significantly less likely to have either discussed pregnancy ahead of time with an endocrinologist or obstetrician (P = 0.01) or taken folic acid (P = 0.001). CONCLUSIONS The results of this study suggest that low functional health literacy among women with pregestational diabetes is associated with several factors that may adversely impact birth outcomes.

Cervical incompetence in multiple gestations

Objective: To investigate the prevalence and timing of cervical incompetence in multiple gestations. Materials and Methods: Our perinatal database was queried for all multiple gestations delivered at Evanston Hospital from December 1995 through August 2000. This list was then crossmatched with billing and medical records for ‘incompetent cervix‘ and ‘cerclage placement.‘ The medical records of all deliveries at 26 weeks of gestation or earlier were reviewed in order to find out whether cervical incompetence was responsible for the preterm delivery. Results: There were 730 deliveries of multiple gestations greater than or equal to 14 weeks over a 57-month period. The number of patients who underwent cerclage placement was 23 (3.2%). The mean gestational age (GA) at cerclage placement was 18.6 ± 4.5 weeks (range 11–24.6). Eight cerclage placements were elective or prophylactic, whereas 15 were ‘urgent‘ or ‘emergent.‘ The mean GA for the 15 emergent cases was 21.4 ± 2.2 weeks (range 17–24.6). When patients who underwent cerclage placement were compared with patients who did not undergo cerclage placement, there was no difference in maternal demographics, including age, parity, previous full-term deliveries, or number of fetuses. There was a significant difference in the GA at delivery for the cerclage versus no-cerclage group: 29.3 ± 5.6 versus 34.4 ± 4.6 weeks, respectively, and in the frequency of losses at 26 weeks or earlier: 8/23 (38%) versus 48/707 (6.8%), P = <0.001. Six of the losses in the no-cerclage group appeared consistent with incompetent cervix, for a 4% rate of cervical incompetence (29/730) in our multiple-gestation population. Conclusion: The relatively low incidence of cervical incompetence in our multiple gestations does not justify prophylactic cervical cerclage placement. Expectant management with serial cervical examinations starting at 16–18 weeks of gestation appears more prudent.