Elliot M. Levine

Mode of delivery and risk of respiratory diseases in newborns

Objective To determine whether there is an increased incidence of persistent pulmonary hypertension in neonates delivered by cesarean, with or without labor, compared with those delivered vaginally. Methods We did a computerized retrospective review of 29,669 consecutive deliveries over 7 years (1992–1999). The incidences of persistent pulmonary hypertension of the newborn, transient tachypnea of the newborn, and respiratory distress syndrome (RDS) were tabulated for each delivery mode. Cases of persistent pulmonary hypertension were reviewed individually to determine delivery method and whether labor had occurred. The three groups defined were all cesarean deliveries, all elective cesareans, and all vaginal deliveries. Results Among 4301 cesareans done, 17 neonates had persistent pulmonary hypertension (four per 1000 live births). Among 1889 elective cesarean deliveries, seven neonates had persistent pulmonary hypertension (3.7 per 1000 live births). Among 21,017 vaginal deliveries, 17 neonates had persistent pulmonary hypertension (0.8 per 1000 live births). χ2 analysis showed an odds ratio 4.6 and P < .001 for comparison of elective cesarean and vaginal delivery for that outcome. Conclusion The incidence of persistent pulmonary hypertension of the newborn was approximately 0.37% among neonates delivered by elective cesarean, almost fivefold higher than those delivered vaginally. The findings have implications for informed consent before cesarean and increased surveillance of neonates after cesarean.

Intrapartum antibiotic prophylaxis increases the incidence of gram-negative neonatal sepsis.

OBJECTIVE: To investigate the influence of the increased use of intrapartum chemoprophylaxis on the incidence of vertically transmitted neonatal sepsis. METHODS: Multiple institutional databases were queried for the number of cases in which intrapartum antibiotics were used, the obstetric risk factors that were present, and the number of resultant cases of neonatal sepsis that occurred for deliveries from 1992 through 1997. Intrapartum antibiotic use was compared between the first and fourth quarter of 1997. Comparisons were made between the years 1992-1996 and 1997 for the incidence of the various pathogens causing neonatal sepsis; group B streptococcus (GBS), gram-negative sepsis, and others. RESULTS: We found a significant increase in intrapartum chemoprophylaxis between the first and fourth quarters of 1997 corresponding to the increased physician awareness of published guidelines. As expected, the incidence of neonatal GBS sepsis was drastically reduced (from 1.7/1000 live births to 0 in 3730 births, P = 0.02). Unfortunately, there was a concomitant increase in the incidence of gram-negative sepsis (0.29/1000 vs. 1.3/1000, P = .02). The overall incidence of neonatal sepsis remained unchanged (2.7/1000 vs. 2.1/1000, P = .69). CONCLUSIONS: Published guidelines have encouraged physicians to increase the use of intrapartum chemoprophylaxis to reduce vertical transmission of GBS. This study confirms the efficacy of this approach. Unfortunately, this reduction comes at the cost of increasing the incidence of ampicillin-resistant gram-negative neonatal sepsis with a resultant increased mortality. These data provide compelling evidence that the policy of providing ampicillin chemoprophylaxis in selected patients needs to be reconsidered.

Intrapartum Management Relating to the Risk of Perinatal Transmission of Group B Streptococcus

OBJECTIVE: To review the incidence of neonatal group B streptococcal (GBS) sepsis and its associated risk factors in our obstetrical population. METHODS: A computerized perinatal database of over 17,000 births (from 1992 to 1996) was queried for the incidence of neonatal GBS sepsis. A more detailed review of 895 births (from the first quarter of 1997) was undertaken to identify the incidence of risk factors known to be associated with neonatal GBS sepsis. RESULTS: In our institution, 30 cases of neonatal early-onset GBS sepsis were identified in over 17,000 births (or 1.7/1,000 deliveries). Risk factors were identified in 17 of those cases (56%). There were two neonatal fatalities. Chemoprophylaxis was provided in 15% of the total deliveries. CONCLUSIONS: In spite of the lack of a uniform policy for identifying patients suitable for GBS chemoprophylaxis, we found only a 43% incidence of neonatal GBS sepsis occurring without risk factors present. Identification of antepartum or intrapartum risk factors in our series, therefore, would have identified the majority of cases resulting in neonatal GBS sepsis, which may have benefited from intrapartum therapy. Some negative potential consequences of chemoprophylaxis are discussed, raising questions regarding the recent recommendations of the Centers for Disease Control and Prevention.

Risk Stratification and Prophylaxis of Venous Thromboembolic Events in Obstetrics

Objective: To identify the risk factors for perioperative venous thromboembolism, and the possible consequences of pharmacologic thromboprophylaxis used with cesarean delivery. Study design: An Enterprise Data Warehouse (EDW) of a multi-hospital system was queried to obtain the incidence of and risk factors for perioperative venous thromboembolism (VTE) and the use of pharmacologic thromboprophylaxis (PTP). Results: Of 337,174 surgical patients over the course of 2010-2013, Cesarean Delivery (CD) occurred 24,608 times, with pharmacologic VTE prophylaxis (PTP) being provided 931 times (4% of the time) and 23,677 times without such prophylaxis. Hemorrhagic complications were recorded 0.08% of the time (0.3% when PTP was provided, and 0.08% without it). As this was found to be statistically significant (p=0.02), this warrants our concern, regarding the appropriateness of using PTP for all cesarean deliveries. Conclusion: Pharmacologic thromboprophylaxis may have the risk of associated hemorrhage with its use, and it may be worthwhile to use risk stratification to decide whether or not to use it for surgical prophylaxis in particular cesarean cases.

Diagnosing placenta accreta.

REFERENCES 1. Shalom DF, Pillalamarri N, Xue X, et al. Sacral nerve stimulation reduces elevated urinary nerve growth factor levels in women with symptomatic detrusor overactivity. Am J Obstet Gynecol 2014;211:561.e1-5. 2. Chaldakov GN, Tonchev AB, Aloe L. NGF and BDNF: from nerves to adipose tissue, from neurokines to metabokines. Riv Psichiatr 2009;44: 79-87. 3. Terry AV Jr, Kutiyanawalla A, Pillai A. Age-dependent alterations in nerve growth factor (NGF)-related proteins, sortilin, and learning and memory in rats. Physiol Behav 2011;102:149-57. 4. Lee JC, Pak SC, Lee SH, et al. The effect of herbal medicine on nerve growth factor in estradiol valerate-induced polycystic ovaries in rats. Am J Chin Med 2003;31:885-95.

Clinical Value of 3-Dimensional Ultrasound in Gynecology: Clinical Value of 3D Ultrasound in Gynecology

This report provides examples of using 3‐dimensional ultrasound diagnostically in gynecology. The cost efficiency it provides and the wide range of applications it has support the routine use of this ultrasound technology in the practice of gynecology.

Predictive Value of Three-Dimensional Transvaginal Sonography for Staging of Endometrial Neoplasia

The goal of this study was to compare the sonographic assessment of endometrial cancer diagnosis and staging using three-dimensional transvaginal sonography with the staging that was ultimately found at surgery. Three-dimensional transvaginal sonography was performed for 20 consecutive cases of presumptive endometrial cancer using power Doppler angiography, virtual organ computer-aided analysis, and volume contrast imaging. These results were compared with the surgical staging found for those identified cases. The sonographic findings predicted the correct minimum endometrial cancer staging in 100% of the 20 cases that were examined and correlated to surgical outcomes. The successful prediction of endometrial cancer staging demonstrated by others was replicated in the organization of this case series. The findings compared favorably with other imaging modalities used for this purpose. This study assists in demonstrating the value of using presurgical three-dimensional sonography to plan for the optimal surgical excision and overall treatment of endometrial cancer.

Unusual Ectopic Pregnancies.

To the Editor: We heartily agree with the authors of “Unusual Ectopic Pregnancies: Sonographic Findings and Implications for Management”1 for their recognition of the important and consequential clinical distinction between “cornual” and “interstitial” ectopic pregnancies, even if they are so often used interchangeably. In fact, that also follows a prior underscoring of this distinction by Fylstra.2 However, we wish to add yet another important (and easily missed) type of unusual ectopic pregnancy: namely, an intramural ectopic pregnancy (found within the myometrial wall), which we recently described.3 Clearly, sonography will often find such occurrences of these clinical entities that cannot otherwise be diagnosed.