George J. Gilson

Changes in hemodynamics, ventricular remodeling, and ventricular contractility during normal pregnancy: A longitudinal study**

Objective To investgate the hemodynamic changes occurring in normal pregnanacy and to see if these changes were associated with an increase in myocardial contractility. Methods In a longitudinal study, primigravidas were studied with echocardiography in early (15 ± 1.8 weeks), mid (26 ± 1.2 weeks), and late (36 ± 1.0 week) gestation, as well as at 6 weeks postpartum. Carkiac dimensions were measured with two-dimensional and M-mode echocardiography and hemodynamic indices were calculated. All measurements were made with subjects in the left lateral decubitus position. Statistical analysis was performed with repeated measures analysis of variance. Results Seventy-six women with normal pregnancy outcomes completed all four studies. From the baseline study to late gestation, an increase in cardiac output of 27% (from [mean ± standard error] 4.2 ± 0.1 to 5.8 ± 0.2 L/min, P = .001). and a decrease in total peripheral resistance of 33% (from 1356 ± 69 to 941 ± 37 dynes/second cm −5, P = .001) occurred. Over this same time period, left ventricular function, while demonstrating a small and non-significant increase in velocity of circumferential fiber shortening (from 1.25 ± 0.02 to 1.27 ± 0.02 cm/second), revealed a 12% decrease in wall stress (from 36.3 ± 1.0 to 31.9 ± 1.0 g/cm2, P = .001) and a 13% decrease in the load-independent wall stress to velocity of circumferential fiber shortening ratio (from 30.0 ± 1.2 to 26.1 ± 1.0, P = .01), impluing enhanced intrinsic myocarial contractility. Conclusion Normal pregnancy is characterized by enhanced myocarial performance.

Active management of labor: Does it make a difference?

OBJECTIVE Our goal was to evaluate whether active management of labor lowers cesarean section rates, shortens the length of labor, and overcomes any negative effects of epidural analgesia on nulliparous labor. STUDY DESIGN We randomly assigned 405 low-risk term nulliparous patients to either an active management of labor (n = 200) or our usual care control protocol (n = 205). Patients who were undergoing active management of labor were diagnosed as being in labor on the basis of having painful palpable contractions accompanied by 80% cervical effacement, underwent early amniotomy, and were treated with high-dose oxytocin for failure to progress adequately in labor. RESULTS The cesarean section rate in the active management of labor group was lower than that of controls but not significantly so (active management, 7.5%; controls, 11.7%; p = 0.36). The length of labor in the active management group was shortened by 1.7 hours (from 11.4 to 9.7 hours, p = 0.001). Fifty-five percent of patients received epidural analgesics; a reduction in length of labor persisted despite the use of epidural analgesics (active management 11.2 hours vs control 13.3 hours, p = 0.001). A significantly greater proportion of active management patients were delivered by 12 hours compared with controls (75% vs 58%, p = 0.01); this difference also persisted despite the use of epidural analgesics (66% vs 51%, p = 0.03). CONCLUSIONS Patients undergoing active management had shortened labors and were more likely to be delivered within 12 hours, differences that persisted despite the use of epidural analgesics. There was a trend toward a reduced rate of cesarean section.

Is amniotic fluid analysis the key to preterm labor? A model using interleukin-6 for predicting rapid delivery

OBJECTIVE Our purpose was to create a model for predicting amnionitis and rapid delivery in preterm labor patients by use of amniotic fluid interleukin-6 and clinical parameters. STUDY DESIGN Amniotic fluid was cultured and analyzed, and a clinical score (incorporating gestational age, amniotic fluid Gram stain, glucose, leukocyte esterase, and maternal serum C-reactive protein) was determined in 111 patients diagnosed with preterm labor. Statistical analysis involved t tests, chi2, logarithmic regression, and multivariate regression analysis (P < or = .05). RESULTS The incidence of positive amniotic fluid cultures was 8.7% (9 of 103 patients). Patients with positive cultures of the amniotic fluid had a shorter delivery interval (4.8 +/- 7.5 vs 28.9 +/- 25.4 days, P < .001). Patients with elevated amniotic fluid interleukin-6 (> or = 7586 pg/ml) were more likely to have a positive amniotic fluid culture (relative risk = 8.8, 95% confidence interval = 1.6 to 47.4, P < .001) and to be delivered within 2 days (relative risk = 16.8, 95% confidence interval = 4.5 to 62.7, P < .001). Stepwise multivariate regression analysis yielded a model using interleukin-6, cervical dilatation, and gestational age (r2 = 0.63, P < .001) with a specificity of 100% for predicting delivery within 2 days of amniocentesis. CONCLUSIONS A mathematical model using maternal amniotic fluid interleukin-6 seems to be a useful clinical tool for quantifying the interval to preterm birth for patients in preterm labor.

Female circumcision: Obstetric issues

Female circumcision is a problem unfamiliar to most Western obstetrician-gynecologists. We present a case illustrative of the unique management problems posed by these patients during labor. A method of releasing the anterior vulvar scar tissue to allow vaginal delivery is described. Sensitivity and a nonjudgmental approach as to what is culturally appropriate care for these women are of paramount importance.

A randomized trial of misoprostol and oxytocin for induction of labor: Safety and efficacy

Objective: To compare the safety and efficacy of misoprostol and oxytocin for induction of labor. Methods: One hundred thirty women requiring induction of labor were randomized to receive either intravenous oxytocin or 100 μg misoprostol, administered intravaginally every 4 hours until labor was established. Results: Compared with women receiving oxytocin, a greater percentage of women in the misoprostol group had Bishop scores of 3 or less (58 versus 38%, P Conclusion: Compared with oxytocin for labor induction, misoprostol results in a shorter induction-to-delivery interval, a reduction in the rate of cesarean delivery for dystocia, and a decreased use of epidural analgesia. Uterine tachysystole is significantly more common with the use of misoprostol.

Epidural analgesia and active management of labor : Effects on length of labor and mode of delivery

OBJECTIVE To determine whether cervical dilatation at the time of placement of patient-requested epidural affects cesarean rates or lengths of labors in actively managed parturients. METHODS The charts of 255 women randomized to active management of labor (n = 125) or control protocols (n = 130) were reviewed and stratified to early epidural placement (up to 4 cm cervical dilatation) versus late placement (more than 4 cm). RESULTS Women with early epidural placement had shorter labors than those with late placement (11.6 +/- 4.6 versus 13.2 +/- 5.6 hours; P = .02). Active management reduced the length of labor compared with controls regardless of epidural timing, with a reduction of 1.4 hours in early epidural placement (10.9 +/- 4.7 versus 12.3 +/- 4.3 hours; P = .04) and 3.6 hours in those with later placement (11.0 +/- 3.6 versus 14.6 +/- 6.2 hours; P = .004). Cesarean rates did not vary significantly (early 14.5% versus late 7.9%; P = .21). Early epidural placement did not lengthen the second stage of labor or increase operative vaginal delivery rates. CONCLUSION Early epidural placement did not affect lengths of labor or cesarean rates and was actually associated with shorter labor compared with late epidural placement. Women managed actively in labor, regardless of timing of epidural placement, had shorter labors than controls.

A prospective randomized evaluation of a hygroscopic cervical dilator, Dilapan, in the preinduction ripening of patients undergoing induction of labor☆☆☆★★★

OBJECTIVE Our purpose was to investigate the safety and efficacy of a synthetic intracervical hygroscopic dilator, Dilapan (Gynotech, Inc., Middlesex, N.J.), on ripening the cervix before medically indicated induction of labor. STUDY DESIGN Two hundred forty patients with a Bishop score of < or = 4 were prospectively randomized to receive either preinduction synthetic hygroscopic dilators (n = 112) or no pretreatment (n = 128) before oxytocin induction. RESULTS Compared with controls, the dilator group exhibited a significant change in median Bishop score, but there was no significant difference in length of labor (dilator 18.8 +/- 12.8 hours vs control 21.7 +/- 14.8 hours) or in the cesarean section rate (dilator 41/112 [36.6%] vs control 49/128 [38.3%]). Relative proportions of nulliparous and multiparous patients, infant weights, and cervical dilation at the time of cesarean section were not significantly different between groups. No adverse maternal or fetal effects could be attributed to use of the device. CONCLUSIONS Preinduction cervical ripening with hygroscopic dilators does not shorten the length of labor or lower the cesarean section rate in patients undergoing induction of labor.

Will cervicovaginal interleukin-6 combined with fetal fibronectin testing improve the prediction of preterm delivery?

OBJECTIVE We sought to investigate if determination of cervicovaginal interleukin-6 (IL-6) levels would enhance the positive predictive value of fetal fibronectin (fFN) for preterm birth. METHODS A prospective cohort study was undertaken of 135 women between 24 and 34 weeks gestation with symptoms of suspected preterm labor. Cervicovaginal secretions were collected for both IL-6 and fFN and measured by immunoassay and ELISA, respectively. Outcome variables included preterm delivery in less than 48 h, within 7 days, and prior to 37 weeks. Statistical analysis was performed with Fishers exact test, regression for logarithmic transform levels, and multivariate logistic regression. ROC curves were created for IL-6 levels. RESULTS IL-6 and fFN levels were both elevated in cervicovaginal secretions of women with symptoms of preterm labor. IL-6 values >100 pg/ml resulted in a odds ratio for delivery at <37 weeks of 1.57 (95%CI=0.89-2.75, P=.11), whereas fFN values >50 ng/ml resulted in a preterm delivery risk of 4.58 (95%CI=1.54-13.35, P=.003). Combining IL-6 and fFN results did not improve upon the predictive value of fFN alone for preterm birth [odds ratio 4.00 (95%CI=1.31-12.17, P=.015)]. CONCLUSION Cervicovaginal IL-6 levels did not provide any additional, independent effect on the prediction of preterm birth beyond that of fFN testing alone.

Diagnosis of cervical change in pregnancy by means of transvaginal ultrasonography

There are no absolute objective diagnostic criteria for cervical incompetence. Abdominal and endovaginal ultrasonographic assessment of endocervical length, both of which have been associated with technical problems, have been used to establish the diagnosis. Cervical cerclage may be useful in preventing silent cervical dilatation; however, no prospective trials with and without cerclage have been performed when endocervical shortening has been demonstrated by ultrasonography.

Hantavirus pulmonary syndrome complicating pregnancy

OBJECTIVE The purpose of this report is to bring to the attention of obstetric care providers the occurrence in pregnancy of a threatening pulmonary syndrome caused by hantavirus infection. STUDY DESIGN Two recent cases of hantavirus pneumonitis in pregnancy, one complicated by adult respiratory distress syndrome, are presented. The clinical characteristics and epidemiology of the illness, which has now been reported in 12 western states, are detailed. RESULTS Hantavirus pulmonary syndrome is characterized by pneumonitis, often progressing to adult respiratory distress syndrome, which is accompanied by thrombocytopenia, lactacidemia, and leukocytosis with a marked left shift. Severe hypoxemia and lactacidemia were associated with a poor perinatal outcome. CONCLUSION The hantavirus pulmonary syndrome occurring during pregnancy may be life-threatening and may result in fetal hypoxemic damage.