Juan Carlos Melchor

A prospective study of the factors associated with the success rate of external cephalic version for breech presentation at term

To determine the factors associated with the success rate of external cephalic version (ECV) for breech presentation at term.

Early neonatal sudden death or near death syndrome. An epidemiological study of 29 cases

Early neonatal sudden death syndrome (SIDS) is a rare but well known disease entity. Between January 1975 and December 1991, 29 full‐term newborn infants delivered in our maternity unit and, considered healthy at birth, suffered early SIDS (n= 15) or early apparent life threatening events (ALTE) (n= 14). Data from the whole population of live full‐term infants born in our hospital during the past five years have been used as a reference (n = 27 841). The general rate of early SIDS was 0.14 per 1000 (15/107 263). Combining early ALTE cases, the overall rate was 0.27 per 1000 (291107263). A postmortem examination was performed for all infants who died (20/29): no cause of death could be determined, and we did not observe a single case with evident sequelae. There were 9 deaths (31 %) within the first hour after delivery and 12 deaths occurred in the early morning hours (04:00–08:00; RR = 3.76; p= 0.0008). The lowest incidence was in the spring (RR = 0.21; p= 0.03). There was a tendency for an increased incidence during the weekend and the summer. No influence of sex, maternal age, gestational age, infant weight presentation, delivery, anesthesia or presence of meconium‐stained fluid was found. In our opinion, SIDS can take place even during the first hour of life and it is not possible to predict when a baby might be affected. Pediatrically trained caregivers, close observation by the mother during the first few days and resuscitation facilities in maternity wards may be the most important preventive measures to reduce the risk of early SIDS and the consequences of ALTE in the early newborn period.

Factors influencing pregnancy outcome in women with type 2 versus type 1 diabetes mellitus

Aim. To compare pregnancy outcome and factors related to adverse perinatal outcome in women with type 1 versus type 2 diabetes mellitus (DM). Material and methods. Multicentre retrospective study. Some 404 women were studied, 257 with type 1 DM and 147 with type 2 DM. Main outcome measures were rates of prematurity, macrosomia, instrumental deliveries, congenital malformations, need for neonatal intensive care unit (NICU), and perinatal mortality. Results. There were no significant differences in pregnancy outcome between women with type 1 and type 2 DM, except for an increased rate of instrumental deliveries in women with type 1 DM. In these women, duration of diabetes was a significant predictor of caesarean delivery (OR =1.06 (1.01–1.12); p = 0.02). Chronic hypertension was positively related to prematurity (p = 0.02), and proved to be a significant predictor of birth weight lower than 2,500 g (OR =3.54 (1.4–12.49); p = 0.043) and perinatal mortality (OR =10.6 (1.15–117.6); p = 0.04). In women with type 2 DM, third trimester higher glycosylated haemoglobin was related to both prematurity (OR 4.9 (1.7–14.4; p = 0.004) and low birth weight. Macrosomia was a significant risk factor for caesarean section. First trimester glycosylated haemoglobin was related to congenital malformations and proved to be a significant predictor of perinatal mortality (OR =2.4 (1.02–5.74); p = 0.04). Conclusions. Duration of DM and chronic hypertension were the most influential factors related to adverse perinatal outcomes in women with type 1 DM, and poor metabolic control and macrosomia in women with type 2 DM.

Prenatal Detection of Congenital Heart Defects: A Survey on Clinical Practice in Spain

Introduction: Second-trimester fetal screening for congenital heart defects (CHD) included in routine obstetric care provides relevant information for decision making. The aim of this study was to describe the clinical practice of prenatal detection of CHD in terms of the process and results. Methods: The characteristics and results of ultrasound screening for major CHD were documented using data provided by hospitals for a national survey in Spain over the period of 2004–2006. Sixty-seven percent of eligible centers (56/83), covering 36% of total births nationwide, responded to the survey; 33 of these returned complete data regarding the screening results. Results: The number of major CHD occurring in the centers which provided data with results of screening was 1,060. The overall prenatal detection rate of major CHD was 65.7% (95% CI 57.8–74.7), but the detection rate in the routine second-trimester scan was 52.6% (95% CI 45.6–60.8). In 61% of these cases the parents chose to terminate the pregnancy. Two independent predictors of increased detection by center were identified: first, the uniformity and systematic character of the examination of the heart showing at least the 4-chamber view and outflow tracts (prevalence ratio 1.3, 95% CI 1.0–1.8) and second, the local availability of specialists in fetal echocardiography (prevalence ratio 1.4, 95% CI 1.1–1.9). Conclusions: The detection of major CHD in the first half of pregnancy has an important impact on parental decision making. The prenatal screening program for CHD should be globally strengthened in terms of qualifications and methodological approaches. To improve its performance locally, close collaboration with fetal heart specialists should be promoted.

Obstetric and perinatal outcome in women with twin pregnancy and gestational diabetes

Objective: The aim of this study was to evaluate pregnancy complications and obstetric and perinatal outcomes in women with twin pregnancy and GDM. Study Design: An observational multicentre retrospective study was performed and 534 pregnant woman and 1068 twins infants allocated into two groups, 257 with GDM and 277 controls, were studied. Main Outcome Measures: Pregnant women characteristics, hypertensive complications, preterm delivery rate, mode of delivery and birthweight were analysed. Results: Pregnant women with GDM were older (p < 0.001) and had higher body mass index (p < 0.001) than controls. GDM was associated with higher risk of prematurity in twin pregnancy (odds ratio 1.64, 95% confidence interval [1.14–2.32], p = 0.005). This association was based on the association with other pregnancy complications. Birthweight Z-scores were significantly higher in the GDM group (p = 0.02). The rate of macrosomia was higher in the GDM group (p = 0.002) and small for gestational age (SGA) babies were significantly less frequent (p = 0.03). GDM was an independent predictor of macrosomia (p = 0.006). Conclusion: The presence of GDM in twin pregnancy was associated with a higher risk of hypertensive complications, prematurity and macrosomia, but significantly reduces the risk of SGA infants. Prematurity was related to the presence of other associated pregnancy complications.

Perinatal outcome of very low birthweight infants by mode of delivery

In order to evaluate the influence of mode of delivery on perinatal morbidity and mortality in vertex infants weighing less than 1500 g (VLBW), we made a retrospective study of 152 singleton newborns, in vertex presentation, with a birthweight of less than 1500 g, delivered in the Cruces Hospital (Vizcaya, Spain), a major perinatal referral center, between 1 January 1987 and 31 December 1989. Twins and infants with lethal congenital anomalies or gross intrauterine growth deviations were excluded from the study (n = 71). Of the infants studied (n = 81), 37 were delivered by cesarean section (mean weight 1120 ± 206 g, range: 680–1495 g) and 44 were delivered vaginally (mean weight 1029 ± 283g, range: 530–1475 g). The patients were divided into four groups: Group A: 500–749 g (n = 10); Group B: 750–999 g (n = 21); Group C: 1000–1249 g (n = 27); and Group D: 1250–1499 g (n = 23). The percentages of cesarean sections in each group were 10%, 42%, 66% and 39%, respectively. A comparison within each group of immediate perinatal outcome (Apgar score and umbilical vein cord pH), as well as mortality and sequelae up to 1 year of age did not yield any significant differences between cesarean and vaginal birth. We conclude that cesarean delivery does not appear to offer improved outcome over vaginal delivery in live births without congenital anomalies. For this reason, we believe that fetal weight should not be the only obstetrical variable considered when deciding whether or not to perform a cesarean section in these circumstances.

Clinical score for the outcome of external cephalic version: A two-phase prospective study

Aim:  To design a score based on clinical parameters to predict the outcome of external cephalic versions (ECVs) at term.

La episiotomía en España. Datos del año 2006

Resumen En una encuesta realizada por la Seccion de Medicina Perinatal de la SEGO, se ha podido comprobar que durante el ano 2006, la tasa de episiotomias en los partos eutocicos fue del 54,08% y en los partos instrumentales del 92,62%.

Influence of chorionicity in intra-partum management of twin deliveries.

Objective: To analyze morbidity and mortality in twin pregnancies as a function of the type of delivery and chorionicity. Design: Retrospective cohort study. Methods: Analysis of the type of delivery, intertwin time interval, and perinatal variables of >1000 twin deliveries during a 10-year period. Main outcome measure: Influence of delivery type and chorionicity on perinatal outcome. Results: The rate of cesarean sections was 42.4%. No differences were found as a function of chorionicity or as a function of presentation of the second twin. Cesarean sections were performed after vaginal delivery of the first twin in 1.8% of cases, being more common if the second baby was in a non-cephalic presentation (6.9% vs. 0.4%, p < 0.05). The average twin-to-twin delivery time interval was longer in the cases where the second had a cephalic presentation (8.26 ± 7.75 min vs. 6.81 ± 5.97 min, p < 0.05). The umbilical artery pH was lower the longer the interval between the birth of the twins, both in monochorionic and dichorionic. Conclusions: According to the results, vaginal delivery is as safe as elective caesarean section in twin pregnancies where the first twin is in cephalic presentation and the intrapartum management should not vary due to chorionicity.

Does fetal weight estimated by ultrasound really affect the success rate of external cephalic version

Objective. To determine whether fetal weight estimated by ultrasound on the day the external cephalic version (ECV) is related to the procedures success rate. Design. Retrospective cohort study. Setting. University hospital. Population or sample. Two hundred women with a singleton pregnancy undergoing an ECV attempt between March 2002 and March 2006. Method. Projected birthweight at delivery was calculated. Logistic regression analysis, by grams and by weight intervals, and multiple correspondence analysis were performed to determine whether or not the weight was related to the procedures success. Specific statistical analysis was undertaken to minimize measurement bias in fetal weight estimation. Main outcome measure. Success of ECV in relation to estimated fetal weight. Results. Measurement bias was ruled out because no statistically significant differences were identified with the Students t‐test (p>0.05), Bland–Altmans agreement analysis, and the interclass correlation coefficient analysis (ICC = 0.829; CI95% 0.772–0.871; p<0.01). By logistic regression analysis, a variable relation between fetal weight estimated by ultrasound and ECV success was detected, while multiple correspondence analysis suggested that variations in fetal weight are weakly related to the procedures success or failure. No relation was identified between ECV and birthweight (p = 0.38) when the delivery took place in the same week as the version. Conclusions. Estimated fetal weight before ECV seems not to be related to the outcome of ECV.