Nancy T. Field

Birth outcomes in teenage pregnancies

OBJECTIVE To evaluate and characterize the racial/ethnic differences in obstetric outcomes of early and late teenagers in California. METHODS A data-set linking birth and death certificates with maternal and neonatal hospital discharge records in California was utilized to identify nulliparous women (11 to 29 years of age) who delivered between January 1,1992 and December 31,1997. Pregnancy outcomes of early (11-15 year) and late (16-19 year) teenagers were compared to those of a control group of women aged 20-29. RESULTS Early (n = 31 232) and late teens (n = 271 470) demonstrated greater neonatal and infant mortality and major neonatal morbidities (delivery < 37 weeks of gestation and birthweight < 2500 g) when compared to pregnancies in the older control women (n = 662 752). Ethnicity adversely affected outcome with African-Americans of all ages having worse outcomes than whites. The higher rate of adverse obstetric outcomes among the teenage pregnancies occurred despite a lower cesarean section rate and was consistent across all ethnic groups. CONCLUSIONS When compared to women aged 20-29, all teen pregnancies were associated with higher rates of poor obstetric outcomes. Other factors besides teen pregnancy appear to be responsible for poor outcomes in certain ethnic groups.

Pregnancy outcomes in women with systemic lupus erythematosus

Objective : The purpose of this study was to examine pregnancy outcomes in women with systemic lupus erythematosus (SLE). Study design : Data from the California Health Information for Policy Project, which links records from birth certificates and hospital discharge records of mothers and newborns who delivered in all civilian hospitals in the state of California between 1 January 1993 and 31 December 1994, were retrospectively reviewed. Patients with a singleton gestation were stratified into the study group if they had a diagnosis of SLE, based on the International Classification of Disease, 9th Revision, or into the control group if they did not have SLE and delivered during the interval from 1 January 1994 to 31 December 1994. Specific maternal outcomes including pregnancy complications and fetal and neonatal outcomes were assessed and compared between the two groups. Results : During the 2-year study period, 555 women had a diagnosis of SLE, and approximately 600 000 women were included in the control group in the year 1994, giving a point prevalence of 0.05%. Specific adverse pregnancy outcomes, including hypertensive complications, renal disease, preterm delivery, non-elective Cesarean section, postpartum hemorrhage and delivery-related deep vein thrombosis all occurred more frequently in the SLE group as compared to controls ( p < 0.001). Additionally, neonatal and fetal outcomes were significantly worse in the SLE group, as documented by a higher prevalence of fetal growth restriction and neonatal death, as well as longer hospital stays ( p < 0.0001). Conclusion : SLE was associated with a significant increase in maternal pregnancy complications and in fetal and neonatal morbidity and mortality as compared to the control population. However, our population-based study found significantly fewer adverse outcomes than were previously reported. This may represent a more accurate clinical picture of the impact of SLE on pregnancy outcomes.

Is fetal heart rate variability a good predictor of fetal outcome

Objective. The purpose of this study was to investigate, in a prospective manner, whether fetal heart rate (FHR) variability serves as a reliable single predictor of fetal outcome.

Preeclampsia: is induction of labor more successful?

Objective To test the hypothesis that preeclamptic women are more readily inducible than are nonpreeclamptic women, regardless of cervical condition. Methods One hundred eighty-three preeclamptic women and 461 nonpreeclamptic women requiring labor induction were studied prospectively. Patients were categorized by Bishop score, parity, gestational age, and method of induction. Outcome variables were success of induction and cesarean delivery rates. Results Failed induction was significantly more common in the preeclamptic group (8.2% versus 1.7%; odds ratio [OR] 5.06; 95% confidence interval [CI] 1.97, 13.28), as was cesarean delivery (28% versus 16%; OR 2.09; 95% CI 1.36, 3.18). When controlled by logistic regression for Bishop score, parity, method of induction, epidural anesthesia, macrosomia, and gestational age, a fourfold higher risk of failed induction and a twofold higher risk of cesarean delivery were found in the preeclamptic group. Conclusions Induction of labor in preeclamptic women has a higher risk of failure and consequently of cesarean delivery than in nonpreeclamptic women. The vast majority of patients achieve vaginal delivery.

Perinatal effects of Gardnerella vaginalis deciduitis in the rabbit

OBJECTIVE We determined the effects of intrauterine infection with Gardnerella vaginalis on maternal and fetal outcome in the rabbit. STUDY DESIGN Both uterine horns of rabbits on day 20 or 21 of gestation (70% of gestation) were inoculated hysteroscopically with either 0.2 ml of 10(5) to 10(7) CFU/ml of G. vaginalis or saline solution. Animals were killed on day 4 or earlier if premature delivery occurred. The following outcome parameters were evaluated: febrile morbidity, preterm labor and delivery, maternal cultures, fetal birth weight, and fetal neuropathologic findings. RESULTS G. vaginalis intrauterine inoculation uniformly resulted in amnionitis and deciduitis. Animals inoculated with G. vaginalis had no greater incidence of fever and preterm delivery than did saline-treated control animals. However, intrauterine infection with G. vaginalis resulted in a significant decrease in the live birth rate when compared with that of controls (80% vs 95%, p < 0.03). G. vaginalis deciduitis was associated with as 23% reduction in the birth weight of the surviving fetuses. Furthermore, animals in the G. vaginalis study group had a 60% incidence of severe brain injury compared with 0% in the saline solution group. CONCLUSION G. vaginalis amnionitis and deciduitis produced minimal maternal morbidity but were associated with decreased birth weight and brain injury in surviving fetuses; thus it appears that G. vaginalis selectively functions as a fetal, but not maternal, pathogen in the rabbit.

Electronic fetal monitoring: What's reassuring?

BACKGROUND To determine which combinations of fetal heart rate pattern abnormalities are associated with normal outcome in term pregnancies. METHODS A cohort of 2200 consecutive deliveries was examined and the fetal heart rate tracings analyzed. Singleton, term patients without chorioamnionitis or serious malformations were used to perform logistic regression analysis to select those FHR patterns associated with increased risk for Apgar<7 and cord pH<7.15, or immediate adverse outcome. RESULTS Patients having no fetal heart rate abnormalities, mild variable decelerations, decreased variability, mild bradycardia, or accelerations present, constituted 84% of all fetal heart rate tracings. These tracings alone, or in combination, predicted 5 minute Apgar score> or =7 in 99.7%, cord pH> or =7.15 in 96.9% and no adverse neonatal sequelae in 96.2% of cases. Accelerations were reassuring regardless of FHR pattern. When these patterns were not present, non-reassuring tracings, the risk for immediate adverse outcome increased 50%. The non-reassuring tracings were both without accelerations and had tachycardia, prolonged bradycardia, severe variable or late decelerations, or a combination of these patterns. This increased risk was independent of the risk of confounders: i.e. thick meconium (1.8-fold), prolonged second stage of labor (>50 min., 1.5-fold), maternal disease (e.g. kidney, respiratory, 3-fold), or hypertensive disease (1.9-fold). CONCLUSIONS The great majority of fetal heart rate pattern abnormalities can be considered reassuring as they are within normal variations of a healthy fetus. The non-reassuring ones identify infants that truly require further evaluation by fetal scalp, vibroacoustic stimulation, or fetal scalp blood sampling.

The effect of clinical chorioamnionitis on cord blood gas at term

OBJECTIVE We sought to determine the effect of clinical chorioamnionitis on cord blood gas values in term pregnancies not complicated by any other disease. STUDY DESIGN 2200 consecutive deliveries were studied. Following exclusion of twins, non-viable malformations and stillbirths, as well as mothers with high-risk pregnancy diseases--i.e. hypertension, diabetes, preterm labor, third-trimester bleeding, IUGR, postdates, oligohydramnios, i.v. drug abused, decreased fetal movement, maternal viral infection, UTI or pneumonia (n = 897)--two groups of patients remained: term pregnancies complicated only by clinical chorioamnionitis (n = 81) and uncomplicated term pregnancies (n = 1246). RESULTS Evaluation of mean cord blood gas values revealed a significant difference in pH, PO2, PCO2 and BE values, with the infants of mothers with clinical chorioamnionitis having lower pH values (7.23 +/- 0.07 vs. 7.28 +/- 0.07). However, evaluating the independent effect of chorioamnionitis on arterial cord blood pH (using a logistic regression model) showed that clinical chorioamnionitis, by itself, did not contribute to this change in arterial cord blood pH. CONCLUSION Chorioamnionitis was neither the explanation nor the cause for differences in arterial cord blood pH found between the two groups in our study. In cases of chorioamnionitis, these differences were attributed to other factors, such as length of labor, mode of delivery, method of delivery and presence of meconium.

Placental Alpha Microglobulin-1 Compared With Fetal Fibronectin to Predict Preterm Delivery in Symptomatic Women

OBJECTIVE To compare the rapid bedside test for placental α microglobulin-1 with the instrumented fetal fibronectin test for prediction of imminent spontaneous preterm delivery among women with symptoms of preterm labor. METHODS We conducted a prospective observational study on pregnant women with signs or symptoms suggestive of preterm labor between 24 and 35 weeks of gestation with intact membranes and cervical dilatation less than 3 cm. Participants were prospectively enrolled at 15 U.S. academic and community centers. Placental α microglobulin-1 samples did not require a speculum examination. Health care providers were blinded to placental α microglobulin-1 results. Fetal fibronectin samples were collected through speculum examination per manufacturer requirements and sent to a certified laboratory for testing using a cutoff of 50 ng/mL. The coprimary endpoints were positive predictive value (PPV) superiority and negative predictive value (NPV) noninferiority of placental α microglobulin-1 compared with fetal fibronectin for the prediction of spontaneous preterm birth within 7 days and within 14 days. RESULTS Of 796 women included in the study cohort, 711 (89.3%) had both placental α microglobulin-1 and fetal fibronectin results and valid delivery outcomes available for analysis. The overall rate of preterm birth was 2.4% (17/711) within 7 days of testing and 4.2% (30/711) within 14 days of testing with respective rates of spontaneous preterm birth of 1.3% (9/703) and 2.9% (20/701). Fetal fibronectin was detected in 15.5% (110/711), and placental α microglobulin-1 was detected in 2.4% (17/711). The PPVs for spontaneous preterm delivery within 7 days or less among singleton gestations (n=13) for placental α microglobulin-1 and fetal fibronectin were 23.1% (3/13) and 4.3% (4/94), respectively (P<.025 for superiority). The NPVs were 99.5% (619/622) and 99.6% (539/541) for placental α microglobulin-1 and fetal fibronectin, respectively (P<.001 for noninferiority). CONCLUSION Although placental α microglobulin-1 performed the same as fetal fibronectin in ruling out spontaneous preterm delivery among symptomatic women, it demonstrated statistical superiority in predicting it.

Maternal and neonatal outcomes among scheduled versus unscheduled deliveries in women with prenatally diagnosed, pathologically proven placenta accreta

Abstract Objective: To evaluate maternal and neonatal outcomes among scheduled versus unscheduled deliveries in cases of prenatally diagnosed, pathologically proven placenta accreta. Study design: Retrospective cohort of placenta accreta cases delivered in five University of California hospitals. Results: Of 151 cases of histopathologically proven placenta accreta, 82% were prenatally diagnosed. Sixty-seven percent of women underwent scheduled deliveries and 33% were unscheduled. There were no differences in demographics between groups except a higher rate of antepartum bleeding in the unscheduled delivery group (81 versus 53%; p = .003). Scheduled deliveries were associated with a later gestational age at delivery (34.6 versus 32.6 weeks; p = .001), lower blood loss (2.0 versus 2.5 l; p = .04), higher birth weight (2488 versus 2010 g; p < .001), shorter postpartum length of stay (4 versus 5 d; p = .03) and neonatal length of stay (12 versus 20 d; p = .005). Conclusion: Despite a prenatal diagnosis of placenta accreta, 1/3 of these cases require unscheduled delivery, portending poorer maternal and neonatal outcomes.