Search

Objective The purpose of this study was to evaluate the efficacy of sublingual nitroglycerin as a tocolytic agent for external cephalic version in parous women. Study design A double-blinded randomized controlled trial was performed. Patients with parity of ≥1 at 36 to 40 weeks of gestation who were eligible for external cephalic version were included. Patients were randomized to receive either two sublingual sprays of 400 μg of nitroglycerin or two sprays of placebo 3 minutes before the trial of external cephalic version. Rates of successful external cephalic version and side effects were compared between groups. Results Of 99 patients in the study, 50 patients received sublingual nitroglycerin, and 49 patients received placebo. There were no differences in maternal age, gestational age, estimated fetal weight, amniotic fluid index, and placental location between the two groups. The success rate of external cephalic version was 48% in the nitroglycerin group compared with 63% in the placebo group ( P =.13). There was a higher incidence of headaches in the nitroglycerin group (42% vs 4%, P Conclusion Sublingual nitroglycerin was associated with a higher rate of headache and did not improve the rate of successful external cephalic version.

Objective: The purpose of this study was to compare the efficacy of sublingual nitroglycerin with that of intravenous ritodrine as a tocolytic agent for external cephalic version in nulliparous women. Study Design: We performed a double-blinded, randomized trial. Nulliparous patients, between 36 and 40 weeks of gestation, were assigned randomly to receive either (1) an intravenous infusion of ritodrine (111 μg/min) for 20 minutes, followed by two puffs of sublingual placebo or (2) an intravenous infusion of sodium chloride 0.9% (placebo) for 20 minutes, followed by two puffs of sublingual 0.4 mg of nitroglycerin. Three minutes after the administration of the sublingual spray, an external cephalic version was attempted. The rate of successful external cephalic version and side effects was compared between groups. Results: Of 74 randomly assigned patients, 38 patients received intravenous ritodrine, and 36 patients received sublingual nitroglycerin. Although not statistically significant, the rate of the successful external cephalic version was higher in the ritodrine group compared with the nitroglycerin group (45% vs 25%, P =.075). The rate of headaches was higher in patients who received nitroglycerin (28% vs 8%, P =.02). Mean blood pressure and maternal heart rate were lower in the nitroglycerin group 10 minutes after the administration of the medication. However, there was no significant difference in the rate of palpitations, hypotension, or fetal bradycardia between the two groups. Conclusion: When compared with intravenous ritodrine, sublingual nitroglycerin was associated with a higher rate of headache, lower blood pressure, and a trend toward a lower rate of successful external cephalic version. (Am J Obstet Gynecol 2003;188:1454-9.)

Objective: This study was undertaken to compare the efficacy and safety of intravenous administration of atosiban versus ritodrine for the treatment of preterm labor. Study Design: Women with preterm labor and intact membranes diagnosed at 23 to 33 gestational weeks (n = 247) were randomly assigned to treatment arms and received atosiban (6.75 mg intravenous bolus, 300 μg/min for 3 hours, then 100 μg/min intravenously) or ritodrine (0.10-0.35 mg/min intravenously) for as long as 18 hours. Tocolytic effectiveness was assessed in terms of the numbers of women who had not been delivered after 48 hours and after 7 days. Safety was assessed in terms of maternal side effects and neonatal morbidity. Secondary outcomes included mean gestational age at delivery and mean birth weight. An intent-to-treat analysis was performed with the Cochran-Mantel-Haenszel test. Results: The proportion of women who had not been delivered at 48 hours was 84.9% (n = 107) in the atosiban group and 86.8% (n = 105) in the ritodrine group. At 7 days 92 women had still not been delivered in both the atosiban (73.0%) and ritodrine (76.0%) groups. Neither of these differences was statistically significant. The incidence of maternal cardiovascular side effects was substantially lower in the atosiban group (4.0% vs 84.3%, P < .001). In addition, intravenous therapy was terminated more frequently as a result of maternal adverse events in the ritodrine group (29.8%) than in the atosiban group (0.8%). The overall occurrences of fetal adverse events in the two treatment groups were comparable. Neonatal morbidity was similar between the treatment groups after adjustment for unbalanced enrollment of women with multiple pregnancies and for gestational ages within treatment groups. Conclusion: Atosiban was comparable in clinical effectiveness to conventional ritodrine therapy but was better tolerated than ritodrine, with no evidence of significant maternal or fetal adverse events. Neonatal morbidity, which was similar between the two treatment arms, was apparently related to the gestational age of the infant rather than to the exposure to either tocolytic agent. (Am J Obstet Gynecol 2000;182:1191-9.)

OBJECTIVE: Our purpose was to study the effect of ritodrine tocolysis on the success rate of external cephalic version at ≥36 weeks' gestation. STUDY DESIGN: This was a prospective, double-blinded, randomized study. All patients were at ≥36 weeks' gestation, confirmed by early ultrasonography. External cephalic version assessment included nonstress testing before and after external cephalic version and ultrasonographic evaluation of type of breech, estimated fetal weight, position of placenta and fetal spine, and amniotic fluid index. Patients were excluded if the breech was not mobile or if they had any contraindications to tocolysis or external cephalic version. After randomization 283 patients received either ritodrine (111 μg/min) or identical placebo by intravenous infusion for ≥20 minutes. Up to three attempts at external cephalic version under ultrasonographic surveillance were performed. With an α error of 0.05 and a β of 0.2, 264 patients were required to complete this study. RESULTS: There were no differences between study groups in maternal age, body mass index, gestational age, amniotic fluid index, position of fetal spine, and placental location. Statistical analysis controlled for parity because parity had a major influence on success rates. There was a higher success rate in the group receiving ritodrine tocolysis (52% vs 42%, p = 0.028). Ritodrine improved success rates in nulliparous patients (43% vs 25%, p = 0.026) but not in parous subjects (66% vs 58%, p = 0.385). CONCLUSION: Ritodrine tocolysis improves the success rate of external cephalic version performed at ≥36 weeks in nulliparous patients. (Am J Obstet Gynecol 1996;175:859-61.)

The purpose of this study was to evaluate the rate and indications of cesarean delivery after a successful external cephalic version.A case-control study was performed from patients who were delivered in a tertiary care center between 1987 and 2000. Each patient who underwent a successful external cephalic version (study group) was compared with the next woman with the same parity, who was delivered at term (control group). Nulliparous and multiparous women were analyzed separately. Chi-squared, Mann-Whitney, and Student t tests were used for statistical analysis. Multivariate logistic regression analysis was performed where appropriate.A total of 602 patients were included in this study. The rates of cesarean delivery in nulliparous women (29.8% vs 15.9%; P.001) and in multiparous women (15.9% vs 4.7%; P.001) were significantly higher when compared with the control group. Patients with successful external cephalic version were more likely to have a cesarean delivery for dystocia (nulliparous, 22.5% vs 11.9%; P=.01; multiparous, 10.9% vs 1.3%; P.01). After an adjustment for confounding variables, a successful external cephalic version was associated with an increased rate of cesarean delivery at term (nulliparous: odds ratio, 2.04; 95% CI, 1.13-3.68; multiparous: odds ratio, 4.30; 95% CI, 1.76-10.54).The rate of cesarean delivery for dystocia is increased after a successful trial of external cephalic version in both nulliparous and multiparous women.

This study was undertaken to assess the association between amniotic fluid index (AFI), success of external cephalic version (ECV), and obstetric outcome in patients undergoing ECV.A prospective observational study was performed that included all patients who had a trial of ECV from 1987 to 2000 in our center. Rates of success, fetal heart decelerations during trial at ECV, and cesarean deliveries were calculated. Groups were divided by an AFI performed immediately before ECV: AFI less than 10 cm, 10 to 15 cm, and more than 15 cm.In our group of 1361 patients undergoing ECV, the rate of success was related to the AFI in both parous women (49.1%, 63.5% and 72.1% [P.001] for each AFI group, respectively) and nulliparous women (36.5%, 43.6%, and 57.3% [P.001]). The rate of cesarean section delivery was related to AFI in nulliparous but not multiparous patients (P.001). The rate of prolonged fetal heart rate decelerations was not significantly related to the AFI.The rate of successful ECV and cesarean section deliveries is related to the amniotic fluid volume. This information may be used to consent patient before a trial of ECV.

Ultrasonographic determination of biparietal diameter/femur length ratios performed at 16 or 17 weeks' gestation in fetuses with trisomy 21 were not statistically different from those of 155 normal fetuses. It appears that this test could not be used for screening for trisomy 21.

Detachment of the cervix, either complete (annular) or partial, during labor is a rare complication.':" Management of this complication has been, in most instances, routine excision of the damaged cervix. I, 2, 4 With the exception of the report by Pelosi and associates," an attempt at repair has not been advocated. Therefore, the purpose of the following is to report a term delivery which took place through a partial detachment of the anterior lip of the cervix and successful postpartum repair.

The nonstress test remains the most widely used method of antepartum fetal health assessment in multiple gestations. However, few data are available on factors influencing its results in those cases. Our observation on 530 such tests has shown results similar to those in singleton gestations. Prematurity was associated with a higher rate of nonreactive tests; however, order and mode of presentation had no impact.