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Abstract Objective: To determine pregnancy outcome in patients with short cervix on transvaginal ultrasound between 16 and 24 weeks' gestation treated with McDonald cerclage compared to weekly intramuscular injections of 17 alpha-hydroxyprogesterone caproate (17OHP-C). Methods: From November 2003 through December 2006, asymptomatic, singleton pregnancies were screened with transvaginal ultrasound between 16-24 weeks' gestation. Patients with a cervical length (CL)

Objective: Our purpose was to determine the efficacy of the obstetric forceps versus the M-cup, a new vacuum extractor cup, and maternal-neonatal complication rates.Study Design: Over a 10-month period operative vaginal deliveries were randomized between the obstetric forceps and the M-cup vacuum extractor cup. Maternal demographics, indication for intervention, analgesia, position, station, degree of asynclitism, fetal caput-molding, and time from application to delivery were prospectively recorded. Episiotomy and extensions, lacerations, and the reason for abandonment of the randomized instrument were noted in both groups. Fetal weight, Apgar scores, cord arterial gases, hyperbilirubinemia, phototherapy, and any evidence of fetal trauma were documented at delivery or in the nursery.Results: Six hundred thirty-seven women were randomized, 315 in the forceps group and 322 in the M-cup group. There were no differences in maternal demographic variables. The station, position, degree of asynclitism, or requirement for rotation was not different between the groups. The corrected efficacy rates were forceps 92% and M-cup 94% (p = 0.217). The M-cup deliveries were accomplished more rapidly than forceps deliveries (p < 0.001) and were associated with a lower rate of episiotomy (p < 0.001), third-degree (p < 0.001) and fourth-degree (p = 0.002) lacerations, but blood loss as clinically estimated (p = 0.232) or as measured by hemoglobin levels (p = 0.166) was not significantly different. Forceps deliveries were associated with fewer clinically diagnosed cephalhematomas (p = 0.015) than M-cup deliveries were, but there were no differences in the number of neonates diagnosed with hyperbilirubinemia (p = 0.377) or in the number of infants treated with phototherapy (p = 0.660).Conclusions: The M-cup vacuum extractor cup appears to be as efficient (and faster) than the obstetric forceps but is associated with significantly more fetal cephalhematomas, whereas maternal injuries are more common with the forceps. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to identify the risk factors that are associated with increased neonatal morbidity in patients who were treated for sonographic evidence of internal os dilation and distal cervical shortening during the second trimester., Study Design: From May 1998 to June 2000 patients between 16 and 24 weeks of gestation with the following sonographic criteria were randomly assigned to McDonald cerclage or no cerclage: internal os dilation and either membrane prolapse into the endocervical canal at least 25% of the total cervical length but not beyond the external os or a shortened distal cervix <2.5 cm. Before randomization, all patients were treated identically with an amniocentesis, multiple urogenital cultures, and therapy with indomethacin and clindamycin for 48 to 72 hours. Except for the cerclage, all patients were treated identically after randomization. Multiple variables of perinatal outcome were analyzed. A regression model with gestational age at delivery as the dependent variable was constructed and repeated with neonatal morbidity as the dependent variable. This model was applied to 3 populations: the cerclage group, the no cerclage group, and both groups combined., Results: Of the 135 patients, 20 patients declined randomization, and 2 patients were diagnosed with acute chorioamnionitis. Of the 113 patients remaining, 55 patients were randomly assigned to the cerclage group, and 58 patients were randomly assigned to the no cerclage group. There were 8 rescue cerclage procedures (4 in each group). Regression analysis showed that readmission for preterm labor, chorioamnionitis, and abruption were consistently associated with early gestational age at delivery and increased morbidity. Cerclage did not affect perinatal outcome., Conclusion: The sonographic findings of second trimester internal os dilation, membrane prolapse, and distal cervical shortening likely represent a common pathway of several pathophysiologic processes. Use of cerclage does not alter any perinatal outcome variables. Increased neonatal morbidity in these patients appears to be associated with subclinical infection, preterm labor, and abruption.

Objective: To determine if the addition of a mechanical ripening agent (transcervical Foley balloon) to a pharmacologic agent (intravaginal misoprostol) improves the efficiency of preinduction cervical ripening., Study Design: Singleton patients with an indication for delivery, unfavorable cervix (Bishop score < or = 5) and no contraindication to labor were randomly assigned to two groups: misoprostol alone (25 micrograms intravaginally every 3 hours for no more than 12 hr) or combination therapy (25-French transcervical Foley balloon inflated to 50 mL of sterile water with identical intravaginal misoprostol dosing). All patients received a history and physical examination (including Bishop score), preripening ultrasound, electronic fetal heart rate and contraction monitoring (to rule out spontaneous labor and document fetal well-being). Multiple variables of perinatal outcome were analyzed, including the main outcome variables of ripening-to-delivery time and cesarean section rate., Results: During August 1998 to August 1999, 81 patients were randomized, 40 to misoprostol alone and 41 to combination therapy. There were no differences between the groups with respect to maternal demographics, preripening Bishop score, maternal complications, intrapartum intervention or neonatal outcome. The misoprostol group spent longer periods of time in active labor, and there was a trend for the combination group to require oxytocin for longer intervals. These findings did not significantly affect the total ripening-to-delivery time or cesarean section rate which were similar for both groups., Conclusion: The addition of mechanical ripening with a transcervical Foley balloon to intravaginal misoprostol did not improve the efficiency of preinduction cervical ripening. Mechanical and pharmacologic cervical ripening agents appear to act independently rather than synergistically.

Background: Risk factors for and management of intrauterine fetal demise (IUFD) have been investigated, but the maternal morbidity has not been evaluated., Methods: Over a 60-month interval, all cases of IUFD after 20 weeks' gestation were reviewed for maternal trauma and maternal postpartum complications., Results: In this retrospective analysis, 498 singleton and 24 twin pregnancies with an IUFD were identified. A cervical or perineal laceration requiring surgical repair complicated 9.4% of pregnancies. One uterine dehiscence and one uterine rupture occurred. Endometritis, the most common postpartum complication, occurred in 63 of 522 patients (12%). One maternal death occurred. Total mean hospital stay was 4.9 +/- 5.7 days., Conclusion: Maternal morbidity and rarely mortality can follow IUFD, but this morbidity is similar to that observed without IUFD.

Objective: To assess the clinical efficacy of pharmacologic, mechanical and combination techniques of cervical ripening., Study Design: From March 1997 to August 1998, all cervical-ripening patients at Lehigh Valley Hospital were randomly assigned to three groups: intravaginal misoprostol, intracervical Foley catheter, or combination prostaglandin E2 (PGE2) gel and Foley catheter. Inclusion criteria included Bishop score < or = 5 and no contraindication to labor. The remaining delivery process was actively managed according to established guidelines. Multiple variables in perinatal outcome were analyzed, with the cesarean section rate and time from ripening to delivery as the main outcome variables., Results: Of the 205 patients, 65 were randomized to the misoprostol group, 71 to the Foley group and 69 to the catheter-and-gel group. There were no differences between groups in delivery indications, maternal demographics, ultrasound findings, labor interventions, intrapartum times, mode of delivery, postpartum complications or neonatal outcomes. The misoprostol group demonstrated a higher rate of uterine tachysystole and required oxytocin less when compared to the two catheter groups., Conclusion: The higher rate of uterine tachysystole with misoprostol did not increase the cesarean section rate. The higher rate of oxytocin required by the two catheter groups did not increase the delivery time intervals. There appears to be no benefit to adding intracervical or intravaginal PGE2 gel to the intracervical Foley balloon. The misoprostol and catheter ripening techniques have similar safety and efficacy.

Objective: The aim of this study was to compare perinatal outcomes of patients with second-trimester ultrasonographic evidence of preterm dilatation of the internal os treated with cerclage versus those of patients not treated with cerclage., Study Design: From May 1998 through June 1999 patients with ultrasonographic evidence of preterm dilatation of the internal os between 16 and 24 weeks' gestation were randomly assigned to receive a McDonald cerclage or no cerclage. Before random assignment all patients underwent amniocentesis and urogenital cultures and then received 48 hours of therapy with indomethacin and antibiotics. After treatment each patient was followed up as an outpatient with bed rest and weekly ultrasonographic evaluation., Results: Of the 61 patients 31 were randomly assigned to cerclage and 30 were randomly assigned to no cerclage. There were no differences between groups with respect to maternal demographic characteristics, risk factors for preterm birth, cervical measurements, rescue procedures, readmission, chorioamnionitis, and abruptio placentae. The mean gestational age at delivery (33.5 +/- 6.3 weeks) and the perinatal death rate (12. 9%) in the cerclage group were similar to the mean gestational age at delivery (34.7 +/- 4.7 weeks; P =.4) and the perinatal death rate (10.0%; P =.9) in the no-cerclage group., Conclusion: Treatment with McDonald cerclage of preterm dilatation of the cervix detected ultrasonographically during the second trimester did not improve perinatal outcomes.

Objective: To determine if maternal hypoglycemia is associated with adverse perinatal outcome, particularly low birth weight., Study Design: In this prospective study, all patients after 24 weeks' gestation were screened for gestational diabetes using 50 gm of glucola (oral) followed by a 1-hour plasma glucose measurement and hypoglycemia was defined as < or = 88 mg/dl., Results: In these 426 women the mean (+/- SD) 1-hour plasma glucose value was 99.8 +/- 22.7 mg/dl. Of these, 16 were diagnosed with gestational diabetes and 46 were lost to follow-up leaving 364 patients; 116 with hypoglycemia and 248 with euglycemia. Women with hypoglycemia weighed less at the beginning of pregnancy and at delivery, but total weight gain during pregnancy was similar between both groups. There was no difference between groups in maternal symptomatology, birth weight, or the rate of fetal growth restriction., Conclusion: Hypoglycemia on the 1-hour glucola screen is not predictive of fetal growth restriction or other adverse perinatal consequence.

A systematic approach to the prenatal and postnatal evaluation of the patient at risk for fetal skeletal anomalies is outlined. The more common anomalies are described within a differential diagnosis table, and a case study is presented.

A retrospective study was performed comparing centralized monitoring to noncentralized monitoring in regard to perinatal outcome. The study was conducted at Lehigh Valley Hospital (Allentown, PA) between August 1994 and February 1995. All deliveries during a 28-week-period were studied retrospectively. The study was designed such that for 14 weeks all patients were centrally monitored (Group A). During the following 14 weeks, no patients were centrally monitored (Group B). Patients not requiring monitoring, such as elective cesarean sections, were excluded from the study. The variables that were studied were the 5-minute Apgar, cord blood pH, perinatal mortality, admissions to the neonatal intensive care unit (NICU), spontaneous vaginal deliveries, cesarean sections, and operative vaginal deliveries. A total of 1,622 deliveries occurred during the 28 weeks of antenatal care. Group A consisted of 805 centralized monitored patients and Group B had 817 noncentralized monitored patients. There was no statistical difference in the 5-minute Apgar, umbilical artery pH, perinatal mortality, or the NICU admissions between the two groups. However, there was a significant statistical difference in the percent of cesarean sections performed for nonreassuring fetal heart rate tracings (Group A, 17.89% vs. Group B, 12.16%; P = 0.02). The overall cesarean section rate was increased in the centrally monitored group (Group A, 23.6% vs. Group B, 18.1%; P = 0.01). There were also statistically significant differences in operative vaginal deliveries (forceps and vacuum) for fetal heart rate abnormalities between Group A, 0.52% vs. Group B, .39% (P = 0.05). Centralized monitoring may be associated with an increase in the overall cesarean section rate. In addition, the rate of operative vaginal and abdominal deliveries appears to be increased for the indication of nonreassuring fetal heart rate tracings with the use of centralized monitoring.

Objective: This study was designed to determine whether epidural anesthesia would improve external cephalic version success in a safe and effective manner., Study Design: All women > 37 weeks' gestation with breech presentation scheduled for external cephalic version at the medical center from Dec. 1, 1993, to July 31, 1996, were randomized to receive an epidural or no epidural anesthesia. Under ultrasonographic guidance up to three version attempts were performed., Results: Sixty-nine women were randomized to receive epidural (n = 35) versus no epidural (n = 34) anesthesia for external cephalic version. There were no statistically significant differences in maternal age, parity, maternal weight, gestational age, estimated fetal weight, or station of the presenting part. The success rate was better for the epidural group (relative risk 2.12, 95% confidence interval 1.24 to 3.62). Neither anterior placentation or oligohydramnios affected the success rate., Conclusion: Epidural anesthesia increases success of external cephalic version without any apparent detrimental effect on the maternal-fetal unit.

Objective: To identify factors involved in the development of fetal cephalohematoma from vacuum extraction., Study Design: Patients at > or = 34 weeks' gestation were randomly assigned to delivery by vacuum (n = 322) using the continuous (n = 164) or intermittent (n = 158) technique. Neonatal outcome with cephalohematoma was analyzed subsequently and related to prospectively recorded data., Results: Approximately equal numbers of cephalohematoma were recorded in the two groups (continuous 20, intermittent 17; P = .686). Station at point of application (P = .008), increasing asynclitism (P < .001) and increasing application to delivery time (P = .002) correlated significantly with cephalohematoma. Only the last two factors achieved significance after stepwise multiple logistic regression analysis. Factors that did not achieve statistical significance were gestational age (P = .755), birth weight (P = .982), instrumental rotation (P = .896) and previous vaginal delivery (P = .051)., Conclusion: In this prospective, randomized, controlled trial of vacuum-assisted delivery, the only predelivery factor found to predispose to neonatal cephalohematoma formation was increasing asynclitism. Although cephalohematoma formation was more likely to develop as the duration of vacuum application increased during delivery, only 28% of neonates exhibited this finding when the time from vacuum application to delivery exceeded five minutes.

Our objective was to determine the factors involved in the development of shoulder dystocia in association with operative vaginal delivery. In this prospective study, patients who were candidates for operative vaginal delivery were randomized either to forceps (N = 315) or vacuum with M-cup (N = 322) and timed from initial placement of instrument to final delivery. Data were gathered prior to and after instrumental delivery. Statistics used were Pearson chi square, Fisher's exact, analysis of variance, and multiple logistic regression. There were a total of 21 patients with shoulder dystocia in both groups (3.3% incidence). Discriminant factors that did nor meet significance included use of epidural analgesia (P = .12), station (P = .99), previous vaginal delivery (P = .99), fetal gender (P = .54), indication for operative vaginal delivery (P = .63), > 45 degrees rotation (P = .68), use of episiotomy (P = .62), maternal weight (P = .26), and maternal diabetes (P = .08). Nearly attaining significance in univariate analysis was randomization to vacuum (P = .052). Significant factors included gestational age (P = .03), time required to effect delivery (P = .007), and birthweight (P = .0001). When these factors were subjected to stepwise multiple logistic regression, three factors remained as significant associations with shoulder dystocia: randomization to vacuum (P = .04), time for delivery (P = .03), and birthweight (P = .0001). In this operative vaginal delivery trial, shoulder dystocia was strongly associated with large fetal size, longer time to delivery, and the use of vacuum for delivery.

Objective: To determine whether two techniques of vacuum extraction delivery-continuous vacuum and intermittent vacuum-have different effects on maternal-fetal outcomes., Methods: Patients to be delivered by vacuum extraction were randomized to receive continuous or intermittent vacuum. All deliveries were performed using the M-cup. In the continuous group, the level of vacuum was brought to 600 mmHg between contractions and was maintained at that level until delivery of the infant. Active efforts were made to prevent fetal loss-of-station between contractions by maintaining traction. In the intermittent group, the level of vacuum was decreased to 100 mmHg between contractions and no effort was made to prevent fetal loss-of-station., Results: A total of 322 patients were randomized: 164 in the continuous arm and 158 in the intermittent group. The continuous method did not effect delivery faster (continuous 167 +/- 175 seconds versus intermittent 167 +/- 150 seconds; P = .97), nor did it lead to a reduction in method failures (continuous 12, intermittent nine; P = .72). The intermittent method did not appear to offer any benefit to the neonate regarding cephalhematoma formation (continuous 20, intermittent 17; P = .686) or any other measure of neonatal outcome. Maternal lacerations and episiotomy extensions were evenly distributed between the groups. Overall, the efficacy rate of the vacuum cup was 93.5% and the cephalhematoma rate was 11.5%., Conclusion: No differences in maternal or fetal outcome could be demonstrated if the level of vacuum was decreased between contractions or if an effort was made to prevent fetal loss-of-station. The clinical results obtained in this trial using the M-cup are similar to the published results with the stainless-steel Malmstrom cup.

Objective: To assess the effect of home uterine contraction assessment (HUCA) in twin pregnancies with preterm labor (PTL) at < 24 weeks' gestation., Study Design: In this retrospective, analytic study, patients were stratified by whether HUCA had been prescribed before or after diagnosis of PTL. The main outcomes studied were time of PTL diagnosis and delivery as well as birth weight and need for neonatal intensive care unit (NICU) admission. In 63 patients, 32 were prescribed HUCA after PTL had been arrested at < 24 weeks (group I). Thirty-one women had HUCA prescribed at 20 weeks' gestational age and then developed PTL at < 24 weeks (group II)., Results: Labor was diagnosed at similar times in both groups (22.8 vs 23.4 weeks), but delivery was earlier in group I (27.6 weeks vs. 34.7 weeks) than in group II. The birth weight in group I was less (918 +/- 255 g), and of the 64 infants, 55 required NICU admission as compared to 2,340 +/- 525 g and 11 of 62 infants (P < .0001, .0001) in group II, respectively., Conclusion: Women with twin gestations and the diagnosis of PTL prior to 24 weeks deliver later in gestation, and their infants weigh more and have fewer NICU admissions if intensive prenatal surveillance is prescribed prior to the onset of labor.

Objective: Our purpose was to determine whether lowering the diagnostic threshold for gestational diabetes mellitus on 3-hour 100 gm oral glucose tolerance testing will select a population at risk for adverse perinatal outcome., Study Design: In this retrospective study 434 patients with an abnormal 50 gm glucose screen result (> or = 140 mg/dl) underwent a standardized 3-hour oral glucose tolerance test. The results were stratified according to maternal weight and the criteria recommended by Sacks or Carpenter. Birth weight and rate of macrosomia were the primary perinatal outcome variables analyzed., Results: Analysis of the data set stratified according to the Sacks criteria revealed results very similar to the Carpenter criteria data set. Patients who would have been newly diagnosed with gestational diabetes mellitus only if the lowered criteria were used (group 2) were older and heavier. No other variable comparisons achieved statistical significance. When the same patients were stratified according to prepregnancy weight, overweight patients were older, gained less weight during the third trimester, underwent cesarean section more often, and had higher cumulative maternal morbidity. Regression analysis showed that the degree of hyperglycemia did not predict macrosomia or influence birth weight, but prepregnant maternal body mass index was associated with macrosomia., Conclusions: Fetal macrosomia is influenced by maternal prepregnant body mass index. Lowering the glucose tolerance test threshold would result in overdiagnosis of gestational diabetes mellitus without improving perinatal outcome.

Objective: Our purpose was to determine whether maintenance oral tocolytic therapy after preterm labor stabilization decreases uterine activity, reduces the rate of recurrent preterm labor and subsequent preterm birth, or improves neonatal outcome., Study Design: Women with documented idiopathic preterm labor stabilized with acute tocolytic therapy were randomized to three groups: placebo, terbutaline 5 mg, or magnesium chloride 128 mg, all given orally every 4 hours. Patients and providers were blinded to group assignment. All subjects were enrolled in a comprehensive system of preterm birth prevention that included preterm labor education, weekly clinic visits, home uterine contraction assessment, daily phone contact, and 24-hour perinatal nurse access., Results: Of the 248 patients who were randomized, 39 were delivered before discharge and 4 were lost to follow-up, leaving 205 for final analysis: 68 placebo, 72 terbutaline, and 65 magnesium. The terbutaline group had significantly more side effects than the placebo group did. All groups had otherwise similar perinatal outcomes when confounding variables were controlled for. Overall, the three groups had a preterm birth rate < 37 weeks of 55.6% delivery, < 34 weeks of 15.6%, a 20.4% rate of newborn intensive care unit admission, and a mean neonatal length of stay of 6.3 days., Conclusions: Maintenance oral tocolytic therapy did not decrease uterine activity, reduce the rate of recurrent preterm labor or preterm birth, or improve perinatal outcome. Overall improvement in perinatal outcome may be achieved with a comprehensive program of preterm birth prevention without the use of maintenance oral tocolytic therapy.

Objective: Our purpose was to determine the incidence of adverse cardiovascular effects of terbutaline sulfate when administered as a continuous subcutaneous infusion in women with arrested preterm labor., Study Design: Over a 6-year period records from 8709 women prescribed this therapy for preterm labor that had previously been arrested with other intravenous tocolytics were reviewed. These women were assessed daily for cardiovascular complaints and tolerance of the medication, while either in the hospital or at the home (by telephone). The main outcomes studied were the occurrence of pulmonary edema, sustained cardiac arrhythmias, chest pain, or myocardial ischemia. Any maternal death regardless of cause was also reviewed., Results: Of the 8709 subjects, 47 (0.54%) had one or more cardiopulmonary problems. Pulmonary edema developed in 28 patients (0.32%) while receiving continuous subcutaneous infusion of terbutaline, 5 at home and 23 in the hospital. Of the total, 17 women were being treated concurrently with large amounts of intravenous fluids and one to three other tocolytic agents. In the 11 remaining subjects, 4 were diagnosed with pregnancy-induced hypertension and/or multiple gestation. Nineteen patients experienced other adverse cardiovascular effects, including electrocardiogram changes, irregular heart rate, chest pain, or shortness of breath., Conclusions: Continuous terbutaline infusion for women with stabilized preterm labor is associated with much fewer adverse effects than previous literature regarding intravenous beta-adrenergic agonist therapy would suggest.

During the last decade it has been shown that patients with major sickle hemoglobinopathies can experience a normal reproductive outcome. This has been accomplished with early aggressive prenatal care, effective counseling, and appropriate intervention by providers with a high index of suspicion for factors that lead to untoward outcomes in such women. Because controversy surrounds the use of transfusion therapy for pregnant patients with sickle cell disease, individualization should depend on patient circumstances and provider experience because this is a key factor in the management of these women. New therapies for those with major sickle hemoglobinopathy are on the horizon, but their use in pregnancy awaits further evaluation.

From July 1, 1988 to June 30, 1989, programs were initiated at the 93d Strategic Hospital at Castle AFB, California, to lower the cesarean (C/S) rate. Programs included vaginal birth after cesarean, external cephalic version, adequate labor documentation, and peer review of all C/S for fetal distress. One year prior (N = 467) was compared to the year after the start of these programs (N = 430). A significant decrease of 21.2% to 10.2% (p < 0.0001) was documented. We conclude that aggressive management of obstetrical patients can reduce the rate of C/S in a small USAF hospital without increasing maternal or neonatal risk.

Endocervical curettage (ECC) is an important tool in the diagnosis and treatment of cervical neoplasia. Its use has been limited, however, because of the pain it can cause. We show that the use of a soft plastic curette cause statistically less pain without compromising the quantity or quality of the sample.