A randomized, double-blinded, controlled trial comparing parenteral normal saline with and without dextrose on the course of labor in nulliparas

OBJECTIVE

The objective of the study was to compare intravenous normal saline with and without dextrose on the course of labor in nulliparae.

STUDY DESIGN

In a double-blinded, controlled trial, term, nulliparae with singletons in active labor were randomized into 1 of 3 groups receiving either normal saline (NS), NS with 5% dextrose (D5NS), or NS with 10% dextrose (D10NS) at 125 mL/h. The primary outcome was total length of labor from onset of study fluid in vaginally delivered subjects. Maternal and neonatal outcomes were also analyzed.

RESULTS

Of 300 subjects enrolled, 289 met inclusion criteria and completed the study. In vaginally delivered subjects, significant differences were noted in the second stage (P = .01) and total length of labor (P = .02). No significant differences were observed in the cesarean section rates between the groups (P = .21). No differences were noted in maternal or neonatal secondary outcomes.

CONCLUSION

Administration of a dextrose solution, regardless of concentration, was associated with a shortened labor course in term vaginally delivered nulliparae subjects in active labor.

Impact of a 'rescue course' of antenatal corticosteroids: a multicenter randomized placebo-controlled trial

OBJECTIVE

Previous studies using repetitive courses of antenatal corticosteroids (ACS) have demonstrated marginal or no benefit and concern over potential risk. No prior prospective or randomized studies have evaluated the option of a single rescue course of ACS on neonatal outcome.

STUDY DESIGN

A multicenter randomized double-blind placebo-controlled trial was performed from May 2003 through February 2008 in 18 private (15) and university (3) medical centers. Patients with singletons or twins < 33 weeks who had completed a single course of ACS before 30 weeks and at least 14 days before inclusion, and were judged to have a recurring threat of preterm delivery in the coming week, were included. Patients were randomized to receive a single rescue course of betamethasone, 2 12-mg doses 24 hours apart, or placebo. Exclusion criteria included: premature rupture of membranes, advanced dilation (> 5 cm), chorioamnionitis, and other steroid use.

RESULTS

In all, 437 patients were randomized (223 rescue steroid group and 214 placebo group). A total of 55% of patients in each group delivered at < 34 weeks. There was a significant reduction in the primary outcome of composite neonatal morbidity < 34 weeks in the rescue steroid group vs placebo (43.9% vs 63.6%; odds ratio, 0.45; 95% confidence interval, 0.27-0.75; P = .002) and significantly decreased respiratory distress syndrome, ventilator support, and surfactant use. Perinatal mortality and other morbidities were similar in each group. Including all neonates in the analysis (regardless of gestational age at delivery) still demonstrated a significant reduction in composite morbidity in the rescue course group (32.1% vs 42.6%, odds ratio, 0.65; 95% confidence interval, 0.44-0.97; P = .0034) and improvement in respiratory morbidities.

CONCLUSION

Administration of a single rescue course of ACS before 33 weeks improves neonatal outcome without apparent increased short-term risk.

Oxytocin: new perspectives on an old drug

Oxytocin is the drug most commonly associated with preventable adverse perinatal outcomes and was recently added by the Institute for Safe Medication Practices to a small list of medications "bearing a heightened risk of harm," which may "require special safeguards to reduce the risk of error." Current recommendations for the administration of this drug are vague with respect to indications, timing, dosage, and monitoring of maternal and fetal effects. A review of available clinical and pharmacologic data suggests that specific, evidence-based guidelines for the intrapartum administration of oxytocin may be derived from available data. If implemented, such practices may reduce the likelihood of patient harm. These suggested guidelines focus on limited elective administration of oxytocin, consideration of strategies that have been shown to decrease the need for indicated oxytocin use, reliance on low-dose oxytocin regimens, adherence to specific semiquantitative definitions of adequate and inadequate labor, and an acceptance that once adequate uterine activity has been achieved, more time rather than more oxytocin is generally preferable. The use of conservative, specific protocols for monitoring the effects of oxytocin on mother and fetus is likely not only to improve outcomes but also reduce conflict between members of the obstetric team. Implementation of these guidelines would seem appropriate in a culture increasingly focused on patient safety.

A comparison of speculum and nonspeculum collection of cervicovaginal specimens for fetal fibronectin testing

OBJECTIVE

Current recommendations include the use of a vaginal speculum for fetal fibronectin specimen collection. This article evaluates the equivalency of nonspeculum methods for collecting fetal fibronectin specimens.

STUDY DESIGN

Two separate prospective studies of patients more than 22 weeks' gestation were performed at 2 institutions with similar hypotheses and methods. Two sequential specimens were collected on each patient: 1 with speculum and 1 with the nonspeculum method. The order of collection was reversed or randomized in both studies. Two alternative nonspeculum collection methods are described.

RESULTS

The 2 study sample sizes were 169 and 31. Comparison of the fetal fibronectin test results between the speculum and nonspeculum methods demonstrated greater than 95% agreement with an intraclass Kappa coefficient greater than 0.85 in both studies. The order of collection did not result in significantly different fetal fibronectin averages.

CONCLUSION

These studies demonstrate that there is excellent agreement between fetal fibronectin results obtained by speculum and nonspeculum collection methods.

The effect of maternal oxygen administration on fetal pulse oximetry during labor in fetuses with nonreassuring fetal heart rate patterns

OBJECTIVE

Using fetal pulse oximetry, we sought to quantify the impact of maternal oxygen administration in the management of nonreassuring fetal heart rate patterns.

STUDY DESIGN

In fetuses with specified abnormal nonreassuring fetal heart rate patterns, oxygen was administered to the mother, and fetal oxygenation was monitored with fetal pulse oximetry. After the fetal oxygen saturation on room air was recorded as a baseline, oxygen was administered to the mother for 30 minutes at 40% fraction of inspired oxygen and then 30 minutes at 100% of inspired oxygen. The average fetal oxygen saturation during the last 15 minutes of each period was calculated. Paired Student t test was used for comparison to baseline values.

RESULTS

Compared with baseline values, a significant increase in fetal oxygen saturation was identified in women who received oxygen at 40% fraction of inspired oxygen (mean increase, 4.9%; P = .001) and at 100% of inspired oxygen (mean increase, 6.5%; P = .003).

CONCLUSION

The administration of supplemental oxygen to laboring patients with nonreassuring fetal heart rate patterns increases fetal oxygen saturation substantially and significantly. Fetuses with the lowest initial oxygen saturations appear to increase the most.

Intrinsic racial differences in the risk of cesarean delivery are not explained by differences in caregivers or hospital site of delivery

OBJECTIVE

This study was undertaken to assess whether racial differences in the risk of cesarean delivery result from differing practices of their caregivers or the hospitals at which they deliver.

STUDY DESIGN

A retrospective cohort study was performed using the Perinatal Database of the Memorial Health Care System. Logistic regression was used to estimate the risk of primary cesarean delivery among patients eligible for labor. The contribution of hospital and physician level cluster correlation was evaluated using fixed and random effects regression models.

RESULTS

Compared with white patients, black and Hispanic patients were 75% and 22% more likely to undergo primary cesarean delivery. Further adjustment for hospital and physician level cluster correlation resulted in persistently increased risks of primary cesarean delivery in black (54%) and Hispanic patients (12%).

CONCLUSION

Hospital site of delivery and individual physician practices do not fully explain racial differences in the risk of primary cesarean delivery.

Hormonal Effect on Psoriasis in Pregnancy and Post Partum

OBJECTIVES

To investigate prospectively how psoriasis fluctuates in pregnancy and post partum and to correlate hormone levels in pregnancy (progesterone and estrogens) with psoriatic change.

DESIGN

Psoriatic body surface area (BSA) in pregnant patients with psoriasis (study group) and nonpregnant, menstruating patients with psoriasis (control group) were assessed 5 times over a year. Hormone levels (progesterone and estrogens) were measured in the study group and correlated with change in BSA.

SETTING

University-affiliated obstetric and dermatology clinics.

PATIENTS

Forty-seven pregnant patients in the psoriasis group and 27 nonpregnant, menstruating patients in the control group.

RESULTS

During pregnancy, 55% of the patients reported improvement, 21% reported no change, and 23% reported worsening. However, post partum, only 9% of patients reported improvement, 26% reported no change, and 65% reported worsening. Psoriatic BSA decreased significantly from 10 to 20 weeks' gestation (P<.001) compared with controls, whereas BSA increased significantly by 6 weeks post partum (P = .001) compared with controls. In patients with 10% or greater psoriatic BSA who reported improvement (n = 16; mean BSA, 40%), lesions decreased by 83.8% during pregnancy. There were significant or near significant correlations between improvement in BSA and estradiol (P = .009, r = 0.648), estriol (P = .06, r = 0.491), and the ratio of estrogen to progesterone (P = .006, r = 0.671).

CONCLUSION

High levels of estrogen correlated with improvement in psoriasis, whereas progesterone levels did not correlate with psoriatic change.

Improved perinatal survival of monoamniotic twins with intensive inpatient monitoring

OBJECTIVE

The purpose of this study was to evaluate the impact of routine hospitalization for fetal monitoring on the perinatal survival and neonatal morbidity of monoamniotic twins.

STUDY DESIGN

This was a multicenter retrospective cohort analysis of 96 monoamniotic twin gestations from 11 university and private perinatal practices. Overall mortality rates were calculated. The risk of intrauterine fetal death and neonatal morbidity was compared among women who were observed as inpatients versus outpatients.

RESULTS

The overall mortality rate from enrollment was 19.8% (mean gestational age at enrollment, 17.4 weeks). The perinatal mortality and corrected perinatal mortality rates were 15.4% and 12.6%, respectively. Eighty-seven women had both twins who were surviving at 24 weeks of gestation; 43 women were admitted electively for inpatient surveillance at a median gestational age of 26.5 weeks; the remainder of the women were followed as outpatients and admitted only for routine obstetric indications (median gestational age, 30.1 weeks). No intrauterine fetal deaths occurred in any hospitalized patient. The risk of intrauterine fetal death in women who were followed as outpatients was 14.8% (13/88) versus 0 for women who were followed as inpatients (P < .001). There also were statistically significant improvements in birth weight, gestational age at delivery, and neonatal morbidity for women who were followed as inpatients.

CONCLUSION

We observed improved neonatal survival and decreased perinatal morbidity among women who were admitted electively for inpatient fetal monitoring.

Placental corticotropin-releasing hormone (CRH), spontaneous preterm birth, and fetal growth restriction: a prospective investigation

OBJECTIVES

Recent advances in the physiology of human pregnancy have implicated placental corticotropin-releasing hormone (CRH) as one of the primary endocrine mediators of parturition and possibly also of fetal development. The aim of this study was (1) to prospectively assess the relationship of maternal plasma concentrations of CRH in the early third trimester of gestation with two prematurity-related outcomes-spontaneous preterm birth (PTB), and small-for-gestational age birth (SGA), and (2) to determine whether the effects of CRH on each of these outcomes are independent from those of other established obstetric risk factors.

STUDY DESIGN

In a sample of 232 women with a singleton, intrauterine pregnancy, maternal plasma was collected at 33 weeks' gestation and CRH concentrations were determined by radioimmunoassay. Each pregnancy was dated on the basis of last menstrual period and early ultrasonography. Parity, obstetric risk conditions for prematurity, mode of delivery, and birth outcomes were abstracted from the medical record.

RESULTS

After adjusting for the effects of established obstetric risk factors, elevated CRH levels at 33 weeks' gestation were significantly associated with a 3.3-fold increase in the adjusted relative risk (RR) for spontaneous preterm birth and with a 3.6-fold increase in the adjusted relative risk for fetal growth restriction. Women who delivered postterm had significantly lower CRH levels in the early third trimester than those who delivered at term. When outcomes were stratified by gestational length and birth weight, the lowest CRH levels at 33 weeks' gestation were associated with the term non-SGA births, intermediate and approximately equal CRH levels were associated with the preterm non-SGA and term SGA births, and the highest CRH levels were associated with the preterm SGA births.

CONCLUSION

For deliveries occurring after 33 weeks' gestation (the time of CRH sampling in this study), our findings support the notion that in humans placental CRH may play an impending, direct role in not only the physiology of parturition but also in processes related to fetal growth and maturation. Our results also support the notion that the timing of onset of parturition may be determined or influenced by events occurring earlier in gestation rather than those close to the time of actual onset of labor (ie, the notion of a "placental clock").

Twins and triplets: the effect of plurality and growth on neonatal outcome compared with singleton infants

OBJECTIVE

Information on outcome by gestational age from large numbers of twins and triplets is limited and is important for counseling and decision-making in obstetric practice. We reviewed one of the largest available neonatal databases to describe mortality and morbidity rates and growth in newborn infants from multiple gestations and compared these data with data for singletons.

STUDY DESIGN

Data from a large prospectively recorded neonatal database that incorporated neonatal records from January 1997 to July 2002 were reviewed. We evaluated birth weight and neonatal mortality and morbidity rates that affected long-term outcome for each week of gestational age from 23 to 35 weeks of gestation for all nonanomolous inborn twins and triplets who were admitted to the neonatal intensive care unit and compared these data to all singletons who met similar criteria during the same time period.

RESULTS

There were 12,302 twin and 2155 triplet births that met the entry criteria. The data for these newborn infants were compared with 36,931 singletons. Average birth weights at each gestational week were similar for all gestational ages until 29 weeks of gestation for triplets and 32 weeks of gestation for twins. After these gestational ages, the entire difference between twins and singletons was due to the weight of the smaller twin; the larger twins' mean weights were similar to singletons at all weeks that were studied. Birth order at each week also did not affect neonatal mortality rates, even when corrected for route of delivery and antenatal steroids. Neonatal morbidities associated with adverse long-term outcomes (intraventricular hemorrhage, retinopathy of prematurity, necrotizing enterocolitis) were also not different between multiple infants and singletons. Intrauterine growth restriction (IUGR) was associated with increased mortality rates at all gestational ages, but in the absences of IUGR, discordance was not.

CONCLUSION

Data on a large number of twins and triplets provide reassurance that neonatal outcome at all viable premature weeks of gestation are similar to singletons. Intrauterine growth restriction and prematurity are therefore the principal issues that drive neonatal mortality and morbidity rates in multiple gestations. These data are important for obstetric decision-making and patient counseling.

Intrauterine growth restriction increases morbidity and mortality among premature neonates

OBJECTIVE

Intrauterine growth restriction (IUGR) is an important reason for premature delivery and has been reported to be associated with increased mortality, but in some studies paradoxically, improved morbidities. Data on neonatal outcomes for infants with IUGR at each viable gestational age at birth from large numbers of deliveries are lacking. More particularly, data on perinatal outcome related to an antenatal diagnosis of IUGR compared with a neonatal diagnosis are particularly deficient. Therefore, by using a large contemporary database, we evaluated the outcomes of neonates with IUGR and the gestational age-specific associations between growth restriction, morbidity, and mortality.

STUDY DESIGN

With the use of a database formed from a computer-assisted tool that generates clinical progress notes and discharge summaries on neonatal intensive care unit (NICU) admissions, we reviewed data on neonates discharged from 124 NICUs between January 1, 1997, and December 31, 2001. We evaluated singleton, inborn neonates who delivered between 23 and 34 weeks, excluding major congenital anomalies. We compared 3 measures of IUGR: antenatally diagnosed IUGR; a birth weight below the 10th percentile (small for gestational age [SGA]), and newborn infants with either or both of these diagnoses against a control group of gestational age-matched infants meeting none of these criteria whose birth weights were no greater than the 90th percentile.

RESULTS

Our sample included 29,916 prematurely born neonates; 1,451 (4.8%) with IUGR, 2,936 (9.8%) who were SGA, and 3,708 (12.3%) had at least 1 of these 2 markers. There were 22,798 (76%) normally grown control neonates. Within each gestational age group from 25 to 32 weeks, each marker of IUGR was associated with increased mortality, necrotizing enterocolitis, need for respiratory support at 28 days of age, and retinopathy of the premature. When corrected for gestational age, exposure to antenatal steroids, gender, and mode of delivery, these associations remained significant.

CONCLUSION

IUGR remains a serious problem that is associated with increased morbidity and mortality among prematurely born neonates, regardless of the definition used or whether the diagnosis is made antenatally or after birth. These results are important for obstetric counseling and decision making and for the anticipation and treatment of premature newborn infants.

Dystocia in nulliparous patients monitored with fetal pulse oximetry

OBJECTIVE

A critical analysis of the United States randomized controlled trial of fetal pulse oximetry concluded that nonreassuring fetal heart rate patterns used for study entry may have been a marker for dystocia. We prospectively studied nulliparous women in labor whose progress was monitored with fetal pulse oximetry to examine the relationship between nonreassuring fetal heart rate patterns and operative delivery for dystocia.

STUDY DESIGN

A prospective nonrandomized observational cohort study compared two distinct classes of nonreassuring fetal heart rate patterns (class I: intermittent, mildly nonreassuring; class II: persistent, progressive, and moderate to severely nonreassuring) among nulliparous patients with the use of fetal pulse oximetry to confirm fetal well-being. Definitions of dystocia included the cessation of labor progress in the first (3 hours) or second (2 hours) stage of labor, despite adequate uterine activity that was assessed with an intrauterine pressure catheter. Independent review confirmed the classification of nonreassuring fetal heart rate patterns and study entry criteria.

RESULTS

Two hundred seventy-four patients met study criteria and had sufficient information for fetal heart rate tracing interpretation. Two hundred thirty-seven patients (86.5%) were class II, and 37 patients (13.5%) were class I. The two classes of patients were comparable in a variety of obstetric, demographic, and perinatal variables. Twelve percent of all patients were delivered for nonreassuring fetal status. Significantly more class II patients (22%) were delivered by cesarean for dystocia than were class I patients (8%). Higher doses and a longer number of hours of oxytocin were required among class II patients. Significantly more occiput posterior positions were noted among all patients who underwent cesarean delivery for dystocia compared with other modes of delivery.

CONCLUSION

Significantly nonreassuring fetal heart rate patterns predict cesarean delivery for dystocia among nulliparous patients with normally oxygenated fetuses in a setting of a standardized labor management protocol. This confirms the observations in the randomized controlled trial of fetal pulse oximetry in the United States and may provide insight into the treatment of nonprogressive labor in contemporary practice.