Severe heart disease complicating pregnancy does not preclude a favourable pregnancy outcome: 15 years' experience in a single centre

Heart disease (HD) in pregnancy remains a major cause of non-obstetric maternal and neonatal mortality and morbidity. This study describes the outcome in 164 pregnant women with HD (158 deliveries in women in New York Heart Association (NYHA) Classes 1 and 2; 17 in NYHA Classes 3 and 4) who received good antenatal care and benefitted from a specific protocol and experience of a dedicated staff. There were no maternal or neonatal deaths; 46 women were diagnosed peripartum. Based on a sub-division into NYHA categories, and when sub-divided by HD, there were no statistically significant differences between groups with regard to maternal age, gestational age at admission or at delivery, birth weight, 5 min Apgar scores, mode of delivery (caesarean delivery), senior obstetric/anaesthesiology staff in attendance or delivery during day/working hours. There was a higher incidence of pre-term deliveries in women with rheumatic heart disease and Marfan syndrome (p = 0.06) relative to others. Babies of women with coronary heart disease had prolonged postpartum course in the NICU (p = 0.0001) and longer total hospital stays for the mother. In conclusion, well-managed, motivated mothers with HD who benefit from comprehensive antenatal care, and are managed primarily by their obstetric and anaesthesia teams, can aspire to a good outcome for themselves and their babies.

PAPP-A levels as an early marker of idiopathic preterm birth: a pilot study

OBJECTIVE

To evaluate late PAPP-A levels as predictive of preterm birth in symptomatic women.

STUDY DESIGN

Prospective cohort study of singleton gestations, 23 to 34 weeks, and symptoms of preterm labor. PAPP-A, IGF-I and IGF-III analysis were performed. Primary end point was delivery < or =7 days. Accuracy and optimally predictive PAPP-A values were based on receiver operator characteristic (ROC) curves.

RESULT

In all, 26 women (51%) delivered < or =7 days post-admission (Group 1); 25 women (49%) >7 days (Group 2). Group 1 mean PAPP-A=38 000 vs 55 333 for Group 2 (P<0.04). Group 1 mean gestational age at delivery=29 weeks vs 37 weeks for Group 2 (P<0.00014). PAPP-A level < or =30,000 mU l(-1) had highest specificity (88%), sensitivity (50%), and positive predictive (81%) and negative predictive (62%) values for delivery < or =7 days. ROC area under curve=0.703.

CONCLUSION

PAPP-A levels < or =30,000 mU l(-1) at admission was associated with increased risk for preterm birth < or =7 days, supporting active management and therapeutic approach in these women.

Temporizing treatment for the respiratory-compromised gravida: an observational study of maternal and neonatal outcome

Acute lung disease may originate in pregnancy because of the pregnancy itself or because of an intercurrent etiology. The purpose of this study was to describe the effect of prolonged antepartum mechanical ventilatory support on the mother and the neonate when the strategy was to prolong the pregnancy rather than deliver preterm. Among 72 312 parturients over eight years, three gravidae required mechanical ventilation 12-48 h after admission for different conditions, 45-91 days before delivery. Gestational age at intubation was 21-28 weeks. Appropriate analgesia, broad-spectrum antibiotics, vasopressors and betamethsone for fetal lung maturity were used in all cases. None received tocolysis. Despite uterine distension, respiratory support provided adequate oxygenation and FiO2 could be maintained below critical levels, obviating the need for early delivery. All women survived, were weaned from ventilatory support, discharged, and delivered healthy neonates at term. Mode of delivery was dictated by obstetrical indicators only. All five infants (two sets of twins) are healthy at 12-36 months with appropriate developmental milestones. We conclude that when the maternal condition is amenable to therapy, and given the risks of labor induction and of prematurity, there is only limited benefit of delivery while on mechanical ventilation.

Number of yolk sacs does not predict amnionicity in early first-trimester monochorionic multiple gestations

OBJECTIVE

To determine the relationship between amnionicity and number of yolk sacs before 11 weeks of gestation.

METHODS

Twenty-two cases of monochorionic multiple pregnancy were scanned before 11 weeks of gestation. There were 21 sets of twins and one of triplets. Amnionicity was determined by visualization of a dividing amniotic membrane between the gestational sacs. The number of yolk sacs was recorded and compared with the presence or absence of a dividing membrane for all fetuses.

RESULTS

In 17/20 (85%) cases of monochorionic diamniotic twins, two yolk sacs were seen. In 3/20 (15%) cases of monochorionic diamniotic twins, a single yolk sac was seen. In the one case of monochorionic diamniotic triplets, two yolk sacs were visualized. In one case of monoamniotic twins, a single yolk sac was observed.

CONCLUSIONS

In monochorionic pregnancies, the presence of two yolk sacs predicts diamnionicity. However, the use of the number of yolk sacs as a predictor of amnionicity may not be accurate in a small proportion of patients. The diagnosis of monoamnionicity can be made only following a careful search for a dividing amniotic membrane.

Maternal and umbilical cord serum leptin concentrations in small-for-gestational-age and in appropriate-for-gestational-age neonates: a maternal, fetal, or placental contribution?

Leptin is secreted during pregnancy by the placenta and by the maternal and fetal adipose tissues. The leptin levels mainly reflect the amount of fat stored and thus are indicative of the energy balance, i.e., small-for-gestational-age (SGA) neonates represent the negative metabolic balance of in utero starved babies. We chose to compare maternal and umbilical cord leptin levels in pregnancies complicated by asymmetrical SGA versus those with appropriate-for-gestational-age (AGA) neonates as well as a model of multifetal growth concordant gestations in order to establish through the 'leptin link' the relative contributions of mother, fetus, and placenta to fetal weight. We found that the maternal leptin levels at delivery correlated poorly with the maternal weight gain/body mass index and with neonatal birth weight. Furthermore, the umbilical cord leptin levels correlated well with neonatal and placental weights in the AGA group but not in the SGA group. As in AGA singleton pregnancies, in multifetal uncomplicated pregnancies, the umbilical cord leptin levels correlated well with the birth weight of individuals, regardless of the status of the twin or triplet in the set. Thus, we speculated that in SGA neonates the birth weight represents the lean body weight and the low adipose tissue content (as opposed to the AGA neonates who have a substantial adipose tissue content) and, therefore, reflects mainly the basic placental contribution.

Cesarean section is not protective against adverse neurological outcome in survivors of preterm delivery due to overt chorioamnionitis

OBJECTIVE

To determine whether the mode of delivery has a protective value on the immediate adverse neonatal neurological outcome of infants born from pregnancies complicated by preterm chorioamnionitis.

METHODS

A comparison of the immediate and long-term neurological outcome of preterm neonates (24-34 weeks' gestation) of pregnancies complicated by chorioamnionitis, was made between those born by Cesarean section and by vaginal delivery.

RESULTS

Of the 73 newborns, 54 (74%) survived the neonatal period; two (2.7%) had incomplete records, leaving 71 for analysis. Thirty (42.2%) were delivered by Cesarean section and 41 (57.7%) vaginally. The obstetric and neonatal characteristics were comparable. Twenty-four (80%) survived in the Cesarean group and 30 (73.2%) in the vaginal delivery group (NS). There was no significant difference in the immediate adverse neonatal neurological outcome between Cesarean and vaginal deliveries.

CONCLUSIONS

The mode of delivery did not significantly affect the immediate neurological status of preterm infants exposed to antenatal intrauterine infection.

[The Zavanelli maneuver--back to the womb]

The Zavanelli maneuver is the manual replacement of a partially-born fetus due to severe shoulder dystocia. It is described in obstetrical textbooks as being among the last to be tried in a series of maneuvers to rescue the fetus with severe shoulder dystocia, as it is considered a very difficult and heroic maneuver. Few obstetricians have seen it and fewer have done it themselves. It is even more rare when a single obstetrician has done the Zavanelli maneuver repeatedly. Therefore, both experienced obstetricians and certainly young residents are fearful when they have to use this maneuver and can lose control in cases of shoulder dystocia. We have found descriptions of 93 cases of use of the Zavanelli maneuver in vertex presentations. We also describe a recent case in our experience. We conclude that this maneuver is safe and not too difficult to perform even without previous experience. Fetal and maternal complications are few, but there is of course a bias against reporting bad results. We recommend that every obstetrician become familiar with this maneuver so as to feel sure that it is safe for him to use in severe cases of shoulder dystocia.

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.

Grandmultiparity. Is it a perinatal risk?

Increased parity is more common in lower-socioeconomic groups. Additionally, GMPs tend to be older. It is for these reasons that there is a tendency for an increased incidence of antenatal complications, such as hypertension and diabetes, among GMP mothers. It appears that the previous conflicting reports on the effect of high parity on perinatal outcome can be related to differences in the socioeconomic conditions of the parturient population under examination. Previous evidence of the unfavorable influence on perinatal outcome of high parity might have been biased by patient selection, because high parity is often inversely linked to social class. Our recent studies of the Israeli maternal population plus comparable reports from other countries allow us to conclude that GMP is not always a great cause for concern in an economically stable and healthy population that has access to high-quality medical care. As such, the term dangerous multipara should be removed from the medical literature and the focus of concern should shift to the organization and the delivery of quality medical services.

Prevention of neonatal group B streptococcal infections. Is there a rational prevention strategy?

Clinicians, both obstetric and pediatric, are currently faced with the need to choose treatment strategies to reduce the persistent high incidence of early-onset GBS neonatal disease without being equipped with adequate data to choose conclusively which of the proposed strategies is ideal. There is an urgent need for well-designed prospective randomized trials comparing the various prevention protocols so as to resolve conclusively the controversy. The ultimate prevention strategy may well be a successful maternal immunization program.

Correlation between fasting glucose in the first trimester and glucose challenge test in the second

OBJECTIVE

To determine if there is a statistically significant correlation between the plasma glucose level obtained following a glucose challenge test at 24-28 weeks' gestation and the fasting plasma glucose level in the first trimester.

METHODS

The study population included 621 healthy women with singleton pregnancies followed in the antenatal clinic of the Hadassah Medical Center, with a fasting plasma glucose level performed during the first trimester. Nine women had fasting blood glucose levels above 105 mg/dL and were excluded from the study. Of the remaining 612 women, 425 (69%) had 50-g glucose challenge tests at 24-28 weeks' gestation.

RESULTS

The mean (+/-standard deviation [SD]) first-trimester fasting glucose level was 77.8+/-9.7 mg/dL and the mean (+/-SD) glucose level 1 hour after the second-trimester glucose challenge test was 109.1+/-29.8 mg/dL. The fasting plasma glucose level and the glucose level following the glucose challenge correlated significantly but not strongly (=.26, P < .001). However, using a linear regression model in which fasting plasma glucose level and maternal weight were explanatory variables and glucose level following the glucose challenge test was the dependent variable resulted in a very low r2 (.10).

CONCLUSION

The correlation between the plasma glucose level obtained following a glucose challenge test and the fasting plasma glucose level in the first trimester is low, indicating that fasting glucose measurement early in pregnancy has no clinical benefits.

Is the obstetric outcome of in vitro fertilized singleton gestations different from natural ones? A controlled study

OBJECTIVE

To determine whether singleton IVF pregnancies carry adverse maternal or fetal outcome when compared with naturally conceived gestations.

DESIGN

An analysis of the obstetric outcome of singleton IVF pregnancies in comparison with matched, naturally conceived singleton controls.

SETTING

In vitro fertilization unit and obstetric service at a tertiary medical center.

PATIENT(S)

Two hundred sixty consecutive singleton IVF pregnancies and 260 naturally conceived singleton controls matched 1:1 for maternal age, parity, ethnic origin, and location and date of delivery.

INTERVENTION(S)

In vitro fertilization-ET.

MAIN OUTCOME MEASURE(S)

The rate of antenatal obstetric complications, nonvertex presentation, cesarean section, preterm labor, low birth weight, small and very small for gestational age, neonatal intensive care unit admissions, and perinatal mortality.

RESULT(S)

The rates of most antenatal complications were similar in both groups. Urinary tract infection was the only complication diagnosed significantly more frequently after IVF (7.3% versus 1.2%); however, the rates of severe urinary tract infection necessitating hospitalization were similar. The incidence of nonvertex presentation was also similar. The cesarean section rate was significantly higher among IVF patients (41.9% versus 15.5%). The rates of preterm labor, low birth weight, small and very small for gestational age, neonatal intensive care unit admissions, and perinatal mortality were comparable.

CONCLUSION(S)

When controlling for maternal age, parity, ethnic origin, and location and date of delivery, singleton IVF pregnancies do not carry an increased risk for prematurity, low birth weight, or maternal or fetal complications. Still, these pregnancies are associated with a high rate of cesarean sections.

Early treatment of gestational diabetes reduces the rate of fetal macrosomia

This study tested the hypothesis that to reduce the rate of macrosomic infants in gestational diabetes cases, good glycemic control should be initiated before 34 completed gestational weeks. The study population included 84 women with gestational diabetes, ascertained by universal screening of all women attending the antenatal clinic of the Hadassah Medical Center, over a 2-year period. The 60 women (71%), who initiated treatment before 34 completed weeks, composed the "early" group. The 24 women (29%), who initiated treatment after the 34th week, composed the "late" group. All patients were managed by an intensified protocol, including stringent glycemic control. In the "early" and "late" groups, mean gestational age at the beginning of treatment was 30.0 +/- 3.8 and 36.2 +/- 1.2 weeks, and duration of treatment was 9.6 +/- 4.1 and 3.7 +/- 1.8 weeks, respectively. Maternal characteristics were similar in the two groups. The rate of macrosomic and large-for-gestational-age infants were 5 and 11%, respectively, in the early group as compared to 25 and 29% in the "late" group (p < 0.05). No significant differences were found between the two groups in the mode of delivery or Apgar scores. We conclude that to reduce the rate of macrosomic infants in gestational diabetes cases, good glycemic control should be initiated before 34 completed gestational weeks.

Outcome of amniotic fluid analysis and neonatal respiratory status in diabetic and nondiabetic pregnancies

OBJECTIVE

To evaluate the likelihood of mature or immature amniotic fluid analysis and subsequent presence or absence of neonatal pulmonary disease in a large population of diabetic and nondiabetic pregnancies.

STUDY DESIGN

Six hundred sixty-eight pregnancies that delivered within seven days of phosphatidylglycerol (PG) and lecithin/sphingomyelin ratio (L/S) testing were analyzed. (PG testing was by Amniostat-FLM and L/S testing by a modified Gluck technique.) Neonatal respiratory outcome and amniocentesis results were stratified by maternal diabetes status and gestational age for comparison. We determined the likelihood of finding correctly mature and correctly immature amniotic fluid analysis for each gestational age category.

RESULTS

We found high rates of incorrectly immature results for PG (53%) and L/S (21%) preterm and for PG at term (20%). Diabetic and nondiabetic pregnancies did not differ.

CONCLUSION

Population-based information on the a priori chances of amniotic fluid and neonatal pulmonary outcome in diabetic and nondiabetic pregnancies is given for use in determining the utility of amniotic fluid analysis in individual clinical settings.

Pemphigus vulgaris and pregnancy

Pemphigus vulgaris (PV), an autoimmune bullous dermatosis, is rarely encountered in pregnancy. Two women with PV and their three pregnancies are described. Pregnancy outcome was generally good, although one of the neonates had characteristic PV skin lesions that resolved spontaneously. The pathophysiology, clinical manifestations, and special issues of PV pertaining to pregnancy are discussed. With our cases added, there are now 23 reports in the English literature on PV in pregnancy. From these data it seems that transient skin lesions may occasionally appear in the neonate regardless of the severity of maternal disease. Such lesions are due to passive transplacental transfer of PV antibodies and do not have long-lasting clinical implication. On the other hand, and contrary to past traditional thinking, PV may be associated with poor neonatal outcome including prematurity and fetal death. Such complications seem to be restricted to pregnancies with clinically severe PV.

Fetal urine production and micturition and fetal behavioral state

The rate of fetal urine production and the incidence of fetal micturition was compared in periods of fetal sleep and awakeness. Sonography and fetal heart rate monitoring were concomitantly performed on 12 normal term pregnancies. Fetal bladder volumes were serially calculated, and the rate of urine production and micturition were compared between the periods of fetal sleep and awakeness. Fetal micturition occurred almost exclusively during periods of fetal awakeness (p = 0.001). There were no demonstrable differences in the rates of urine production during periods of fetal sleep and awakeness. Fetal micturition is behavioral-state dependent. Nevertheless, the fetal behavioral state is not a necessary consideration when applying urine production measurements as a test of fetal well-being.

Antenatal bleeding and fetal heart rate

Objective of the paper was to determine the fetal heart rate (FHR) changes that occur in preterm fetuses whose mothers have suffered antepartum bleeding, versus uncomplicated controls. Over a 12-year span, 91 patients with significant antenatal bleeding (bleeding requiring inhospital observation) were examined and compared to 75 controls with uncomplicated normal pregnancies. None of the women were in labor and all were evaluated at 25-37 weeks' gestation. Excluded were: patients with any other complication (i.e., premature rupture of membranes, intrauterine growth retardation, diabetes, hypertension, collagen vascular disease, postuterine surgery, substance abuse and twins). Analysis of the FHR tracings included baseline heart rate, long-term FHR variability, and number and amplitude of FHR accelerations in 20-min segments. There was no difference in baseline heart rate in the preterm fetuses of pregnancies complicated by antepartum bleeding versus controls. However, the parameters associated with FHR reactivity (number of accelerations in 20 min, and amplitude of accelerations) were higher to a statistically significant degree in fetuses of pregnancies complicated by antenatal bleeding than in controls. Fetuses of mothers suffering antenatal bleeding exhibited significant higher rates of reactive FHR patterns at earlier gestational ages than did controls. In conclusion, there is a significant increase in FHR reactivity in pregnancies in which significant antenatal bleeding occurs, suggesting a probable acceleration in fetal central nervous system maturation in these fetuses.

Meconium-stained amniotic fluid: increased risk for adverse neonatal outcome

OBJECTIVE

To determine the risk of adverse neonatal outcome associated with meconium-stained amniotic fluid independent of that related to antepartum or intrapartum abnormalities.

METHODS

A cohort of 2200 consecutive deliveries was examined and the fetal heart rate (FHR) tracings analyzed independently. Singleton term pregnancies without fatal malformations were stratified by the consistency of meconium and compared.

RESULTS

Moderate or thick meconium increased the risk for adverse outcome more than threefold (relative risk 3.2, 95% confidence interval 2.0-5.2). This risk was independent of fetal heart tracing abnormalities or maternal hypertensive, kidney, or heart disease.

CONCLUSION

Thick meconium alone should alert the physician to a high-risk fetal condition. This phenomenon requires continuous FHR monitoring and reassurance of fetal well-being by acid-base assessment or the equivalent, regardless of maternal disease status or the presence of abnormal FHR tracings.

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.

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.

METHODS

We undertook a prospective study of 2,200 consecutive deliveries. Preterms < 37 weeks, twins, stillbirths and fetal malformations were excluded from the study. FHR tracings were analyzed for variability in every delivery. Three windows were evaluated: 1) early in labor (30 min); 2) in the active phase of labor - 1 h prior to complete cervical dilatation (30 min); and 3) throughout the second stage of delivery, in segments of 30 min. Using the tracings taken at admission and prior to delivery, FHR variability was scored according to five previously used evaluative methods, and was correlated to the following three fetal outcome parameters: a) arterial cord blood pH < 7.2, > 7.2; b) 5-min Apgar >6, < 7; and c) immediate outcome ('good' defined as newborn going home after 2-5 days, with no neonatal intensive care unit (NICU) admission).

RESULTS

1. The majority of cases with adverse fetal outcome exhibited good FHR variability (mean, 80%). 2. Low FHR variability is not common in newborns with adverse general outcome (mean, 11.5%). 3. The predictability of FHR variability (using the five most common scoring methods) for evaluating adverse fetal outcome revealed low sensitivity (mean, 20.3%) and low predictive value (mean, 11.6%).

CONCLUSION

FHR variability by itself cannot serve as the only indicator of fetal wellbeing. The presence of low variability should alert the physician; however, good FHR variability should not be interpreted as reassuring.

Recurrent stillbirth. Significance and characteristics

We sought to identify the significance of recurrent stillbirth and to determine the contributory etiologic factors for this phenomenon. Data were analyzed and retrospective chart review conducted for all stillbirths occurring during a 13-year period. Subjects were divided into two groups: those for whom the current stillbirth was the first and those who had had a previous stillbirth. The study included 48,479 consecutive multiparous women, of whom 403 had delivered stillborn infants (8.31/1,000 live births). For 34 of these subjects, this represented a recurrent stillbirth (84.36/1,000 live births). The recurrent-stillbirth group had a 10.15-fold higher risk for stillbirth. Additionally, this group had a twofold higher incidence of diabetes and hypertensive disease than did those women experiencing their first stillbirths; furthermore, the gestational age and birth weight of the stillborn infants were significantly lower in the recurrent-stillbirth group (P < .0004 and < .007, respectively). Such factors as socioeconomic class, chorioamnionitis and erythroblastosis fetalis, traditionally cited as contributing to repeated fetal loss, were not significant. Although recurrent stillbirth remains an unsolved problem, improving health care to specific groups within high-risk populations may reduce fetal loss.

The Israel perinatal census

A nation-wide perinatal census which included 22,815 deliveries was carried out. The cesarean section rate was 9.6% and the perinatal mortality rate was 13.5/1000. Using a logistic regression analysis the risk factors for cesarean section and for perinatal mortality were ranked. Breech presentation and one uterine scar were found to be the most important risk factors for cesarean section and breech presentation, maternal disease and multiple pregnancy for perinatal mortality. Low birth weight rate was 6.9% with nonsignificant differences between the various ethnic groups. The national cesarean section rate in breech presentation was 57.8%. It was performed mainly at the extremes of birth weight. From those with one previous cesarean section 55.1% delivered vaginally and 44.9% abdominally. The chance for vaginal delivery is higher (67.2%) providing the woman had delivered vaginally in the past. Comparison between primiparae and multiparae showed that preeclampsia, hypertension and diabetes mellitus were all significantly more frequent among older parturients and among primiparae.

Shoulder dystocia: should the fetus weighing greater than or equal to 4000 grams be delivered by cesarean section?

A total of 75,979 women who were delivered vaginally in the period 1970 to 1985 were stratified into diabetic and nondiabetic groups. Overall, the incidence of macrosomia (greater than or equal to 4000 gm) was 7.6% (5674/74390) in the nondiabetic group and 20.6% (328/1589) in the diabetic group. Patients were further subdivided by weight categories at 250 gm intervals. Eight percent of shoulder dystocia occurred in the diabetic group when fetal weight was greater than or equal to 4250 gm. In contrast, 20% of shoulder dystocia in the nondiabetic group could have been prevented by elective cesarean section when the fetal weight was greater than or equal to 4500 gm. Furthermore, logistic regression analysis demonstrated that birth weight, diabetes, and labor abnormalities were the principal contributors to shoulder dystocia. Elective cesarean section is strongly recommended for diabetics with fetal weights greater than or equal to 4250 gm, and trial of vaginal delivery for nondiabetic fetuses with weights greater than or equal to 4000 gm is recommended. In all cases the clinician must be watchful for labor abnormalities in macrosomic fetuses.

The value of menotrophin treatment for unexplained infertility prior to an in-vitro fertilization attempt

This work was undertaken in order to evaluate retrospectively the relative efficacy of ovulation induction by menotrophins and that of in-vitro fertilization and embryo transfer (IVF-ET) in the treatment of unexplained infertility. These two treatments were compared between two groups of patients: 87 couples undergoing 446 cycles of ovulation induction by menotrophins (group A) and 72 couples undergoing 108 cycles of IVF-ET (group B). A total of 30 and 20 pregnancies were achieved in groups A and B for a rate of 34 and 28% per patient, respectively. A similar cumulative pregnancy rate (CPR) was achieved for three cycles of ovulation induction (23%) and one cycle of IVF-ET (22%). The cumulative live birth rate (CLBR) in group A was 22% after three cycles and exceeded that of one IVF-ET cycle (17%). It is concluded that menotrophin treatment in unexplained infertility is highly beneficial and should precede an IVF attempt.

Incidence of spontaneous and evoked fetal movements in the first half of twin pregnancy

Fetal movements (FM) may be spontaneous, originating in the fetus itself, or evoked, caused by external stimuli. The FM in 21 normal twin pregnancies at 10 and 21 weeks of gestation were studied. The percentage rate of evoked FM which occur simultaneously in both twins was 4.96% of all observed FM. The rate of the spontaneous FM which occur independently in each fetus was 95.04% of all FM. The low incidence of evoked FM, at an early gestational age (10-21 weeks) emphasizes the ability of these young fetuses to perceive external stimuli and to react to them by FM.

[The high risk pregnancy unit]

During the past 30 years there has been great progress in perinatology. However, perinatal mortality has remained relatively high. To reduce perinatal mortality and morbidity, high risk pregnancy units have been established throughout the world. Our unit was established in 1976 for women with diseases complicating pregnancy, and in whom evaluation of fetal respiratory and metabolic function is indicated. The cesarean section rate during these 12 years was 33%. There was no maternal mortality. The intrauterine fetal death rate was 10.3 per 1,000 (very low for this unique population) and the corrected perinatal mortality was 3.4 per 1,000. The monitoring and treatment protocols, developed and applied in this unit, resulted in a significant decrease in fetal morbidity and mortality. These dramatically improved results demonstrate and justify the need for high risk pregnancy units.

The effect of maternal age and socioeconomical background on neonatal outcome

This population-based study examined whether the neonatal outcome of primiparae is determined by maternal age or by her socioeconomic background. Data on all births in Israel during a three-month period was made available from a nation-wide census. Primiparae 30 years of age or older had a significantly (P less than 0.001) higher risk of low birthweight and prematurity. Perinatal mortality rates and low 5-min Apgar scores were not associated with maternal age, but were significantly (P less than 0.001) increased for the socioeconomically disadvantaged parturients. Our results suggest the growth retardation and short gestation among older primiparae may reflect biological aging of maternal tissues and the effect of diseases of pregnancy such as hypertension and preeclampsia, found significantly (P less than 0.001) more common for these mothers. Excessive perinatal mortality, on the other hand, may be attributable to environmental disadvantage of socioeconomically deprived populations.

The effects of the socioeconomic status on the perinatal outcome of grand multipara

Grandmultiparity has been considered as an obstetric hazard both to the mother and the fetus. Since high paritius tend to be more common in the lower socioeconomic groups, the effect of the socioeconomic status on perinatal outcome was evaluated in this study. This survey covers all the deliveries in Israel (22,815) in a 3 month period. The 1542 grand-multiparous women were divided into two groups: low socioeconomic group (947) and high socioeconomic group (595). Perinatal mortality and low birth weight were found to be in correlation with low socioeconomic status but not with grand multiparity. Maternal diseases complicating pregnancy were found to be significantly more common for grand multipara for both socioeconomic groups. This study shows that the grave association of parity and mortality found for the total population was due to the predominance of parturients of low socioeconomic class in the high birth order group.

Ranking the risk factors for cesarean: logistic regression analysis of a nationwide study

The risk factors that influenced the decision to perform cesarean were ranked in a nationwide census of deliveries conducted in Israel. The study encompassed 22,815 women who gave birth between November 1, 1983 and January 31, 1984 in the 30 maternity departments in the country; 2179 deliveries were by emergency cesarean. Multivariate stepwise logistic regression technique indicated that the most important risk factors affecting the decision were the presentation of the fetus and the presence of a uterine scar, followed in descending order by placenta previa or abruptio placentae, maternal disease, primiparity, low birth weight, twins, and advanced maternal age. The mother's ethnic background and type of hospital played an insignificant role in the decision-making process. The specific statistical method applied in this work permits listing the indicators that constitute risk factors for cesarean and provides the net effect of each factor on the decision-making process.

Vaginal delivery following one previous cesarean birth: nation wide survey

The present state of vaginal delivery following a previous cesarean section (CS) was evaluated through a nation wide survey, including 22,815 deliveries. The overall cesarean rate was 9.6%. Of all the parturients with one previous cesarean section 55.1% delivered vaginally. A previous CS and labor arrest were the major indications for a repeated CS in 28.7% and 26.4%, respectively. Rupture of the uterus following vaginal delivery was found more often in the group with a previous CS than in those with no uterine scar (1.2% and 0.03%, respectively), (P less than 0.0001). None of the uterine ruptures was fatal neither to the mother nor to the fetus. Post partum fever appeared more often among vaginal deliveries following a CS than among those with no uterine scar. However, CS is followed by fever 10.8 times more than vaginal delivery. Intrapartum and neonatal death rates following vaginal delivery were similar for those with or without a previous CS (3.42% and 3.38%, respectively). An average of 3 hospitalization days were saved for each vaginal birth replacing a repeated CS. It is concluded that vaginal delivery, following CS, does not cause substantial morbidity, nor mortality either to the mother or the neonate, and may be practiced with a reasonable margin of safety in well selected cases.

Grand multiparity--a nationwide survey

Grand multiparity has been considered to be an obstetric hazard to both the mother and the fetus. In order to evaluate this statement we analyzed the information of a nationwide survey. The delivery records of all women (22,814) attending 30 obstetric wards in Israel between November 1983 and January 1984 were analyzed and the medical and obstetric complications associated with grand multiparity were investigated. Diabetes, hypertension, malpresentations, multiple births, large-for-gestational-age deliveries and perinatal deaths were found to be significantly more common in 1,542 multiparae who had seven or more deliveries. The association between parity and age partially accounted for this observation.

The 1984 national perinatal census: design, organization and uses for assessing obstetric services in Israel

A nationwide perinatal census was conducted in Israel, in which medical, social, ethnic and demographic information on all births that took place in Israel within a predefined 3-month period was collected. The present study is the first to include 22,814 births that took place in all the obstetric units in Israel. The perinatal mortality rate decreased from 23.7 in 1964-68 to 13 in 1983-84. The frequency of cesarean section deliveries almost doubled over the last decade, while the use of forceps decreased significantly and the use of vacuum extraction did not change. The rate of low birthweight, however, remained constant over the last two decades. The level of hospital care has been shown to be significantly associated with perinatal mortality. The Israeli Perinatal Census may be used to provide information needed for promoting priority objectives for pregnancy and infant health, such as improving health status, identifying risk factors, increasing public and professional awareness, and improvement in services by protecting mother and fetus.

The human sperm hypoosmotic swelling test: its practical application and suggestions for improvement

Semen samples of 209 males of infertile couples were evaluated by the sperm hypoosmotic swelling (HS) test, the in vitro human sperm zona-free hamster ovum penetration assay (SPA), and by the three main parameters of the spermatogram (concentration, motility, and morphology). Whereas the HS test and SPA were poorly correlated with one another, the former showed a correlation with motility, particularly in oligo-, astheno-, and teratospermic semen samples. The simple and inexpensive HS test may prove a worthwhile tool in the diagnosis of male infertility.

Low birth weight in a heterogenic population

In order to elucidate some of the factors which influence the low birth weight rate, 22,815 deliveries were studied. It is already known that low birth weight (LBW) underlies the majority of infant deaths. It is also associated with an increased risk of permanent disability such as cerebral palsy, learning difficulties, and mental retardation of various degrees in survivors. In modern society these problems require major resources from the health budget. The Israeli population is composed of Jews and non-Jews, who differ not only in their religion but also in their customs. Most of the Jews are immigrants from many parts of the world who still retain many of the habits, customs and lifestyles of the societies they had lived in for many generations. We evaluated the LBW rate in these different groups. Jews and non-Jews have similar rates of LBW and similar mean birth weights. Other factors such as maternal age, parity, and hypertensive disorders of pregnancy showed some statistically significant differences. LBW rates increase from 6.9% in the babies of women aged 24-40 years to 8.5% in those less than 24 years, and 9.5% in those over 40. The risk of LBW was increased in primiparae to 10%. The highest rates were found in babies of mothers with hypertension. Pregnancy induced hypertension is associated with a LBW rate of 15.6% and chronic hypertension with a rate of 23%. Moderate and severe preeclampsia are important risk factors since they increase the rate to 15% and 47.1%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Ranking risk factors for perinatal mortality. Analysis of a nation-wide study

This paper analyses data from the Israeli nationwide perinatal census, with the aim of revealing the possible causes of perinatal death, and to assess the effects of risk factors, using a logistic regression analysis. The analysis provided an estimate of the net effect of each characteristic independently, thus identifying high-risk pregnancies that should be monitored with greater intensity. Five variables were found to have a significant effect on perinatal death. Among these, in order of decreasing risk: fetal presentation, maternal diseases complicating pregnancy, number of fetuses, ethnic origin, and maternal age. Other variables such as parity, standard of hospital, the mother's country of birth and domiciliary circumstances, did not significantly affect perinatal mortality.

Fryns syndrome: a predictable, lethal pattern of multiple congenital anomalies

Fryns syndrome is a unique pattern of lethal multiple congenital malformations with variable expression. A family in which all four sibs conformed to Fryns syndrome is detailed and substantiates the criteria for definition of the syndrome; perinatal mortality, hypoplastic lungs, and facial deformities should be highly suggestive of the syndrome. The addition of a strong family history, diaphragmatic hernias, distal limb deformities, and early onset of polyhydramnios with subsequent premature delivery should definitely confirm the diagnosis.

Incidence of spontaneous and evoked fetal movements

Fetal activity is composed of fetal movements (FM), which are either nonreflexive, originating in the fetus itself, or evoked reflexive FM which are stimulated by the fetal environment. The relative ratio of the spontaneous to evoked FM has not yet been documented. Since it is impossible to differentiate in a singleton pregnancy between these two types of FM on the basis of maternal perception alone, the natural model of twin pregnancy was used. It has previously been shown that the number of FM in a singleton pregnancy is similar to that of each individual fetus in a twin pregnancy of the same gestational age. It was assumed that the factors which cause spontaneous and evoked FM are similar in singleton and twin pregnancies. The fetal activity in 44 twin and 76 singleton pregnancies between 28 and 39 weeks of gestation was assessed during 20 min of nonstress test recording. The means of FM in twins were significantly higher than those in singleton pregnancies. The rate of the spontaneous FM was calculated to be 50-59% of all FM in singleton pregnancies and that of the evoked FM 41-50%.

Fetal heart rate accelerations and fetal movements in twin pregnancies

The rate of fetal heart rate accelerations associated with fetal movements to total fetal movements of twin pregnancies was found to be significantly lower than that of pregnancies with singleton infants. The number of fetal heart rate accelerations was similar. As fetal heart rate accelerations are reflective of fetal movements, the results indicate increased fetal activity in twins that is related to an additive effect of two normally active fetuses.