Arrest Of Dilatation Research Articles

Evaluation of Nursing Interventions to Reduce the Primary Cesarean Rate

To determine the effectiveness of upright positioning and frequent maternal repositioning on primary cesarean births performed for failure to progress, arrest of descent, arrest of dilatation, and/or cephalopelvic disproportion among laboring women. A quasi-experimental research design was utilized. Birth outcomes from June 2013 to December 2014 were compared to the baseline period of January 2013 to May 2013 at a rural hospital in south central Kentucky. The conceptual framework for this program evaluation was the plan-do-check-act cycle. Labor and delivery nurses attended a one-day evidence-based practice seminar on labor support and then implemented a standardized approach to positioning mothers during labor: upright positions and frequent position change every 15 to 30 minutes. Data analysis demonstrated a decrease in the number of primary cesarean births for all indications and number of primary cesarean births for arrest disorders (t = –0.75, p = .46). The primary cesarean birth rate decreased 2% from 43% to 41% over an 18 month timeframe. This downward trend suggests that upright and frequent maternal repositioning by registered nurses reduced the primary cesarean birth rate for arrest disorders.

Index of Suspicion in the Nursery

A 4.1-kg, 10-day-old, term Hispanic male infant presents to the emergency department (ED) with multiple episodes of paroxysmal jerky movements, irritability, and an episode of cyanosis. Parents report decreased responsiveness and oral intake 3 days before presentation. Patient was born at 40.1 weeks to a G2P1001 via cesarian delivery for arrest of dilatation. The Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. Prenatal course and delivery history are unremarkable, including negative maternal serologies and group B Streptococcus (GBS) culture. While in the ED, the patient has 5 episodes of tonic-clonic seizures, with dropping oxygen saturation to 70%, and is intubated for airway protection. Vital signs reveal temperature of 101.5°F, heart rate of 170 beats per minute, respiratory rate of 42 breaths per minute, and blood pressure of 90/60 mm Hg. Physical examination reveals markedly decreased responsiveness with no other positive findings. A full sepsis evaluation is performed including cultures of blood, urine, cerebrospinal fluid (CSF), and computed tomography (CT) of the head. Lorazepam is started for seizures. Empiric broad-spectrum antimicrobial therapy including ampicillin, gentamicin, cefotaxime, and acyclovir is initiated. The infant is admitted for further diagnostic and therapeutic management. ### Diagnosis and Hospital Course Laboratory results revealed white blood cell (WBC) count …

Characterization of the myometrial transcriptome in women with an arrest of dilatation during labor.

The molecular basis of failure to progress in labor is poorly understood. This study was undertaken to characterize the myometrial transcriptome of patients with an arrest of dilatation (AODIL). Human myometrium was prospectively collected from women in the following groups: (1) spontaneous term labor (TL; n=29) and (2) arrest of dilatation (AODIL; n=14). Gene expression was characterized using Illumina® HumanHT-12 microarrays. A moderated Student's t-test and false discovery rate adjustment were used for analysis. Quantitative reverse transcription-polymerase chain reaction (qRT-PCR) of selected genes was performed in an independent sample set. Pathway analysis was performed on the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway database using Pathway Analysis with Down-weighting of Overlapping Genes (PADOG). The MetaCore knowledge base was also searched for pathway analysis. (1) Forty-two differentially expressed genes were identified in women with an AODIL; (2) gene ontology analysis indicated enrichment of biological processes, which included regulation of angiogenesis, response to hypoxia, inflammatory response, and chemokine-mediated signaling pathway. Enriched molecular functions included transcription repressor activity, heat shock protein (Hsp) 90 binding, and nitric oxide synthase (NOS) activity; (3) MetaCore analysis identified immune response chemokine (C-C motif) ligand 2 (CCL2) signaling, muscle contraction regulation of endothelial nitric oxide synthase (eNOS) activity in endothelial cells, and triiodothyronine and thyroxine signaling as significantly overrepresented (false discovery rate <0.05); (4) qRT-PCR confirmed the overexpression of Nitric oxide synthase 3 (NOS3); hypoxic ischemic factor 1A (HIF1A); Chemokine (C-C motif) ligand 2 (CCL2); angiopoietin-like 4 (ANGPTL4); ADAM metallopeptidase with thrombospondin type 1, motif 9 (ADAMTS9); G protein-coupled receptor 4 (GPR4); metallothionein 1A (MT1A); MT2A; and selectin E (SELE) in an AODIL. The myometrium of women with AODIL has a stereotypic transcriptome profile. This disorder has been associated with a pattern of gene expression involved in muscle contraction, an inflammatory response, and hypoxia. This is the first comprehensive and unbiased examination of the molecular basis of an AODIL.

Subsequent pregnancy after two uterine artery embolizations

Uterine artery embolization (UAE) was first described in 1995 as an effective alternative in the treatment of symptomatic uterine leiomyomas [1]. This procedure has remained a popular option for women wishing to avoid surgery (myomectomy or hysterectomy) and preserve the uterus [2]. For women wishing to maintain fertility, the safety of this procedure remains controversial. There have been a limited number of reports describing the surveillance and outcome of pregnancy after embolization. Complications such as fetal malpresentation, small for gestational age, premature delivery, cesarean delivery, and postpartum hemorrhage have been previously reported in pregnancies occurring after a single UAE [3]. Here, we describe the first reported case of pregnancy after undergoing two prior uterine artery embolizations. A 34-year-old G2P0010 was referred to our practice for a perinatal consultation at 16 weeks due to a history of two prior uterine artery embolizations. The patient experienced menometrorrhagia with severe anemia secondary to extensive uterine leiomyomas 2 years prior to conception. Treatment options were offered including a myomectomy to preserve fertility. She ultimately chose UAE to avoid a laparotomy. 1 year after her initial uterine artery embolization procedure, she continued to experience menometrorrhagia with anemia and was found to have persistent leiomyomas. After extensive counseling, she chose a second uterine artery embolization procedure. An MRI obtained 3 months following the second procedure revealed significantly smaller, devascularized leiomyomas. 6 months later, she underwent a hysteroscopic resection of a submucosal fibroid. She spontaneously conceived an intrauterine pregnancy about 1 year after the second UAE procedure. The patient was extensively counseled regarding the potential risks including small for gestational age, premature delivery, cesarean delivery, and postpartum hemorrhage, which have been previously described with pregnancy following a single uterine artery embolization procedure. She elected to continue her pregnancy. She underwent close follow-up with monthly serial growth ultrasounds, and twice weekly fetal testing beginning at 32 weeks. Biometry and growth were appropriate for gestational age throughout the pregnancy and her antepartum course remained uncomplicated. At 40 weeks and 6 days, the patient presented for a scheduled induction of labor. She subsequently underwent a primary low transverse cesarean section for arrest of dilatation and delivered a healthy male infant, weighing 3,288 g. Her postpartum course was uncomplicated. Uterine artery embolization is a treatment option that is increasingly used for women who experience symptoms of menorrhagia and/or pelvic pressure due to uterine leiomyoma [4, 5]. The effectiveness of this minimally invasive and uterine preserving procedure makes UAE an attractive option. Currently, myomectomy is the only recommended surgical option for women with leiomyomas who desire future fertility [4]. However, one study found that 30% of patients who underwent UAE desired future fertility [6]. Embolization has also been employed in the management of postpartum hemorrhage and uterine arteriovenous S. F. Ravangard (&) Department of Obstetrics and Gynecology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030, USA e-mail: Sravangard@resident.uchc.edu

The myometrial transcriptome in spontaneous labor at term and in failure to progress in labor (arrest of dilatation and arrest of descent)

FAILURE TO PROGRESS IN LABOR (ARREST OF DILATATION AND ARREST OF DESCENT) POOJA MITTAL, ADI L. TARCA, SORIN DRAGHICI, JIMMY ESPINOZA, JYH KAE NIEN, RICARDO GOMEZ, BO HYUN YOON, JUAN PEDRO KUSANOVIC, SONIA HASSAN, ROBERTO ROMERO, GERARD TROMP, Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, Wayne State University, Department of Computer Science, Detroit, Michigan, Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, CEDIP, Sotero del Rio Hospital, OB-GYN, Universidad Catolica de Chile, Puento Alto, Chile, Seoul National University College of Medicine, Department of Obstetrics and Gynecology, Seoul, South Korea, Wayne State University, Center for Molecular Medicine and Genetics, Detroit, Michigan OBJECTIVE: Functional genomics was used to characterize genes differentially expressed in human myometrium during normal and abnormal labor at term. STUDY DESIGN: Human myometrium from the lower uterine segment was obtained at the time of cesarean section in patients in four clinical groups: 1) not in labor at term (n=9); 2) early labor at term (n=9); 3) arrest of dilatation (n=10); and 4) arrest of descent (n=9). Patients with histologic chorioamnionitis were excluded. Gene expression was characterized using Affymetrix HGU133plus2 microarrays. Data pre-processing was performed using RMA and GC-RMA algorithms. A moderated t test was used to detect differential expression, and a false discovery rate adjustment of the p values was applied to correct for multiple testing (p!0.05). RESULTS: 1) No differences in the myometrial transcriptome were found between women not in labor and women in labor after adjusting for multiple comparisons; 2) Arrest of dilatation as well as arrest of descent had a stereotypic transcriptome that differed significantly from that of women not in labor at term. Of interest is that the number of differentially expressed genes characterizing the arrest of dilatation (w5300 probesets) was nearly double the one characterizing the arrest of descent (w2800 probesets). CONCLUSION: 1) Contrary to our expectations, no changes in the lower uterine segment myometrial transcriptome were demonstrated in spontaneous labor at term; 2) Arrest of dilatation and arrest of descent showed stereotypical changes in the myometrial transcriptome, suggesting that either major changes in the transcriptome may not occur acutely during labor or that the present global transcriptome analysis is insensitive to detect the changes required for physiologic, but not pathologic, parturition.

Insights into the Physiology of Childbirth Using Transcriptomics

Few biological processes as central to the survival of viviparous species are so incompletely understood as childbirth (parturition) [ 1]. Premature labor and prolonged gestation due to failure of labor to commence are associated with an increased risk for perinatal death and long-term handicap. Even when labor begins at term, “failure to progress” is so frequently diagnosed that at least 20% of all births occur through cesarean delivery, the most common operation performed worldwide. The rationale for performing a cesarean delivery in women whose cervix has failed to dilate in active labor (arrest of dilatation), or in whom the fetal head does not descend after complete dilatation of the cervix (arrest of descent), is that “failure to progress” is an indicator of cephalopelvic disproportion. However, this explanation is unlikely to be true in many cases, because a proportion of mothers with a previous cesarean delivery due to “failure to progress” in labor will deliver a larger baby vaginally in a subsequent pregnancy. Thus, a central question in reproductive biology is: what is “failure to progress” in labor? A “functional disorder,” rather than cephalopelvic disproportion, may be the underlying reason for a proportion of cesarean deliveries performed after labor has begun. Such “functional disorders” could be due to inadequate preparation of the uterine muscle (myometrium) and/or the cervix for labor. Indeed, accumulating evidence suggests that the myometrium develops a contractile phenotype as pregnancy approaches term and the cervix also undergoes preparatory changes [ 2]. The cellular and biochemical phenomena underpinning preparation of the uterine muscle and the cervix [ 3] are different and have been the focus of intensive investigation [ 4, 5].

The role of ultrasound in the aggressive management of obstructed labor secondary to fetal malformations

Eleven cases of major congenital anomalies were diagnosed in conjunction with arrest of dilatation or descent. In three cases, the diagnosis of fetal death was made. In the remainder, despite extensive counseling, the mothers refused cesarean section for an anomalous fetus. Fetal decompression resulted in prompt vaginal delivery in 10 of 11 cases.