Dysfunctional Labor Research Articles

Maternal Body Mass Index, Myometrium Contractility and Uterotonic Receptor Expression in Pregnancy

Pregnant individuals with obesity (body mass index, BMI ≥ 30 kg/m2) are more likely to experience prolonged labor and have double the risk of cesarean compared with individuals with normal weight (BMI < 25 kg/m2). The aim of this study was to evaluate whether obesity in pregnancy is associated with reduced spontaneous and oxytocin-stimulated myometrial contractile activity using ex vivo preparations. We also assessed the relationship between maternal BMI and the expression of oxytocin (OXTR) and prostaglandin (FP) receptors in the myometrial tissue. We enrolled 73 individuals with a singleton gestation undergoing scheduled cesarean delivery at term in a prospective cohort study. This included 49 individuals with a pre-pregnancy BMI ≥ 30 kg/m2 and 24 with BMI < 25.0 kg/m2. After delivery, a small strip of myometrium was excised from the upper edge of the hysterotomy. Baseline spontaneous and oxytocin stimulated myometrial contractile activity was measured using ex vivo preparations. Additionally, expression of oxytocin and prostaglandin receptors from myometrial samples were compared using qRT-PCR and western blot techniques. Spontaneous and oxytocin-stimulated contraction frequency, duration, and force were not significantly different in myometrial samples from the obese and normal-weight individuals. Myometrial OXTR gene and protein expression was also similar in the two groups. While FP gene expression was lower in the myometrial samples from the obese group, protein expression did not differ. These data help to address an important knowledge gap related to the biological mechanisms underlying the association between maternal obesity and dysfunctional labor.

Investigation of the uterine modulating activities and mechanisms of Brachystegia eurycoma Harms (Leguminosae) methanol stem bark extract and fractions

Dysfunctional labour (DL) is a major cause of maternal and neonatal deaths worldwide. The only clinically available drug is oxytocin which is about 50% effective. Therefore, the development of new effective drugs for DL is a necessity. The medicinal plant Brachystegia eurycoma Harms (synonym B. spiceaformis) is used for labour management in ethnomedicine. In the search for new lead compounds for DL therapy, the stem bark of B. eurycoma was subjected to bioactivity-guided fractionation procedures to elucidate its uterine-modulating activities and active compounds. B. eurycoma stem bark extract (BE) was fractionated via vacuum liquid chromatographic techniques. The fractionation process was guided by ex vivo uterine contractility assays on the mouse uterus, performed using spontaneous, oxytocin, and high KCl-induced contractility assays. Furthermore, the characterization of the chemical constituents was performed using nuclear magnetic resonance (NMR) and mass spectrometry (MS). BE produced dual effects on uterine contractility which was dependent on the reconstitution period. The freshly prepared crude extract (BEF) inhibited uterine contractility (IC50 amplitude = 0.8 ± 0.1 mg/ml; IC50 frequency = 1.4 ± 0.2 mg/ml). However, contractility was augmented when the reconstituted extract was stored for 24 h and beyond (BES) (EC50 amplitude = 0.2 ± 1.2 mg/ml; EC50 frequency = 0.91 ± 1.2 mg/ml). In addition, the compounds caffeine, genistein, and prunetin were identified from the potent BE fractions via the different spectroscopic and spectrometric tools. This study demonstrated a storage-dependent dual effect of BE where BEF induced inhibition and BES augmented uterine contractility. Findings from this study also suggest that caffeine and phytoestrogens contributed to the uterine-modulating activities of BE. Thus, further investigation of these compounds in combination and as separate lead compounds is required for DL therapeutic management.

Maternal and perinatal health indicators from 2019 to 2022: Data from the POGS Nationwide Statistics System

OBJECTIVES: The objectives of this study were to present maternal and perinatal health indicators for the years 2019–2022. METHODOLOGY: This is a cross-sectional review that analyzed data on maternal and perinatal health indicators, generated from submissions of POGS-accredited hospitals (training and service) from January 2019 to December 2022. The data were compared to the national data obtained from official public documents published by the Philippine Statistics Authority in 2022 and 2023. RESULTS: The number of member hospitals has steadily increased over the years, and compliance rates have been consistently over 85%. The total number of registered cases and live births declined in 2020 and 2021, but has increased to prepandemic levels in 2022. The primary cesarean section (CS) rates remained above 20%, with the highest rate noted in 2021 (25.5%). The top three-most common indications for primary CS were dysfunctional labor, fetal distress, and malpresentation. Stillbirth, perinatal, and maternal mortality rates showed an increase from 2019 to 2022, with peak rates registered for the year 2021. The top five causes of maternal death are: medical complications, hemorrhage, hypertension, infection, and others (unspecified). The case fatality rate among pregnant patients with confirmed COVID-19 infection was 1.18%. CONCLUSION: From 2019 to 2021, there was a decline in the number of registered cases and live births, and an increase in the primary CS rates, maternal mortality ratio, perinatal death rates, and stillbirth rates. This may be explained by the prevailing social, health, and economic impact of the COVID-19 pandemic during these years.

ULTRASOUND FETAL KIDNEY LENGTH FOR ASSESSMENT OF GESTATIONAL AGE

Fetal kidney length (FKL) has recently been found to have a strong correlation with gestational age. According to the findings of these investigations, the fetal kidney length may be utilized to estimate gestational age when dates are ambiguous or when women seek ultrasound fetal biometry dating during the third trimester itself.&#x0D; GA estimation is also a prerequisite to interpret certain tests (amniotic fluid assay, serum assay, chorionic villus sampling) and to plan timing of various forms of fetal therapy. Failure in estimating GA accurately can result in unnecessary induction, dysfunctional labor, operative delivery, iatrogenic prematurity or post maturity, false interpretation of tests and delay or failure of fetal therapy, thereby increasing perinatal morbidity and mortality.&#x0D; This review looks in to various studies assessing correlation of Fetal kidney length with gestational age in third trimester of pregnancy and provide a comprehensive view on use of Fetal kidney length for estimation of gestational age in third trimester of pregnancy.

Chorioamnionitis Is an Independent Risk Factor for Third- and Fourth-Degree Perineal Lacerations in the United States [ID: 1377609

INTRODUCTION: The objective was to determine the effect chorioamnionitis has on the risk of third- and fourth-degree perineal lacerations (3/4 PL). METHODS: This represents a retrospective cohort based on the Centers for Disease Control and Prevention Natality Live Birth database (2016–2020). We compared the rates of 3/4 PL in term, singleton vaginal births across the United States based on diagnosed intrapartum chorioamnionitis. We used Pearson chi-square and multivariate logistic regression to control for confounding variables. Statistical significance was determined as P&lt;.05, and results were displayed as adjusted odds ratios (aORs) with 95% CI. RESULTS: Of the 11,677,671 who met inclusion criteria, 139,174 (1.2%) women experienced 3/4 PL. Intrapartum chorioamnionitis was associated with a staggering 3.96% rate of 3/4 PL compared to a 1.15% rate in women without chorioamnionitis (aOR 1.85, 95% CI 1.80–1.90). CONCLUSION: Based on this current U.S. database we identified chorioamnionitis as a major risk factor for 3/4 PL. The potential explanation may be due to dysfunctional labor, increased perineal edema secondary to protracted labor, or increased friability of tissue. Understanding this association may assist in better counseling and potentially reduce the rates of 3/4 PL in gravidas with chorioamnionitis.

The impact of maternal obesity on in vivo uterine contractile activity during parturition in the rat.

Maternal obesity is associated with increased risk of prolonged and dysfunctional labor and emergency caesarean section. To elucidate the mechanisms behind the associated uterine dystocia, a translational animal model is required. Our previous work identified that exposure to a high-fat, high-cholesterol (HFHC) diet to induce obesity down-regulates uterine contractile associated protein expression and causes asynchronous contractions ex vivo. This study aims to investigate the impact of maternal obesity on uterine contractile function in vivo using intrauterine telemetry surgery. Virgin female Wistar rats were fed either a control (CON, n=6) or HFHC (n=6) diet for 6 weeks prior to conception, and throughout pregnancy. On Day 9 of gestation, a pressure-sensitive catheter was surgically implanted aseptically within the gravid uterus. Following 5 days recovery, intrauterine pressure (IUP) was recorded continuously until delivery of the 5th pup (Day 22). HFHC induced obesity led to a significant 1.5-fold increase in IUP (p=0.026) and fivefold increase in frequency of contractions (p=0.013) relative to CON. Determination of the time of labor onset identified that HFHC rats IUP (p=0.046) increased significantly 8h prior to 5th pup delivery, which contrasts to CON with no significant increase. Myometrial contractile frequency in HFHC rats significantly increased 12 h prior to delivery of the 5th pup (p=0.023) compared to only 3h in CON, providing evidence that labor in HFHC rats was prolonged by 9h. In conclusion, we have established a translational rat model that will allow us to unravel the mechanism behind uterine dystocia associated with maternal obesity.

CAMP Compartmentalisation in Human Myometrial Cells.

Preterm birth is the leading cause of childhood mortality and morbidity. A better understanding of the processes that drive the onset of human labour is essential to reduce the adverse perinatal outcomes associated with dysfunctional labour. Beta-mimetics, which activate the myometrial cyclic adenosine monophosphate (cAMP) system, successfully delay preterm labour, suggesting a key role for cAMP in the control of myometrial contractility; however, the mechanisms underpinning this regulation are incompletely understood. Here we used genetically encoded cAMP reporters to investigate cAMP signalling in human myometrial smooth muscle cells at the subcellular level. We found significant differences in the dynamics of the cAMP response in the cytosol and at the plasmalemma upon stimulation with catecholamines or prostaglandins, indicating compartment-specific handling of cAMP signals. Our analysis uncovered significant disparities in the amplitude, kinetics, and regulation of cAMP signals in primary myometrial cells obtained from pregnant donors compared with a myometrial cell line and found marked response variability between donors. We also found that in vitro passaging of primary myometrial cells had a profound impact on cAMP signalling. Our findings highlight the importance of cell model choice and culture conditions when studying cAMP signalling in myometrial cells and we provide new insights into the spatial and temporal dynamics of cAMP in the human myometrium.

20α-Hydroxysteroid Dehydrogenase Expression in the Human Myometrium at Term and Preterm Birth: Relationships to Fetal Sex and Maternal Body Mass Index

The mechanism by which human labor is initiated in the presence of elevated circulating progesterone levels remains unknown. Recent evidence indicates that the progesterone-metabolizing enzyme, 20α-hydroxysteroid dehydrogenase (20α-HSD), encoded by the gene AKR1C1, may contribute to functional progesterone withdrawal. We found that AKR1C1 expression significantly increased with labor onset in term myometrium, but not in preterm myometrium. Among preterm laboring deliveries, clinically diagnosed chorioamnionitis was associated with significantly elevated AKR1C1 expression. AKR1C1 expression positively correlated with BMI before labor and negatively correlated with BMI during labor. Analysis by fetal sex showed that AKR1C1 expression was significantly higher in women who delivered male babies compared to women who delivered female babies at term, but not preterm. Further, in pregnancies where the fetus was female, AKR1C1 expression positively correlated with the mother’s age and BMI at the time of delivery. In conclusion, the increase in myometrial AKR1C1 expression with term labor is consistent with 20α-HSD playing a role in local progesterone metabolism to promote birth. Interestingly, this role appears to be specific to term pregnancies where the fetus is male. Upregulated AKR1C1 expression in the myometrium at preterm in-labor with clinical chorioamnionitis suggests that increased 20α-HSD activity is a mechanism through which inflammation drives progesterone withdrawal in preterm labor. The link between AKR1C1 expression and maternal BMI may provide insight into why maternal obesity is often associated with dysfunctional labor. Higher myometrial AKR1C1 expression in male pregnancies may indicate fetal sex-related differences in the mechanisms that precipitate labor onset at term.

Gestational weight gain adequacy and intrapartum oxytocin and cesarean section use: Observational population-based study in France.

Research on maternal prepregnancy weight suggests adiposity is associated with dysfunctional labor, but knowledge about how gestational weight gain (GWG) affects labor is sparse. Our objective was to evaluate associations between GWG adequacy and intrapartum obstetric interventions (oxytocin administration; cesarean section) necessitated by labor dysfunction. Using national, population-based French National Perinatal Survey 2016 data, we included term cephalic singleton pregnancies involving trial of labor (n=9724). For the intrapartum oxytocin administration analysis, we included only women with spontaneous labor (n=7352). GWG was calculated as the difference between end of pregnancy and prepregnancy weight (both self-reported) and categorized as insufficient, adequate (reference group), or excessive by prepregnancy body mass index (BMI; underweight <18.5, normal weight 18.5-24.9, overweight 25-29.9, obese ≥30 kg/m2 ) using the 2009 Institute of Medicine thresholds. Multilevel generalized estimating equation logistic regression models, unadjusted and adjusted for a priori confounders, evaluated intervention-GWG adequacy associations within BMI categories (under/normal weight combined), stratified by parity (primiparas; multiparas). GWG adequacy was associated with oxytocin use among under/normal weight women (primiparas: insufficient 57.3%, adequate 60.8%, excessive 65.0%, p=0.014; multiparas: insufficient 27.2%, adequate 29.1%, excessive 36.2%, p < 0.001) and overweight primiparas (insufficient 56.0%, adequate 58.7%, excessive 72.5%, p=0.002). In unadjusted and adjusted models, trends of increased odds of oxytocin administration among women with excessive GWG were found regardless of parity and prepregnancy BMI. Similarly, among under/normal weight women, GWG adequacy was associated with intrapartum cesarean section (primiparas: insufficient 10.7%, adequate 12.7%, excessive 15.3%, p=0.014; multiparas: insufficient 3.1%, adequate 3.5%, excessive 6.3%, p < 0.001) with increased cesarean section among multiparas with excessive GWG persisting in adjusted models (adjusted odds ratio 1.9, 95% confidence interval 1.3-2.7). However, intrapartum cesarean section was reduced among multiparas with overweight and obese prepregnancy BMI and excessive GWG. Excessive GWG was associated with intrapartum oxytocin administration, regardless of parity or prepregnancy BMI, and cesarean section among women with under/normal weight prepregnancy BMI, providing evidence for benefits of healthy GWG for normal labor progression. Additional research is needed to verify our findings and understand differences by BMI.

The Outcome of Obesity in Pregnancy: A Cross-Sectional Study

Objective: To find out fetal and maternal outcomes among obese pregnant females.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Department of Gynaecology and Obstetrics, Combined Military Hospital Rawalpindi, from Jun 2020 to Jun 2021.&#x0D; Methodology: A total of 124 pregnant obese women (BMI more than 30kg/m2), gestational age between 13-24 months, having fasting blood glucose and blood pressure within normal limits were enrolled in the study and were subsequently followed throughout pregnancy upon antenatal visits scheduled as per guidelines. Participants with diabetes mellitus or hypertension,above 40 years of age, family or previous history of gestational diabetes, and pre-eclampsia were also excluded from the study. Fetal and maternal outcomes were noted.&#x0D; Results: One hundred and twenty-four (124) pregnant obese women were enrolled in the study with a mean age of 33.7±4.1 years (21 -38 years). Out of which, 86(69.4%) had cesarean section primarily due to pre-eclampsia, prolonged or dysfunctional labour causing fetal distress. There were 8 cases of miscarriage and 3 cases of stillbirth. 26(21.0%) women presented with gestational diabetes mellitus, 31(25.0%) with pre-eclampsia and 12(9.7%) developed both conditions. There were 7(5.6%) participants who delivered babies with macrosomia, 1(0.8%) anencephaly, 3(2.4%) congenital deafness and 1(0.8%) cleft lip.&#x0D; Conclusion: Obesity in pregnancy can lead to serious maternal and fetal outcomes ranging from abortions to neonatal anomalies and fetal death. A high index of suspicion is required to diagnose and manage these difficult conditions.

Cervical dilatation rate following augmentation of dysfunctional labour with oxytocin alone versus oxytocin and drotaverine among term nulliparas in the Rivers State University Teaching Hospital, Port Harcourt, Nigeria

Background: Dysfunctional labour is the commonest abnormality of the first stage of labour. It complicates 50% of nulliparous deliveries and is associated with increased perinatal morbidity and mortality. Dysfunctional labour occurs when the progress in the active phase of labour is abnormally slow (&lt;1 cm/hr). It is largely due to ineffective uterine contractions or slow cervical dilatation. Augmentation of labour with oxytocin is the standard management of dysfunctional labour as it enhances uterine contractions. In many cases, despite good uterine contractions slow progress persists due to cervical smooth muscle spasms. Drotaverine a smooth muscle relaxant can be used to relieve cervical smooth muscle spasms. Aim/objective: This study compared the cervical dilatation rate in term nulliparas following augmentation of dysfunctional labour with oxytocin versus oxytocin and drotaverine. Methods: The study was a single-blinded randomized clinical trial involving 156 term nulliparous women with dysfunctional labour, who were randomized into two groups. Each group had 78 participants and received either oxytocin with a placebo or oxytocin with drotaverine. They were monitored until delivery and the cervical dilatation rates in both groups were compared. Data obtained were analysed using SPSS version 23 software. The level of significance was set at 0.05. Results: The two groups were similar in their baseline characteristics, the mean pre-intervention cervical dilatation rate were also similar (0.53 cm/hr vs. 0.52 cm/hr, p = 0.85). Following augmentation, the cervical dilatation rate in the oxytocin-drotaverine group was significantly faster than in the oxytocin-placebo group (1.60 cm/hr vs. 1.20 cm/hr, p &lt; 0.01). Conclusion: The use of drotaverine with oxytocin in managing dysfunctional labour in term nulliparous women leads to a faster cervical dilatation rate.

Cervical dilatation rate following augmentation of dysfunctional labour with oxytocin alone versus oxytocin and drotaverine among term nulliparas in the Rivers State University Teaching Hospital, Port Harcourt, Nigeria

Cervical dilatation rate following augmentation of dysfunctional labour with oxytocin alone versus oxytocin and drotaverine among term nulliparas in the Rivers State University Teaching Hospital, Port Harcourt, Nigeria

Outcome of Unengaged Fetal Head at Term in Nullipara

Introduction: Engagement of fetal head is usually regarded as a phenomenon of labor in nullipara. It commonly occurs during the last few weeks in nullipara, in majority by 38 weeks or even during the first stage of labor. The aim of this study was to determine the outcome of unengaged fetal head at term in nullipara. Materials And Methods: This study was conducted at obstetrics and gynecology unit, tertiary care teaching hospital, Peshawar. This was a descriptive cross-sectional study which was conducted during 12th Jan 2021 to 10th April 2022, in which a total of 111 patients were included in the study using 16.89% proportion of caesarean section¸95% confidence level and 7% margin of error under WHO software for sample size determination. Results: In this study, patients were in age range 19-35 years and heights of the patients were 140-160cm. Among 111 patients, normal vaginal delivery occurred in 71.71% patients, instrumental delivery in 10.8% and 18.2% patients underwent low segment caesarean section. Total number of nullipara with unengaged head were divided into four groups based on fetal head station in early labor. Total number of nullipare in each group of which 30.6% were free head, 43.2% at -3 station group, 21.62%-2 station group and 45% in -1 group Practical implication in nulliparous patients a high station at the onset of labour is not necessarily an omnious finding, even though the incidence of arrest disorders are higher when station is -3,or floating ,obstetricians can still be optimistic towards vaginal delivery. Conclusions: Nullipara with unengaged head at term during labors should be regarded with suspicion and as such should be regarded with apprehension in labor. Dysfunctional labor occurs in only small proportion of patients with unengaged head. It is concluded that the incidence of active surgical intervention in nullipara with unengaged fetal head at term is quite high. Keywords: Primigravidae, engagement of head, delivery, LSCS, Head station.

Signaling Pathways Regulating Human Cervical Ripening in Preterm and Term Delivery.

At the end of gestation, the cervical tissue changes profoundly. As a result of these changes, the uterine cervix becomes soft and vulnerable to dilation. The process occurring in the cervical tissue can be described as cervical ripening. The ripening is a process derivative of enzymatic breakdown and inflammatory response. Therefore, it is apparent that cervical remodeling is a derivative of the reactions mediated by multiple factors such as hormones, prostaglandins, nitric oxide, and inflammatory cytokines. However, despite the research carried out over the years, the cellular pathways responsible for regulating this process are still poorly understood. A comprehensive understanding of the entire process of cervical ripening seems crucial in the context of labor induction. Greater knowledge could provide us with the means to help women who suffer from dysfunctional labor. The overall objective of this review is to present the current understanding of cervical ripening in terms of molecular regulation and cell signaling.

Midwifery Management of a Birthing Person with Cervical Edema During Labor.

During active labor, a birthing person with cervical edema often has a dysfunctional or prolonged labor and, therefore, an increased risk for cesarean birth. Midwives seeking evidence on how to manage cervical edema when they are faced with this clinical situation will note a gap in the literature regarding the management of cervical edema that this report aims to fill. This case will discuss the use of intravenous diphenhydramine (Benadryl), the application of ice to the cervix, side-lying release, epidural analgesia use, manual reduction of the cervix, and various positions to encourage reduction in cervical swelling. It is hoped these strategies will add to a midwife's clinical resources by providing ways to promote vaginal birth in the setting of cervical edema during labor.

The impact of embryo vitrification on placental histopathology features and perinatal outcome in singleton live births

Does embryo vitrification affect placental histopathology pattern and perinatal outcome in singleton live births? Embryo vitrification has a significant effect on the placental histopathology pattern and is associated with a higher prevalence of dysfunctional labor. Obstetrical and perinatal outcomes differ between live births resulting from fresh and frozen embryo transfers. The effect of embryo vitrification on the placental histopathology features associated with the development of perinatal complications remains unclear. Retrospective cohort study evaluating data of all live births from one academic tertiary hospital resulting from IVF treatment with autologous oocytes during the period from 2009 to 2017. All patients had placentas sent for pathological evaluation irrelevant of maternal or fetal complications status. Placental, obstetric and perinatal outcomes of pregnancies resulting from hormone replacement vitrified embryo transfers were compared with those after fresh embryo transfers. A multivariate analysis was conducted to adjust the results for determinants potentially associated with the development of placental histopathology abnormalities. A total of 1014 singleton live births were included in the final analysis and were allocated to the group of pregnancies resulting from fresh (n = 660) and hormone replacement frozen (n = 354) embryo transfers. After the adjustment for confounding factors the frozen embryo transfers were found to be significantly associated with chorioamnionitis with maternal (odds ratio (OR) 2.0; 95% CI 1.2-3.3) and fetal response (OR 2.6; 95% CI 1.2-5.7), fetal vascular malperfusion (OR 3.9; 95% CI 1.4-9.2), furcate cord insertion (OR 2.3 95% CI 1.2-5.3), villitis of unknown etiology (OR 2.1; 95% CI 1.1-4.2), intervillous thrombi (OR 2.1; 95% CI 1.3-3.7), subchorionic thrombi (OR 3.4; 95% CI 1.6-7.0), as well as with failure of labor progress (OR 2.5; 95% CI 1.5-4.2). Since the live births resulted from frozen-thawed embryos included treatment cycles with previously failed embryo transfers, the factors over embryo vitrification may affect implantation and placental histopathology. The study results contribute to the understanding of the perinatal future of fresh and vitrified embryos. Our findings may have an implication for the clinical decision to perform fresh or frozen-thawed embryo transfer. Authors have not received any funding to support this study. There are no conflicts of interest to declare. N/A.

The oxytocin signaling complex reveals a molecular switch for cation dependence.

Oxytocin (OT) and vasopressin (AVP) are conserved peptide signaling hormones that are critical for diverse processes including osmotic homeostasis, reproduction, lactation and social interaction. OT acts through the oxytocin receptor (OTR), a magnesium-dependent G protein-coupled receptor that is a therapeutic target for treatment of postpartum hemorrhage, dysfunctional labor and autism. However, the molecular mechanisms that underlie OTR activation by OT and the dependence on magnesium remain unknown. Here we present the wild-type active-state structure of human OTR bound to OT and miniGq/i determined by cryo-EM. The structure reveals a unique activation mechanism adopted by OTR involving both the formation of a Mg2+ coordination complex between OT and the receptor, and disruption of transmembrane helix 7 (TM7) by OT. Our functional assays demonstrate the role of TM7 disruption and provide the mechanism of full agonism by OT and partial agonism by OT analogs. Furthermore, we find that the identity of a single cation-coordinating residue across vasopressin family receptors determines whether the receptor is cation-dependent. Collectively, these results demonstrate how the Mg2+-dependent OTR is activated by OT, provide essential information for structure-based drug discovery efforts and shed light on the molecular determinants of cation dependence of vasopressin family receptors throughout the animal kingdom.

Association between plasma leptin and cesarean section after induction of labor: a case control study

BackgroundObesity in pregnancy is common, with more than 50% of pregnant women being overweight or obese. Obesity has been identified as an independent predictor of dysfunctional labor and is associated with increased risk of failed induction of labor resulting in cesarean section. Leptin, an adipokine, is secreted from adipose tissue under the control of the obesity gene. Concentrations of leptin increase with increasing percent body fat due to elevated leptin production from the adipose tissue of obese individuals. Interestingly, the placenta is also a major source of leptin production during pregnancy. Leptin has regulatory effects on neuronal tissue, vascular smooth muscle, and nonvascular smooth muscle systems. It has also been demonstrated that leptin has an inhibitory effect on myometrial contractility with both intensity and frequency of contractions decreased. These findings suggest that leptin may play an important role in dysfunctional labor and be associated with the outcome of induction of labor at term. Our aim is to determine whether maternal plasma leptin concentration is indicative of the outcome of induction of labor at term. We hypothesize that elevated maternal plasma leptin levels are associated with a failed term induction of labor resulting in a cesarean delivery.MethodsIn this case-control study, leptin was measured in 3rd trimester plasma samples. To analyze labor outcomes, 174 women were selected based on having undergone an induction of labor (IOL), (115 women with successful IOL and 59 women with a failed IOL). Plasma samples and clinical information were obtained from the UI Maternal Fetal Tissue Bank (IRB# 200910784). Maternal plasma leptin and total protein concentrations were measured using commercially available assays. Bivariate analyses and logistic regression models were constructed using regression identified clinically significant confounding variables. All variables were tested at significance level of 0.05.ResultsWomen with failed IOL had higher maternal plasma leptin values (0.5 vs 0.3 pg, P = 0.01). These women were more likely to have obesity (mean BMI 32 vs 27 kg/m2, P = 0.0002) as well as require multiple induction methods (93% vs 73%, p = 0.008). Logistic regression showed Bishop score (OR 1.5, p < 0.001), BMI (OR 0.92, P < 0.001), preeclampsia (OR 0.12, P = 0.010), use of multiple methods of induction (OR 0.22, P = 0.008) and leptin (OR 0.42, P = 0.017) were significantly associated with IOL outcome. Specifically, after controlling for BMI, Bishop Score, and preeclampsia, leptin was still predictive of a failed IOL with an odds ratio of 0.47 (P = 0.046). Finally, using leptin as a predictor for fetal outcomes, leptin was also associated with of fetal intolerance of labor, with an odds ratio of 2.3 (P = 0.027). This association remained but failed to meet statistical significance when controlling for successful (IOL) (OR 1.5, P = 0.50).ConclusionsMaternal plasma leptin may be a useful tool for determining which women are likely to have a failed induction of labor and for counseling women about undertaking an induction of labor versus proceeding with cesarean delivery.

Outcome of Pregnancies Associated with Fibroids

Objectives: To evaluate the behaviour of uterine leiomyoma, their frequency and impact on the course of pregnancy Design: It was a descriptive study. Setting: Gynaecology and Obstetric Unit, Hayatabad Medical Complex, PGMI, Peshawar. Subjects: All the patients presenting to antenatal clinic or emergency having a pregnancy associated with fibroids from 1st July 2001 to 30th June 2002. Subject and Methods: Women diagnosed with leiomyoma during pregnancy were evaluated clinically and the findings were confirmed by ultrasound. Detection of leiomyoma during caesarean section also made the patient eligible for the study. In all there were 76 patients in the study. The size of leiomyoma, the type of leiomyoma, their effect on pregnancy outcome and complications were noted. Patients obstetric, and fertility history was recorded on a questionnaire. The concerned doctors were required to fill a performa regarding the outcome and complications the delivery of such patients. Data Analysis: After data collection, the data was analyzed using various statistical tests like percentage, relative risk (R.R), ods ratio (O.R), mean, standard deviation (S.D) confidence interval (C.I), using software SPSS version 8.0 and Epi-Info 6. Main Outcome Measures: The main outcome measures were noted down as the frequency of spontaneous pregnancy loss, vaginal delivery or the caesarean section. Results: Out of 76 patients (1.9%), 16 underwent spontaneous pregnancy loss (21 %, O.R 1.16. R.R 1.13, P 0.59), 31 had vaginal delivery (40.8%, O.R 0.21, R.R 0.62, P 0.0000) and 29 had caesarean section (38.2%. O.R 4.71, R.R 2.91, P 0.0000). The frequency of complicated deliveries was 73.3%. The different complications occurring were antepartum haemorrhage, acute abdomen, laparotomy, preterm labour, dysfunctional labour, retained placenta and retained products of conception. Conclusion: Although abortions, preterm delivery, dysfunctional labour and cesarean sections were common, the neonatal outcome in viable pregnancies was fairly good in women with uterine leiomyomas. Because of increased risk of complications all the patients with leiomyomas having pregnancy should be considered as high-risk cases.

Applicability of the GAIA Maternal and Neonatal Outcome Case Definitions for the Evaluation of Adverse Events Following Vaccination in Pregnancy in High-income Countries.

The Brighton Collaboration Global Alignment of Immunization Safety in Pregnancy (GAIA) project developed case definitions for the assessment of adverse events in mothers and infants following maternal immunization. This study evaluated the applicability of these definitions to data collected in routine clinical care and research trial records across 7 sites in high-resource settings. Data collection forms were designed and used to retrospectively abstract the key elements of the GAIA definitions from records for 5 neonatal and 5 maternal outcomes, as well as gestational age. Level of diagnostic certainty was assessed by the data abstractor and an independent clinician, and then verified by Automated Brighton Case logic. The ability to assign a level of diagnostic certainty for each outcome and the positive predictive value (PPV) for their respective ICD-10 codes were evaluated. Data from 1248 case records were abstracted: 624 neonatal and 622 maternal. Neonatal outcomes were most likely to be assessable and assigned by the level of diagnostic certainty. PPV for preterm birth, low birth weight, small for gestational age and respiratory distress were all above 75%. Maternal outcomes for preeclampsia and fetal growth restriction showed PPV over 80%. However, microcephaly (neonatal outcome) and dysfunctional labor (maternal outcome) were often nonassessable, with low PPVs. The applicability of GAIA case definitions to retrospectively ascertain and classify maternal and neonatal outcomes was variable among sites in high-resource settings. The implementation of the case definitions is largely dependent on the type and quality of documentation in clinical and research records in both high- and low-resource settings. While designed for use in the prospective evaluation of maternal vaccine safety, the GAIA case definitions would likely need to be specifically adapted for observational studies using alternative sources of data, linking various data sources and allowing flexibility in the ascertainment of the elements and levels of certainty of the case definition.