Obstetric Implications Research Articles

710: Obstetric and metabolic implications of excessive gestational weight gain in pregnancy

710: Obstetric and metabolic implications of excessive gestational weight gain in pregnancy

Gynecologic and obstetric implications of the joint hypermobility syndrome (a.k.a. Ehlers–Danlos syndrome hypermobility type) in 82 Italian patients

Joint hypermobility syndrome (JHS) emerges as likely the most common clinical form of Ehlers-Danlos syndrome. Given the striking predominance of affected women, practitioners often face gynecologic and obstetric issues. However, their decisions are still based on personal experience rather than literature due to the lack of a consistent body of evidence. We collected a set of gynecologic and obstetric features in 82 post-puberal women with JHS attending two Italian centers. Common gynecologic findings were dysmenorrhea (82.9%), meno/metrorrhagias (53.7%), irregular menses (46.3%), and dispareunia/vulvodinia (31.7%). Forty women were nulliparous and 42 had one or more pregnancy for a total of 93 diagnosed conceptions. Of them, 16.1% were spontaneous abortions, 6.5% voluntary interruptions, 10.7% preterm deliveries, and 66.7% deliveries at term. Overall outcome of proceeding pregnancies was good with no stillbirth and fetal/neonatal hypoxic/ischemic event. Non-operative vaginal delivery was registered in 72.2%, forceps/vacuum use in 5.5% and cesarean in 22.3%. Local/total anesthesia was successfully performed in 17 pregnancies without any problem. Major post-partum complications included abnormal scar formation after cesarean or episiotomy (46.1%), hemorrhage (19.4%), pelvic prolapses (15.3%), deep venous thrombosis (4.2%), and coccyx dislocation (1.4%). Prolapses were the most clinically relevant complication and associated with episiotomy. Gathered data were discussed for practically oriented considerations.

Stopping breastfeeding to prevent vertical transmission of HTLV-1 in resource-poor settings: beneficial or harmful?

In a recent issue of this journal Mylonas et al. [1] reviewed human T-lymphotropic virus type 1 (HTLV-1) infection and its implications in gynecology and obstetrics. Although HTLV-1 is rare in many populations, it occurs worldwide and is associated with a substantial disease burden and a high risk of vertical transmission. The authors provide recommendations for prevention of sexual and vertical transmission of HTLV-1. One of the recommendations is the following: ‘If stopping breastfeeding is not possible, for example due to socio-economical circumstances, short-term breastfeeding for 3 to a maximum of 6 months should be advocated’. The recommendation in the review is based on two studies from Japan showing reductions of vertical transmission by limiting or avoiding breastfeeding. To our knowledge, no international guidelines exist (e.g. from the WHO or CDC) on breastfeeding and HTLV-1 prevention in resource-poor, developing countries. Therefore, it is important to carefully take into account the risks versus the benefits of advocating short-term breastfeeding in developing countries. Various studies have shown that prolonged breastfeeding is associated with an increased risk of HTLV-1 transmission and avoiding breastfeeding can lead to a dramatic reduction in transmission [2]. A high maternal proviral load in combination with waning antibodies in the child leads to an increased risk of HTLV-1 transmission, especially after 6–12 months after birth [3]. However, the key question is whether the benefits of avoiding HTLV-1 infection outweigh the risks of not breastfeeding. As the review points out, HTLV-1 causes adult T-cell leukemia (ATL) or tropical spastic paraparesis (TSP) in about 5% of infected individuals and is associated with a number of infections and inflammations. On the other hand, the risks of early weaning are substantial. The promotion of breastfeeding for 6–11 months has been estimated to be the most effective strategy to prevent child mortality in resource-limited settings and the WHO recommends at least 6 months of exclusive breastfeeding [4]. Our work in Guinea-Bissau, one of the poorest countries in Sub Saharan Africa with a high prevalence of HTLV-1 (5%) [5, 6], has shown that early weaning (before 12 months) is associated with increased mortality and increased risk of diarrheal diseases among children [7, 8]. For example, the mortality among weaned children was sixfold higher compared to breastfed children during the civil war in Guinea-Bissau in 1996–1997 [7]. In many Sub Saharan countries, vertical transmission of HIV is of major concern. In an editorial from 2010, Humphrey points out the increasing amount of data supporting the fact that in Sub Saharan Africa the risks of early weaning do not outweigh the risks of a possible HIV infection [9]. The 2010 UNAIDS guidelines advice at least 6 months of exclusive breastfeeding and advice to continue breastfeeding after this time if replacement feeding is not feasible, even when anti-retroviral (ARV) drugs are not available (if available, ARVs are recommended for mother and child to reduce the risk of transmission) [10]. Thus, for an infection that has much larger health implications than HTLV-1, breastfeeding longer than 6 months is recommended in certain settings where replacement feeding is not feasible. HTLV-1 infected pregnant women from a poor socio-economic background in a developed country merit extra attention and the advice about not breastfeeding should be tailored to the exact circumstances of the woman. However, it is very likely that these women will have access to good replacement feeding and therefore it seems rational to advise them similarly as women from higher socio-economic status, i.e., to refrain from breastfeeding altogether. In conclusion, in resource-poor settings, like Guinea-Bissau, the immediate health risks of the advocated weaning at 3–6 months are likely to be bigger than the risks of HTLV-1 related morbidity and mortality. This is likely to vary by country and will strongly depend on the socio-economic circumstances and current breastfeeding practices in the country. The available data so far do not support early weaning to prevent vertical transmission of HTLV-1 in resource-limited settings.

Neurologic Issues and Obstetric Anesthesia

The rising popularity of regional anesthesia in the last several decades has greatly changed the experience of labor. Although the use of regional anesthesia has aided in decreasing maternal morbidity and mortality, a new dimension of neurologic issues, particularly headache and peripheral neuropathy, is apparent. Obstetric anesthesiologists frequently encounter patients with preexisting neurologic disease. Although very few of these disorders contraindicate the use of neuraxial technique, there are limited published data on specific neurologic and neuromuscular disorders in pregnancy. Neurologists are often consulted by anesthesiologists and obstetricians to evaluate pregnant patients for the feasibility of labor analgesia and when postpartum neurologic complications arise. Early consultation with an obstetric anesthesiologist, discussion with a neurologist, and communication with the obstetrician allows for the education and discussion of the risks and benefits of both the mode of delivery and anesthetic options. This multidisciplinary approach is crucial in forming reasonable expectations for the patient. The aim of this discussion is to provide an obstetric anesthesiologist's perspective on regional anesthesia and its implications in obstetrics, and to enhance communication between our specialties.

Ultrasound-Detected Subchorionic Hemorrhage and the Obstetric Implications

To estimate the association between the ultrasonographic diagnosis of subchorionic hemorrhage and adverse pregnancy outcomes. This was a retrospective cohort study of all consecutive women undergoing routine ultrasonography before 22 weeks with a singleton gestation at one institution from 1994 to 2008. Presence or absence of subchorionic hemorrhage defined the two study groups. The primary outcomes were abruption, intrauterine growth restriction defined as birth weight less than the 10th percentile, and nonanomalous intrauterine fetal demise after 20 weeks. Secondary outcomes included preeclampsia, preterm premature rupture of membranes, and preterm delivery before 37 weeks and before 34 weeks of gestation. Univariable, bivariate, and multiple logistic regression analyses were performed. Of the 63,966 women in the patient population, 1,081 had subchorionic hemorrhage (1.7%). Women with a subchorionic hemorrhage were at increased risk of abruption (n=432, 3.6% compared with 0.6%, adjusted odds ratio 2.6, 95% confidence interval 1.8-3.7) and of preterm delivery (n=6,601, 15.5% compared with 10.5%, adjusted odds ratio 1.3, 95% confidence interval 1.1-1.5), even after adjusting for bleeding during pregnancy, chronic hypertension, body mass index, race, diabetes mellitus, tobacco use, and previous preterm delivery. Women with ultrasound-detected subchorionic hemorrhage before 22 weeks of gestation are at increased risk of placental abruption and preterm delivery but are not at increased risk of other adverse pregnancy outcomes. II.

Pregnant women with congenital heart disease: cardiac, anesthetic and obstetrical implications

Remarkable advances in surgical and clinical management have resulted in survival to adulthood in the large majority of patients with congenital heart malformations, even with the most complex disease. Over 1 million adults with congenital heart disease currently live in the USA, approximately half of whom are women of childbearing age. Collectively, congenital malformations are the most common form of heart disease in pregnant women. Indeed, in North America, congenital defects are now the leading cause of maternal morbidity and mortality from heart disease. This article begins with a summary of cardiovascular changes during pregnancy and highlights key features in pre-pregnancy counseling, maternal cardiac and obstetric risk, and neonatal complications. Management issues regarding pregnancy and delivery are elaborated, including anesthesia considerations. While it is beyond the scope of this article to discuss particulars related to all forms of congenital heart disease, selected subtypes are detailed at greater length. In the absence of clinical trial evidence to inform the care of pregnant women with congenital heart disease, this article is inspired by the premise that knowledgeable multidisciplinary assessment and management provides the best opportunity to substantially improve outcomes for mother and baby.

Cardiac drug use in pregnancy: safety, effectiveness and obstetric implications

Morbidity and mortality due to cardiovascular disease is increasing in pregnancy. The physiologic changes of normal pregnancy serve as a ‘stress test’ on the cardiovascular system. This may lead to the unmasking of a latent underlying cardiac condition or the new onset of maternal cardiovascular disease, with an attendant increase in adverse maternal and fetal outcomes. Some women with pre-existing cardiac conditions may be receiving medications that need to be altered during pregnancy owing to a risk of adverse effects on the developing fetus, but for most cardiac conditions, there are safe and effective treatment options. Women should be educated that abrupt discontinuation of cardiac medications during pregnancy usually poses a greater risk than the medications themselves, and a plan of judicious drug selection should be implemented (ideally prior to conception).

Rectovestibular fistula—rarely recognized associated gynecologic anomalies

Introduction Vestibular fistulas are the most common anorectal malformations (ARMs) in females. Associated gynecologic defects are rarely mentioned in the literature but may have serious clinical implications if undetected. The definitive repair of the ARM offers an opportunity for diagnosis and treatment of these conditions. Methods Two hundred seventy-two patients with vestibular fistula were retrospectively reviewed, with emphasis on gynecologic defects. Results Forty-eight patients (17%) had 83 gynecologic anomalies. Fourteen patients had a vaginal septum, all with 2 uterine cervices. All septa were resected at the main repair. Twenty-six patients had no vaginal opening. Twenty of them had absent vagina. Eighteen of those had an absent uterus. Patients with absent vagina underwent vaginal replacement with distal rectum (12), sigmoid (6), and ileum (2). Six patients had a patent upper vagina; 3 reached the perineum after mobilization and 3 required replacement; 2 with sigmoid and 1 with rectum. Conclusion Vaginal septa are easily diagnosed and can be resected during the repair of the vestibular fistula. The presence of 2 cervices has important obstetric implications. Absent vagina requires a technically demanding repair, with special preoperative planning. Vaginoscopy or careful inspection should precede surgical reconstruction.

Increased Aerobic Fitness In Late Pregnancy Predicts Shorter Labor In Nulliparous, But Not Multiparous, Women.

Similar to the general population, the level of physical activity is inadequate among pregnant women. The ensuing state of over-nutrition as a consequence of physical inactivity prolongs labor and thereby the risk of several obstetrical implications including fetal asphyxia, infections and obstetrical fistulas. Well-trained women who maintain physical exercise during pregnancy have shorter labor compared to those who stop training before the end of the first trimester. Much less is known about whether aerobic fitness in a general cohort of pregnant women is related to duration of labor. PURPOSE: We wanted to investigate the effect of aerobic fitness on duration of labor among nulli- and multiparous women using two valid indicators, namely measurement of maximal oxygen uptake and calculation of anaerobic threshold. METHODS: Maximal oxygen uptake and anaerobic threshold were measured in 59 nulli- and 51 multiparous women at 36 weeks of gestation. Duration of labor was defined as the time between three cm cervical dilation with regular uterine contractions and delivery. Unpaired sample t-test, Pearson correlation test and multiple linear regression were used for statistical analysis. RESULTS: Maximal oxygen uptake was similar for both groups (mean 2.1 L/min). Labor was as expected longer (p < 0.001) in the nulliparous compared to the multiparous women: 9.3±5.0 and 4.5±2.3 hours, respectively. For nulliparous women who started labor spontaneously, duration of labor was inversely associated with maximal oxygen uptake (p=0.03). This indicates that for an increase in maximal oxygen uptake of 0.1 L/min, labor would be shortened by on average 33 minutes. In contrast, in multiparous women who started labor spontaneously, anaerobic threshold was positively associated with duration of labor (p=0.002). This indicates that an increase in anaerobic threshold of 0.1 L/min would prolong labor by on average 22 minutes. Conclusion: Increased maximal oxygen uptake is associated with shorter labor in nulliparous women who start labor spontaneously, whereas increased anaerobic threshold is associated with prolonged labor in multiparous women.

Obstetric morbidity and the diagnostic dilemma in pregnancy in rudimentary horn: retrospective analysis

Pregnancy in rudimentary horn of uterus, a form of ectopic gestation, is associated with significant rates of morbidity and mortality. Despite the recent advances in the ultrasonography, diagnosis of cornual pregnancy still remains elusive; with confirmatory diagnosis usually made during laparotomy. The aim of the present study is to analyze the obstetric implications and the diagnostic dilemma of rudimentary horn pregnancy. Records of women diagnosed with ectopic pregnancy in the rudimentary horn, during the years 2004 to 2008, managed in a referral hospital in northern India; were reviewed for their diagnostic difficulties and the associated morbidity. During the four year study period, rudimentary horn pregnancies accounted for 12 pregnancies. Non communicating horn accounted for 75% of the cases. The mean age of women at presentation was 26 +/- 5.11 years and the period of gestation at diagnosis varied between 10 and 34 weeks. Preruputure diagnosis was possible only in two cases and sensitivity of ultrasonographic diagnosis was 33.3%. Laprotomy with excision of rudimentary horn and salpingectomy was done in all cases. Multiple blood transfusions were required in 83.3% of women. Management of pregnancy in a rudimentary uterine horn continues to be a challenge to this day. Maintaining a higher degree of alertness, especially in high risk groups by emergency staff is required to prevent the morbidity, as they may present with acute uterine rupture in pregnancy.

Cervical mucus status can be accurately estimated by transvaginal ultrasound during fertility evaluation

Examinations of the cervical mucus for determining its quantity and physical characteristics are used to provide a clinical marker for the timing of ovulation. We propose that transvaginal ultrasound, which is routinely used as a tool for monitoring follicular growth in patients undergoing ovulation induction, might also be used simultaneously for estimating cervical mucus measurements. With no additional effort or expense, these data may help to optimize individual patient management.

Obstetric implications of current Australian product information for thyroid‐related medications

Obstetric implications of current Australian product information for thyroid‐related medications

Obstetric implications of multiple gestation

Obstetric implications of multiple gestation

Four decades of conjoined twins at Red Cross Children's Hospital--lessons learned.

Conjoined twins represent a rare but fascinating congenital condition, the aetiology of which remains obscure. Over the past four decades, the paediatric surgeons at Red Cross Children's Hospital have been involved in the management of 46 pairs of conjoined twins, of which 33 have been symmetrical and 12 asymmetrical. Seventeen symmetrical twins have undergone separation with 22 children (65%) surviving; all of the live asymmetrical twins survived separation. We describe the important features of this unique cohort, outline our approach to management and present the results of this approach. We consider some of the ethical and moral dilemmas we have confronted, and discuss the prenatal diagnosis, obstetric implications and postnatal care of these children, including the relevant investigations and anaesthetic and surgical management. Specific aspects related to the cardiovascular system, hepatobiliary and gastrointestinal tracts, urogenital tract, central nervous system and musculoskeletal system are highlighted.

Editorial

Editorial

Ultrasonographic characterization of the uterine artery in the nonestrus bitch

The canine species is often used as an experimental animal model in medicine. Doppler ultrasound of uterine arteries has important clinical implications in obstetrics and gynecology in women and animal species. To our knowledge, the ultrasonographic features of uterine arteries in the bitch have not been reported. Thus, an ultrasonographic technique to locate the uterine arteries in the bitch is described in this study. A total of 11 nonspayed nonestrus bitches underwent abdominal ultrasound examination. Pulsed-wave, color and power Doppler settings were used to detect the location and characterize the flow of the uterine arteries. Mean values for systolic peak velocity, diastolic peak velocity, diastolic reversal flow and resistive index were calculated. Uterine arteries had a high pulsatility flow in all cases. Future work is needed to fully assess the clinical importance of the uterine artery flow in the bitch, as well as to study possible waveform changes at different estrus phases and throughout gestation. (E-mail: fernandoxy@yahoo.com)

Obstetric implications for and identification of women with a normal clomiphene citrate challenge test result who have a poor response to gonadotropins

To determine the incidence and obstetric implications and to identify prospectively women with a poor response to hMG with a normal clomiphene citrate challenge test (CCCT) result. Retrospective chart review. Tertiary fertility center. One hundred sixty-three women who underwent ovulation induction with hMG for IUI, and 266 women who underwent ovulation induction with GnRH analogue and hMG for IVF. All had a CCCT before stimulation. Seventy-five percent of IUI patients (123 of 163) and 89% of IVF patients (238 of 266) had normal CCCT results. A poor response to hMG was defined as a response less than the 90th percentile of women with an abnormal CCCT result (peak E(2) [pg/mL] level per ampule hMG used: 90th percentile </=30). Clomiphene citrate challenge test and ovulation induction for IUI or IVF. Response to gonadotropins and pregnancy outcome after treatment. Thirty-five percent of IUI patients (43 of 123) and 52% of IVF patients (123 of 238) with a normal CCCT result had a poor response to hMG. Intrauterine insemination patients with a poor response to hMG had significantly lower delivery rates than IUI patients with a normal response (19% vs. 39%). In vitro fertilization patients with a poor response to hMG had similar delivery rates compared with IVF patients with a normal response (32% vs. 35%). For both groups of patients, an FSH >12 mIU/mL (IMx assay) on either day 3 or day 10 (normal </=14.5 IMx) was highly predictive of a poor response to hMG, the elevated FSH level being a much better predictor than the woman's age. A poor response to hMG with a normal CCCT result (false negative) is a common event. A day-3 or day-10 FSH >12 mIU/mL (IMx assay) or 20 mIU/mL (converted to the original RIA) will identify approximately 80% (IUI) and approximately 94% (IVF) of the women who will experience a poor response to hMG. When identified, the data suggest that these patients will benefit significantly from the more aggressive IVF.

Anorectal malformations in females—facts for the gynaecologist

Anorectal malformations in females are characterized by an abnormal position of the anal orifice, anterior to the normal site. In such children, there is a close association between the anorectum and the genitourinary systems, with possible gynaecologic and obstetric implications. The malformations include a spectrum of defects, ranging from the least severe, where the anus opens on the perineum, to the most severe—the common cloaca. Here the urinary, genital and alimentary systems open into a common orifice. There is a high incidence of genital and urinary anomalies associated with the cloaca. At times, the vagina may have to be reconstructed. The surgery of anorectal anomalies is usually done through the posterior sagittal approach. This approach allows for good visualization and access to the anorectal and genital region. Frequently, it is possible to observe, but not correct the associated genital anomalies, which are usually asymptomatic in childhood. However, on attaining menarche, such anomalies may be manifest. Also, these anomalies may be of significance at the time of conception and childbirth.

Ultrasound imaging of the pelvic floor. Part I: two-dimensional aspects.

Ultrasound imaging is rapidly replacing radiological methods in the investigation of pelvic floor disorders. Transrectal, transvaginal/introital and transperineal/translabial methods are being employed, with the latter probably the most widespread due to ease of use and availability of equipment. Position and mobility of the bladder neck, bladder wall thickness, pelvic floor muscle activity and uterovaginal prolapse can be quantified, and color Doppler may be used to document stress urinary incontinence. Ultrasound imaging has simplified audit activities and enhanced our understanding of the effects of incontinence and prolapse surgery, such as the new synthetic suburethral slings. In recent years, imaging methods have contributed significantly to our understanding of the traumatic effects of childbirth on the pelvic floor. Finally, the assessment of pelvic floor biomechanics may have implications for clinical obstetrics and ultimately for the prevention of delivery-related pelvic floor trauma.

Obstetric implications of low-lying placentas diagnosed in the second trimester

Objectives: To determine the obstetrical outcome of pregnancies initially complicated by a low-lying placenta in the second trimester. Methods: We reviewed the obstetric outcome of all women with singleton deliveries from 1 January 1997 to 31 March 1999 and compared the 703 women with low-lying placentas (placentas in the lower uterine segment) with the 6938 women with placentas that were normally situated in the upper uterine segment at 16–22 weeks’ gestation. Results: Pregnancies complicated by a low-lying placenta in the second trimester were not associated with antepartum hemorrhage, preterm births, preterm prelabor rupture of membranes, pregnancy-induced hypertension, fetal growth restriction or cesarean births. However, they had a higher incidence of postpartum hemorrhage (odds ratio 1.768, 95% confidence interval 1.137, 2.748) than women with a normally situated placenta in the second trimester. Conclusions: Pregnant women with low-lying placentas in the second trimester have a higher incidence of postpartum hemorrhage and hence, it would be prudent to carefully manage the third stage of labor in these women.