Low 5-minute Apgar Score Research Articles

Editor's Choice

Editor's Choice

Audit of perinatal deaths in a tertiary level hospital in Latvia (1995–1999) using the Nordic-Baltic perinatal death classification: Evidence of suboptimal care

Objective. The objective of this study was to explore applicability of the Nordic-Baltic perinatal death (PND) classification in a single hospital via evaluation of changes of the preventability of PND over the time period in a tertiary level perinatal care center in Latvia.Method. All PND cases during the period 1995–1999 at a tertiary referral perinatal care center, the Riga Maternity Hospital (RMH), were analyzed using the common Nordic-Baltic PND classification.Results. The total perinatal mortality rate (PNMR) did not decline at the RMH over the study period. The rate of antenatal and intrapartum deaths at <28 weeks of gestation increased (p < 0.01). Early neonatal deaths at 28–33 weeks of gestation with a low 5-minute Apgar score became less frequent (p < 0.05). There was a trend towards more cases of probably suboptimal care (p < 0.005) and the proportion of preventable PND cases increased from 14.7% in 1995 to 36.4% in 1999 (p = 0.01).Conclusion. The perinatal audit performed at the RMH using the Nordic-Baltic PND classification disclosed a requirement for further improvement of perinatal care in the hospital. The classification can be used to evaluate the preventability of perinatal death cases in a single hospital, and its application in other hospitals in Latvia could provide information necessary for the improvement of perinatal care in the country.

Predictors of Nonadherence to Single-Dose Nevirapine Therapy for the Prevention of Mother-to-Child HIV Transmission

Adequate adherence is required for prevention of mother-to-child transmission of HIV (pMTCT) programs to be effective. We investigated predictors and extent of nonadherence to single-dose nevirapine. Data on nevirapine intake and possible predictors were collected among 760 HIV-positive women with liveborn babies enrolled in a study in Lusaka, Zambia. Most (94%) women took nevirapine before delivery, and most (91%) newborns received it soon after delivery. Maternal nonadherence was associated with home births (odds ratio [OR]: 3.2; 95% confidence interval [CI]: 1.3 to 7.4), no high school education (OR: 2.4; 95% CI: 1.1 to 5.3), and low newborn birth weight (OR: 4.6; 95% CI: 1.3 to 20.1). Disclosure of HIV status and couples counseling was only associated with adherence among home births. Failure to administer nevirapine to the newborn was associated with birth at the tertiary hospital (OR: 7.2; 95% CI: 3.7 to 13.8), lower 5-minute Apgar scores (OR: 0.5; 95% CI: 0.4 to 0.7), and neonatal death (OR: 5.8; 95% CI: 2.0 to 16.3). Excellent adherence to single-dose nevirapine for pMTCT can be achieved. Nonadherence seems to be affected by place of birth and by poor health status of the newborn. Procedures to ensure that viable yet ill neonates receive nevirapine should be part of clinical protocols and training within pMTCT programs.

Low Apgar scores and umbilical cord acidosis in preterm infants

LOCATELLI, ALESSANDRO GHIDINI, FRANCESCA ASSI, MADDALENA INCERTI, VALENTINA DORIA, CLAUDIA BONARDI, GIUSEPPE PATERLINI, University ofMilan-Bicocca, Obstetrics andGynecology,Monza, Italy, University ofMilan-Bicocca, Neonatology, Monza, Italy OBJECTIVE: To evaluate whether in preterm infants, cases of low Apgar scores associated with acidosis have distinguishing characteristics compared with those without acidosis. STUDY DESIGN: From a cohort of 653 consecutive singleton neonates born after spontaneous or iatrogenic preterm delivery at 24.0-33.6 weeks from 1/ 1993 to 12/2002 we selected those with 5-minute Apgar score !7. Demographic, obstetric (gestational age, pregnancy complications, mode of delivery), neonatal (sex, weight, unfavorable outcome) and placental histology variables were evaluated in reference to umbilical artery evidence of fetal acidemia, defined as pH !7.10. Excluded were stillbirths and congenital anomalies. Statistical analysis included Spearman’s correlation, Fisher’s exact test and Student t-test with P!0.05 considered significant. RESULTS: We observed a significant correlation between Apgar score at 5 minutes and pH of umbilical artery (R = 0.5356, p!0.001). A 5-minute Apgar score !7 was recorded in 70/653 (10.7%) infants born at !34 weeks, and 13 of them (19%) had umbilical artery gas analysis suggestive of acidosis. Acidotic babies differed from non-acidotic babies with low 5-minute Apgar score in rates of indicated prematurity (69% vs 31%, P=0.02) and presence of vascular placental lesions (69% vs 29%, P=0.02) but not in rates of obstetric complications, labor, delivery, and neonatal characteristics and complications. CONCLUSION: Preterm deliveries at !34 weeks with 5-minute Apgar scores !7 are at increased risk for acidosis if prematurity is obstetrically indicated and placenta pathology shows evidence of vascular lesions.

Characteristics of acidotic vs non-acidotic cases of low Apgar scores at 5 minutes in term infants

AT 5 MINUTES IN TERM INFANTS ALESSANDRO GHIDINI, MADDALENA INCERTI, ANNA LOCATELLI, ANNA LONGONI, ELENA CIRIELLO, GIUSEPPE PATERLINI, University of Milan-Bicocca, Obstetrics and Gynecology, Monza, Italy, University of Milan-Bicocca, Neonatology, Monza, Italy OBJECTIVE: Low Apgar scores are frequently considered to be indicators of perinatal asphyxia. We have evaluated the prenatal and perinatal characteristics of term infants with low Apgar scores at 5 minutes in relation to the results of cord blod gas analysis to evaluate the strength of this association. STUDY DESIGN: From a cohort of 26,838 consecutive singleton neonates born after 37 weeks from 1/1993 to 12/2003, we selected those with 5-minute Apgar score !7. Demographic, obstetric (gestational age, pregnancy complications, induction of labor, sentinel events during labor, fetal heart rate monitoring pattern, meconium-stained fluid, oligohydramnios or polyhydramnios, mode of delivery) and neonatal variables (sex, weight, multisystem organ dysfunction) were evaluated in reference to umbilical artery evidence of fetal acidemia, defined as pH !7.0 or base excess O 12. Excluded were stillbirths and congenital anomalies. Statistical analysis included Fisher’s exact test and Student t-test with P!0.05 considered significant. RESULTS: Apgar score at 5 minutes !7 was present in 87/26838 infants (0.3%). Cord gas analysis was not performed in 8 cases, and 27 of the remaining cases (34%) had acidosis. Acidotic babies differed from nonacidotic babies with low 5-minute Apgar score only in rates of preeclampsia (11% vs 0%, P=0.03), but not in rates of other obstetric complications, labor, delivery, or neonatal characteristics. CONCLUSION: Umbilical artery evidence of acidosis is present in only about 1/3 of babies with low Apgar scores at 5 minutes, and preeclampsia is the only prenatal or perinatal variable associated with greater risk of acidosis among such cases.

Outcome of Neonates Less Than 30 Weeks Gestation With Histologic Chorioamnionitis

Rates of preterm delivery, preterm premature rupture of membranes, and neonatal illness all are reportedly increased when histologic chorioamnionitis is present. There also are strong associations with intrauterine infection and poor neonatal outcomes. The disorder often is not clinically apparent. The investigators examined perinatal outcomes for infants delivered at or before 30 weeks gestation when there was documented histologic chorioamnionitis. Among 392 newborn infants born at or before 30 weeks gestation, seen in the years 1989 through 1999, histologic chorioamnionitis was confirmed in 41% of 342 cases in which complete placental assessment was possible. Affected infants received antepartum antibiotics by either the oral or intravenous route within 24 hours of delivery in addition to 2 doses of antenatal steroids. Compared with infants lacking histologic chorioamnionitis, those affected delivered earlier (26.3 vs 27.5 weeks), had lower birth weights (920 vs 1030 g), and had lower 5-minute Apgar scores. Overall mortality was not affected. Rates of necrotizing enterocolitis and severe intraventricular hemorrhage did not differ in the infants with and those without chorioamnionitis, but respiratory distress syndrome (RDS) was markedly less frequent in affected infants. Histologic chorioamnionitis related strongly to neonatal septicemia and pneumonia. Associated with histologic chorioamnionitis were a temperature above 38°C, a white blood cell count exceeding 15,000 leukocytes/mm 2 , and malodor at the time of delivery. The duration of membrane rupture did not differ. On logistic regression analysis, the chance of dying perinatally was slightly but not significantly increased. The chance of dying in the neonatal period, however, was more than halved in the presence of histologic chorioamnionitis. The investigators conclude that histologic chorioamnionitis correlates with increased risks of preterm delivery and neonatal septicemia. Both RDS and neonatal mortality were reduced in the present study of infants at less than 30 weeks gestation when histologic chorioamnionitis was definitely present.

Re-evaluating the role of the MFM specialist: Lead, follow, or get out of the way

Objective. To assess the effect of sub-specialty prenatal care provided to high-risk obstetrical patients in a community perinatal center as a function of whether consultation and referral to a Maternal–Fetal Medicine (MFM) sub-specialist was at the discretion of the generalist, required by the insurance carrier, or by patient choice.Methods. Demographics, management, and perinatal outcomes for high-risk patients managed exclusively by MFM were compared with those managed by generalists who were later referred to MFM after problems arose.Results. Despite similar demographics, high-risk patients managed exclusively by a single MFM had less prematurity, lower cesarean section rates, fewer low 5-minute Apgar scores (1.3% vs. 5.5%, p < 0.001), and lower perinatal mortality rates (8.0/1000 vs. 47.6/1000, p < 0.001) than those referred at a later date.Conclusions. In this setting, earlier MFM care resulted in better outcomes. These data suggest that the ‘gatekeeper’ model of generalist to MFM might be better the other way around.

Umbilical Cord Unbound Free Fatty Acid Concentration and Low Apgar Score

Increased levels of unbound Free Fatty acid (FFAu) have been found in adults undergoing coronary angioplasty as a result of acute hypoxia-ischemia. We hypohesized that infants suffering from a 1-minute Apgar score of less than 5 will demonstrate elevated FFAu levels in the cord blood. One hundred ninety-nine infants between 25 and 41 weeks gestational age were enrolled in the study. Infants with an Apgar score of less than 5 at 1 minute served as the study group. Blood samples were collected from the umbilical cord and serum FFAu levels were measured with the fluorescent probe acrylodan-derivatized intestinal fatty acid binding protein. The low Apgar score group (n=32, birthweight 3153+/-780 g, gestational age 37.9+/-3.1 weeks) and normal Apgar score group (n=167, birthweight 3067+/-847 g, gestational age 37.5+/-3.5 weeks) were significantly different with respect to Apgar score at 1 minute (3.0+/-1.2 versus 8.4+/-1.1), Apgar score at 5 minutes (6.9+/-versus 8.9+/-0.5), cord pH (7.16+/-0.12 versus 7.28+/-0.07), and in the frequency of meconium passage (40.6% versus 14.9%). Cord FFAu levels were 4.4+/-1.7 versus 3.2+/-1.2 nM (p<0.001), respectively. Cord FFAu correlated inversely with Apgar score at 1 minute (r=-0.31, p<0.05) and with cord pH (r=-0.12, p<0.05), but not with birthweight or gestational age. In infants with low 1-minute Apgar scores, cord free fatty acid levels were significantly elevated compared with those from controls.

Infant Morbidity Following Amniocentesis and Chorionic Villus Sampling for Prenatal Karyotyping

Although invasive methods, including amniocentesis and chorionic villus sampling, are now an established part of obstetric care and are offered for low-risk indications, the extent of risk to the fetus and infant-if any-is not clear. Both miscarriages and major orthopedic postural abnormalities have been ascribed to these procedures. All women 35 to 49 years of age who had a single birth in Sweden in the years 1991 to 1996 were included in this population-based cohort study. The total group of 71,586 mothers included 21,748 women having amniocentesis, 1984 having chorionic villus sampling, and 47,854 having neither of these procedures. Amniocentesis typically was done at 13 to 16 weeks gestation and chorionic villus sampling at 10 to 12 weeks. Compared with nonexposed women, those having amniocentesis were at increased risk of musculoskeletal malformations (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.11-1.57). The risk was significantly increased only when amniocentesis was done earlier than 14 weeks gestation. Amniocentesis also increased the risk of club foot (OR, 1.45; 95% CI, 1.06-1.99) and hip dislocation (OR, 1.22; 95% CI, 0.99-1.5). Although the numbers were low, women in the amniocentesis group had elevated risks of congenital arthrogryposis, curving of the leg bones, and knee dislocation. Musculoskeletal malformations did not appear to be increased by chorionic villus sampling. Limb reduction defects were similarly frequent in all 3 groups. Respiratory disturbances were more prevalent in infants whose mothers underwent amniocentesis (OR, 1.12; 95% CI, 1.02-1.24), especially when the procedure was done at 14 to 15 weeks gestation. Neonatal pneumonia also was more prevalent after amniocentesis (OR, 1.29; 95% CI, 1.02-1.65). Meconium aspiration was more frequent, but only with amniocentesis done at 13 weeks gestation (OR, 1.77; 95% CI, 1.06-2.93). Neonatal pneumonia did not correlate with either meconium aspiration or chorioamnionitis. In women having chorionic villus sampling, OR values were at approximately the same level above unity but the differences were not statistically significant. Neither procedure was associated with low 5-minute Apgar scores. Preterm births were less frequent in women having one of the invasive procedures. Fetal deaths were less frequent in the chorionic villus sampling group than in nonexposed women. None of the observed effects were modified when taking age into account. The central findings in this large cohort study of women aged 35 to 49 years were that the risk of postural deformities is increased when amniocentesis is done earlier than 14 weeks gestation, and that the risk of respiratory disorders is elevated after amniocentesis at 14 and 15 weeks gestation.

Chorioamnionitis and Neonatal Encephalopathy in Term Infants With Fetal Acidemia: Histopathologic Correlations

The aim of this study was to determine whether the presence or severity of histologic abnormalities of infection/inflammation such as chorioamnionitis, vasculitis, or funisitis confers an additional risk for neonatal encephalopathy in term infants delivered in the presence of severe fetal acidosis. The medical records as well as placental pathology of term infants (n = 51) born with a cord umbilical arterial pH <7.00 were reviewed. Abnormal outcome was predefined as Sarnat stage 2 or 3 neonatal encephalopathy in the first week of life or neonatal death as a consequence of severe brain injury. Consistent with prior data, the presence of severe fetal acidemia, a low 5-minute Apgar score, and need for cardiopulmonary resuscitation were significantly associated with neonatal encephalopathy. However, the presence of histologic chorioamnionitis had a poor predictive value and did not confer additional risk for the subsequent development of neonatal encephalopathy.

Increased risk of adverse pregnancy outcome among Somali immigrants in Washington state

The purpose of this study was to compare maternal and neonatal morbidity among Somali immigrants, US-born blacks and whites in Washington state. Washington state birth certificate data was linked to hospital discharge records comparing singleton deliveries among Somali immigrants with US-born blacks and whites between 1993 and 2001, in a 1:3 ratio. Outcomes were compared using unconditional multiple logistic regression models calculating odds ratios (ORs), and 95% confidence intervals (95% CIs). Five hundred seventy-nine pregnancies from Somali women were compared with 2384 and 2435 pregnancies from black and white women, respectively. Nulliparous Somali women were more likely to have a cesarean delivery than black or white control women, OR 1.6 (95% CI, 1.1-2.3) and 2.0 (95% CI, 1.4-2.8), respectively. Among all women who had cesarean deliveries, Somali women more commonly had cesarean deliveries associated with fetal distress and failed induction of labor. They were 9 times more likely than both control groups to deliver after 42 weeks gestation, and 4 times more likely than black women and 8 times more likely than white women to have oligohydramnios. Somali women were more likely to have gestational diabetes and significant perineal lacerations, and less likely to smoke. Newborns of Somali women were at increased risk for prolonged hospitalization, lower 5-minute Apgar scores, assisted ventilation, and meconium aspiration. Pregnancy outcomes should be evaluated within ethnically and culturally unique groups; Somali immigrants are a high-risk subpopulation.

Effect of Prenatal Diagnosis on Outcome in Patients With Congenital Heart Disease

After completing this article, readers should be able to: 1. List the most frequent prenatally diagnosed forms of congenital heart disease. 2. List the fetal indications for echocardiography. 3. List the maternal indications for echocardiography. 4. Review the findings of studies comparing the outcome of prenatally versus postnatally diagnosed newborns who have congenital heart disease. 5. List the advantages of prenatal diagnosis of congenital heart disease. Congenital heart disease (CHD) continues to be a major source of neonatal mortality. Since the development of echocardiographic screening for fetal cardiac anatomy in the 1980s, an increasing number of affected newborns are identified prior to delivery. (1) A recent study in a population that had risk factors for CHD found that the sensitivity of fetal echocardiography was 38%, with a false-positive rate of only 0.05%. (2) However, when performed by skilled operators viewing outflow tracts in addition to the four-chamber view, an accuracy as high as 96% has been reported. (3) These prenatal diagnoses are heavily skewed toward more severe CHD, with disorders of the atrioventricular junction (endocardial cushion defects), univentricular hearts, and hypoplastic left heart syndrome (HLHS) being the most common (Table 1). | Diagnosis | Proportion of All Fetal Diagnoses | Proportion of CHD in Newborns in Study | |:-------------------------------------------:| --------------------------------- | -------------------------------------- | | Hypoplastic left heart syndrome | 31% | 15% | | Atrioventricular septal defect | 30% | 25% | | Univentricular heart | 20% | 9% | | Pulmonary atresia intact ventricular septum | 8% | 5% | | Total anomalous pulmonary venous return | 0.3% | 1% | | Tetralogy of Fallot | 9% | 28% | | Transposition of the great arteries | 1.7% | 17% | Table 1. Relative Frequencies of Congenital Heart Defects (CHD) at Fetal Diagnosis and Seen At Birth* The ability to identify the most severe forms of CHD prior to delivery has changed the population of liveborn infants who have CHD. Prenatal diagnosis allows for extensive parental counseling and coordination of care. The fetal diagnosis of CHD prompts genetic testing to identify chromosomal abnormalities, which are found in 10% of cases, and a detailed anatomic evaluation to assess associated extracardiac anomalies, which coincide in 15% of cases. (1) In cases of poor prognosis, early prenatal diagnosis gives the parents the option of terminating …

Prognostic Value of Change in Amniotic Fluid Color During Labor

Meconium staining of amniotic fluid (AF), seen in an estimated 7% to 22% of term pregnancies, has been viewed as a sign of fetal maturity. There is, however, some evidence that it may also reflect a response of the fetal gastrointestinal tract to acute or chronic hypoxia. This study was planned to determine the prevalence of altered AF color, its clinical significance, and whether it can predict perinatal outcomes. Changes in AF color were monitored in all singleton pregnancies during the years 1992-1999 that presented at 37-42 weeks, excluding stillbirths, congenital anomalies, and elective cesarean deliveries. Among 19,090 cases were 16,975 with clear AF at admission and at delivery; 973 with clear AF at admission light or thick meconium at delivery; and 156 with light meconium on admission and thick meconium at delivery. Changes in AF color during labor were more prevalent in nulliparous women. Gestations with a change in AF color during labor were associated with significantly higher rates of low 5-minute Apgar scores and of an umbilical artery pH less than 7.10. Using women with clear AF throughout as a baseline, acidosis was more frequent when there was a change in AF color during labor-especially from clear AF to meconium-and only the latter group had a greater chance of admission to neonatal intensive care. Meconium aspiration syndrome was more frequent in cases with light meconium at admission changing to thick meconium during labor. Cesarean deliveries were more numerous in cases with meconium at admission and no change during labor (relative risk [RR], 2.1; 95% confidence interval [CI], 1.6-2.6); in cases with a change from clear AF to meconium (RR, 4.2; 95% CI, 3.4-5.1); and in cases with a change from light to thick meconium (RR, 4.6; 95% CI, 3.0-7.2). The increased risk did not depend on whether labor was spontaneous or induced. These findings suggest that the color of AF be evaluated early in labor. New ways are needed to assess AF color accurately and noninvasively.

Outcome of Neonates Less Than 30 Weeks Gestation with Histologic Chorioamnionitis

The purpose of this study was to determine the short-term outcome of newborns less than 30 weeks gestation when there is definite placental histologic chorioamnionitis. A retrospective analysis was performed of records of all neonates delivered at our institution from January 1989 through January 1999. This information was retrieved from our perinatal database and pathology database. The population was stratified according to the presence or absence of histologic chorioamnionitis. Statistical analysis was performed using student t-test and Mann-Whitney method. Logistic regression was used to control for potential confounding variables. There were 392 neonates less than 30 weeks gestation delivered during this time period. Complete placental histology was available for 342 patients (87.4%). Histologic chorioamnionitis was identified in 140 (40.9%) cases. Those with histologic chorioamnionitis delivered sooner (26.3 versus 27.5 weeks), were of lower birth weight (920.1 versus 1029.8 g), and had lower 5-minute Apgarscores. Neonatal septicaemia and pneumonia were strongly associated with underlying histologic chorioamnionitis. There was a significant reduction in the incidence of respiratory distress syndrome (RDS) when histologic chorioamnionitis was present. Severe histologic chorioamnionitis increases the risk of premature delivery and is strongly associated with neonatal sepsis. There is a significant reduction in the incidence of RDS and neonatal mortality.

Outcome of term breech births: 10‐year experience at a district general hospital

To review the short and long term outcomes among singleton infants with breech presentation at term delivered in a geographically defined population over a 10-year period. Retrospective, cohort study. District General Hospital. 1433 term breech infants alive at the onset of labour and born between January 1991 and December 2000. Data abstracted from birth registers, neonatal discharge summaries and the child health database system were used to compare the short and long term outcomes of singleton term breech infants born by two different modes of delivery (prelabour caesarean section and vaginal or caesarean section in labour). Fisher's exact test was used to compare the categorical variables. Short term outcomes: perinatal mortality, Apgar scores, admission to the neonatal unit, birth trauma and neonatal convulsions. Long term outcomes: deaths during infancy, cerebral palsy, long term morbidity (development of special needs and special educational needs). Of 1433 singleton term infants in breech presentation at onset of labour, 881 (61.5%) were delivered vaginally or by caesarean section in labour and 552 (38.5%) were born by prelabour caesarean section. There were three (0.3%) non-malformed perinatal deaths among infants born by vaginal delivery or caesarean section in labour compared with none in the prelabour caesarean section cohort. Compared with infants born by prelabour caesarean section, those delivered vaginally or by caesarean section in labour were significantly more likely to have low 5-minute Apgar scores (0.9% vs 5.9%, P < 0.0001) and require admission to the neonatal unit (1.6% vs 4%, P= 0.0119). However, there was no significant difference in the long term morbidity between the two groups (5.3% in the vaginal/caesarean section in labour group vs 3.8% in the prelabour caesarean group, P= 0.26); no difference in rates of cerebral palsy; and none of the eight infant deaths were related to the mode of delivery. Vaginal breech delivery or caesarean section in labour was associated with a small but unequivocal increase in the short term mortality and morbidity. However, the long term outcome was not influenced by the mode of delivery.

Frequency and Natural History of Subdural Hemorrhages in Babies and Relation to Obstetric Factors

The view that subdural hematomas are uncommon in term infants is based chiefly on findings in symptomatic neonates and those in whom a hematoma is found incidentally. This prospective magnetic resonance imaging (MRI) study aimed at establishing the frequency of subdural hemorrhage in asymptomatic infants born at term. A total of 111 infants had MRIs within 48 hours of birth. An experienced neonatal radiologist who did not know obstetric details or the method of delivery interpreted the images. The predominant modes of delivery were normal vertex presentation without instruments, cesarean section, ventouse, and forceps after failed ventouse. Nine infants were found to have clinically silent subdural hemorrhages. None of these infants developed symptoms during follow up, and all the hematomas resolved within 4 weeks. Neurologic assessment disclosed no abnormalities in these neonates. Considering mode of delivery, infants delivered by forceps after attempted ventouse delivery were the likeliest to have a subdural hemorrhage, with a rate of 28%. The risk was 6% after normal vaginal delivery and 8% after ventouse delivery. None of 25 infants born by cesarean delivery had hematomas. Those infants who did have a hematoma had relatively low 1-minute Apgar scores, but 5-minute scores did not differ. Six of the 9 affected infants had isolated infratentorial hematomas, 2 had bleeding in both compartments, and 1 had an isolated supratentorial hematoma. Subdural hematoma in an asymptomatic newborn infant does not necessarily indicate excessive birth trauma. Most (but not all) of these bleeds are associated with instrumental delivery. In the present series, all hemorrhages were small and resolved completely within the first month of life.

Cervical length in the early second trimester for detection of triplet pregnancies at risk for preterm birth.

Preterm triplet delivery is common and has a tremendous impact on neonatal mortality and morbidity. We aimed at assessing early second-trimester cervical length as a means of detecting triplet pregnancies at risk for preterm birth. Cervical length was measured in triplet pregnancies during weeks 14 to 20. Cervical length of less than 25 mm was used as a cutoff to divide individuals into 2 groups. Perinatal outcome parameters were compared between the 2 groups and included gestational age at delivery, birth weights, and neonatal intensive care unit admission rates. Sensitivity, specificity, and positive and negative predictive values were calculated for cervical length as a screening method for preterm birth. We evaluated 36 triplets during weeks 14 to 20. Cervical length of less than 25 mm was measured in 14 (group I), 12 of which were delivered before 32 weeks (mean +/- SD, 28.4 +/- 3.1 weeks). Four of 22 women with cervical length of greater than 25 mm (group II) had delivery before 32 weeks (mean, 30.1 +/- 1.8 weeks). The mean gestational age at delivery for all parturients from group II was 33.1 +/- 2.1 weeks (P < .05). Group I neonates had lower birth weights (972 versus 1889 g; P < .001) and higher rates of low 5-minute Apgar scores and neonatal intensive care unit admissions compared with group II neonates. The sensitivity of a shorter cervix as a predictor of preterm labor was 75%, with specificity of 90%, a positive predictive value of 83%, and a negative predictive value of 81%. Cervical length of less than 25 mm at 14 to 20 weeks' gestation is associated with preterm delivery and adverse perinatal outcome in triplet pregnancies.

Neonatal morbidity in second twin according to gestational age at birth and mode of delivery

Objective This study was undertaken to assess the risk of neonatal morbidity in the second twins. Study design We carried out a cohort study of 128,219 live born second twins in the United States, 1995 through 1997. The study subjects were divided into 3 groups: second twins delivered by cesarean section after vaginal delivery of the first twin (V-C), both twins delivered vaginally (V-V), and both twins delivered by cesarean section (C-C). Results The rates of low 5-minute Apgar score, mechanical ventilation, and seizure were higher in the V-C group (8.27%, 13.39%, and 0.31%) than in the V-V (3.07%, 7.51%, and 0.08%) and the C-C (2.66%, 8.53%, and 0.06%) groups. The V-C associated increase in risk remained after adjustment for confounding factors and was more evident at term than preterm. Conclusion The risk of neonatal morbidity is increased in second twins who had a cesarean section after vaginal delivery of the first twin, especially at term.

Long-term outcome after neonatal parenchymatous brain lesions.

Although considered of high prognostic impact, knowledge on the long-term outcome after neonatal parenchymatous brain lesions (PBL) is limited. 29 children with either unilateral (n = 19) or bilateral (n = 10) hemorrhagic/ischemic PBL. The patients were reinvestigated at 9 9/12 +/- 3 4/12 years of age, using a standardized clinical investigation, the Beery-Buktenica Scales of Visuomotor Integration (VMI) and the Bruininks-Oseretzky Test of Motor Proficiency (BOT). The parents were questioned by means of a standardized questionnaire and the Child Behavior Checklist (CBCL). 90 % of the children showed cerebral palsy (including 12 with hemi- and 8 with tetraplegia). Only 11 % showed normal results on BOT and 39 % on VMI testing. 50 % were bed wetters. Six had required ventriculoperitoneal shunting and 11 were on long-term antiepileptic therapy. Herewith bilateral versus unilateral lesions and low 5-minute APGAR scores were associated with poorer outcome (Cox model and Kaplan-Meier analysis). During follow-up the impact of different disabilities changed. Despite the high rate of cerebral palsy, 71 % learned to walk unaided and 86 % to communicate with words. The last patient learned to walk at 7 years of age. Only one showed poor seizure control. No severe shunt-related complications occurred after 5 years of age. Social, cognitive and behavioral problems increased with age. Only 34 % could attend mainstream schools or kindergartens, and only 50 % displayed normal behavior according to CBCL data, with attention deficiency and social problems being the most important domains. In consequence, nearly all children required 24-hour supervision. After birth, organic problems such as delayed motor development, epilepsy and ventriculoperitoneal shunting are of major importance for children with PBL. Although delayed, basic skills such as verbal communication are achieved by the majority of patients. In later childhood and adolescence, social, behavioral and cognitive problems increase. In the future, vast resources will be required to provide adequate education and carers as substitutes for elderly parents.

Persistent fetal occiput posterior position: obstetric outcomes

Objective To evaluate the obstetric outcomes associated with persistent occiput posterior position of the fetal head in term laboring patients. Methods We performed a cohort study of 6434 consecutive, term, vertex, laboring nulliparous and multiparous patients, comparing those who delivered infants in the occiput posterior position with those who delivered in the occiput anterior position. We examined maternal demographics, labor and delivery characteristics, and maternal and neonatal outcomes. Results The prevalence of persistent occiput posterior position at delivery was 5.5% overall, 7.2% in nulliparas, and 4.0% in multiparas ( P < .001). Persistent occiput posterior position was associated with shorter maternal stature and prior cesarean delivery. During labor and delivery, the occiput posterior position was associated with prolonged first and second stages of labor, oxytocin augmentation, use of epidural analgesia, chorioamnionitis, assisted vaginal delivery, third and fourth degree perineal lacerations, cesarean delivery, excessive blood loss, and postpartum infection. Newborns had lower 1-minute Apgar scores, but showed no differences in 5-minute Apgar scores, gestational age, or birth weight. Conclusion Persistent occiput posterior position is associated with a higher rate of complications during labor and delivery. In our population, the chances that a laboring woman with persistent occiput posterior position will have a spontaneous vaginal delivery are only 26% for nulliparas and 57% for multiparas.