Maternal-Fetal Medicine Units Research Articles

Pregnancy outcomes in women complicated by thalassemia syndrome at Maharaj Nakorn Chiang Mai Hospital

To determine the maternal and fetal outcomes of women complicated with thalassemia syndrome. Retrospective descriptive study. The database of Maternal-Fetal Medicine unit and medical records, between January 2001 and April 2008, were reviewed to search for pregnant women complicated with thalassemia syndrome and medical records were reviewed for patient's baseline characteristics and pregnancy outcomes. The inclusion criteria consisted of (1) pregnant women diagnosed for thalassemia syndrome by hematologist either during or before pregnancy based on hemoglobin typing, (2) attending the antenatal care clinic and delivery at Maharaj Nakorn Chiang Mai hospital, and (3) available data of pregnancy outcomes. During the study period, 80 pregnant women with thalassemia syndrome were recruited, including 52 (65%) cases of HbH disease, 23 (28.8%) cases of beta-thalassemia/HbE disease, 2 cases of AE Bart's disease, 2 cases of EF Bart's disease and 1 case of beta-thalassemia major. Excluding 2 twin pregnancies and 1 case with beta-thalassemia major, 77 were available for analysis of the outcomes. The mean gestational age (+/-SD) at delivery was 37.40 (+/-2.6) weeks, range 27-42 weeks. Twenty-five (32.5%) had delivery by cesarean section and the remainder had successful vaginal delivery. Fetal growth restriction was found in 21 cases (27.3%), 16 (20.8%) had preterm births and the rate of low birth weight (<2,500 g) was 44.1%. Regard to the type of thalassemia, baseline hemoglobin levels and mean birth weight of women with beta-thal/Hb E was significantly lower than the levels of those with Hb H disease. This series indicates that, in spite of an attempt to keep hemoglobin levels above 7.0 g/dl, pregnancy with thalassemia is likely to be associated with an increased rate of fetal growth restriction, preterm birth and low birth weight.

P27.13: Central nervous system anomalies in maternal fetal medicine unit

Congenital anomaly incidence is about 2–4% from all live birth. This anomaly contribute to perinatal mortality about 30%, especially in developing countries. Manifestation in fetus consist of anomalies in central nervous system (CNS), cardiovascular, gastrointestinal tract, musculuskeletal, which in solitary or in coexistence form. To find out the incidence of central nervous system congenital anomalies in Maternal Fetal Medicine Unit, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine University of Indonesia in 2007. Data was collected retrospectively from medical record in our ultrasound policlinic unit from January to December 2007. Patients were sent by Ob/Gyn to get second opinion or ultrasound confirmation with suspicious of CNS anomalies. All patients were examined by using 2 ultrasound machine, Accuvix (Medison, 2001, Korea) and Medison SA 8000 (2000, Korea). There were 13.472 patients visit our policlinic in 2007, and there were 357 cases (2.6%) of congenital anomalies. Congenital anomalies cases consist of 54 coexistence anomalies and 303 solitary anomaly. And for CNS anomalies, the incidence is 38% (137 cases). Anencephaly is the most frequent CNS anomalies (62%), followed by ventriculomegaly (18.2%), holoprosencephaly (13.8%), Dandy Walker syndrome (11.6%), and exencephaly (10.2%). Another anomalies were hydrocephaly, phorencephaly, microcephaly, hydrancephaly, meningocele, and meningoencephalocele. CNS anomalies is a common anomalies in our policlinic, which it's incidence about 38%. And the most frequent CNS anomaly in our ultrasound policlinic was anencephaly. There were 40 cases (62%) of anencephaly from all CNS anomalies. Ventriculomegaly and holoprosencephaly were the next most frequent anomalies.

Vaginal Birth after Cesarean (VBAC) Outcomes Associated with Increasing Number of Prior VBACs

Evaluation of: Mercer BM, Gilbert S, Landon MB et al., for the National Institute of Child Health and Human Development Maternal-Fetal medicine Units Network: Labor outcomes with increasing number of prior vaginal births after cesarean delivery. Obstet. Gynecol. 111(2), 285-291 (2008). From a prospective US multicenter cohort of 45,988 patients with a singleton gestation and a prior cesarean, 13,532 women that elected to attempt a vaginal birth after cesarean (VBAC) were selected for this secondary analysis. This study was conducted to estimate the success rates and risks of an attempted VBAC according to the number of previously successful VBAC attempts. Outcomes evaluated included VBAC success, maternal major morbidity (e.g., uterine rupture and surgical complications), neonatal morbidity (e.g., intensive care nursery admission and acidemia) and maternal and neonatal death. The VBAC success rate rose incrementally from 63.3 to 91.6% in patients that had from zero to four or more prior successful VBACs. Uterine rupture and peripartum risks decreased by 50% after the initial successful VBAC and did not increase with increasing prior VBAC number. Neonatal morbidity did not increase with increasing VBAC number.

Preeclampsia More Than 1 Disease

In this issue of Hypertension , Rasmussen and Irgens provide strong support for the relationship of preeclampsia and intrauterine growth restriction (IUGR). They also provide data that support but also some that argue against the concept that the pregnancy complication, preeclampsia, may be more than one disease.1 In previous studies these authors demonstrated that women who have had a growth-restricted infant without preeclampsia are more likely to have preeclampsia in a subsequent pregnancy.2 Those data and similar findings in the current study support pathological findings indicating the similarity of IUGR and preeclampsia.3 In preeclampsia, IUGR and interestingly also in about one third of cases of preterm birth,4 the maternal myometrial and decidual vessels perfusing the placental site do not undergo the normal remodeling of pregnancy. In normal pregnancy trophoblastic invasion is associated with a greatly increased diameter and removal of vascular smooth muscle from the wall of these vessels. This results in large diameter, flaccid, unresponsive tubes that greatly increase placental perfusion. These changes are not present in pregnancies complicated by IUGR, preeclampsia, and some with preterm births. Implicit in the current study is the concept that preterm birth as well as IUGR is related to subsequent preeclampsia. Although preterm birth is not assessed directly, the effect of low birth weight (IUGR and preterm birth) was greater than the effect of IUGR alone. In a far smaller study our group was able to more directly support the relationship of preterm birth and preeclampsia, as women with early onset preeclampsia were more likely to have preterm birth in a subsequent nonpreeclamptic pregnancy.5 The current study extends the prior observation of the relationship of IUGR and preeclampsia but also raises other interesting points. In this larger study the authors were …

Utilization of obstetrical ultrasound in a referral population

Objective. To determine the number of ultrasounds performed prior to presentation to a maternal-fetal medicine (MFM) sub-specialist and the patient's perceived reason for referral.Study design. Women presenting for their first targeted ultrasound at an MFM unit in an urban center between November 2003 and April 2004 reported the number, location, and gestational age (GA) of prior ultrasounds and whether their insurance company had been billed for these studies. They also reported their current GA, insurance type, and perceived reason for referral. Pearson correlation and Kruskal–Wallis were used where appropriate; p < 0.05 was considered significant.Results. Six hundred fifty-five women were invited to participate; 207 declined, leaving 448 available for the final analysis. The median number of prior ultrasounds was two (range 0–11). Twelve percent reported no prior ultrasound, 30% reported having had one, 28% reported having had two, and 29% reported having had three or more. Women presented at a mean GA of 21.3 ± 5.4 weeks. They reported having had their first ultrasound at 9.9 ± 2 weeks and their most recent prior ultrasound at 16.9 ± 6.7 weeks. GA at presentation did not correlate with the number of prior ultrasounds (r = 0.17). Of 396 women with at least one prior ultrasound, 336 had at least one performed in their doctor's office and 74 had at least one performed in an ultrasound clinic; 183 stated that their insurance had been billed and 168 did not know if their insurance had been billed. The majority, 60%, had private insurance, 37% had Medicaid, and 2% had no insurance. Women with private insurance had a higher number of prior ultrasounds than women with Medicaid (2.3 ± 1.4 vs. 1.5 ± 1.3, p < 0.001). In response to the perceived reason for referral, 280 women stated their reason for referral to the MFM unit was for a routine ultrasound or to determine gender, 158 women reported that they were referred because their doctor was concerned about ‘something’, and 10 were unsure of their indication.Conclusion. Most women have at least one ultrasound prior to presenting to an MFM unit for a targeted scan. Many, especially those with private insurance, have had several prior ultrasounds. Patient education is needed about reasons for referral to an MFM unit for ultrasound and the possible increased financial burden of multiple ultrasounds.

Long-Term Outcomes After Repeat Doses of Antenatal Corticosteroids

Administering corticosteroids to mothers at risk of preterm delivery substantially reduces perinatal mortality and morbidity. Because of concerns that these favorable effects may diminish as the post-treatment interval lengthens, some clinicians advocate giving repeat steroid courses to mothers who remain undelivered. However, 2 recent trials have noted reduced birth weight following repeat courses of steroids after adjusting for gestational age. This randomized trial, conducted by the Maternal-Fetal Medicine Units Network of the National Institute of Child Health and Human Development, enrolled women at 23 to 31 weeks' gestation who remained pregnant 1 week after an initial course of either betamethasone or dexamethasone. Participants, all of whom were viewed as being at high risk of spontaneous preterm delivery, were randomly assigned to receive weekly courses of either 12 mg of betamethasone, given intramuscularly and repeated at 24 hours, or placebo. Of 583 infants discharged alive, 556 children were available for evaluation at age 2 to 3 years using the Bayley Scales of Infant Development; 87% were physically examined and 84% underwent Bayley testing. Mean body weight, height, and head circumference did not differ significantly between the groups, nor did the proportions of children with values below the age-specific 10th percentile. There were fewer children with asthma in the repeat steroid group (8.3% in the repeat steroid group vs. 14.4% in the placebo group, P = 0.05; RR = 0.6 [0.3-1.0]), but there were no significant group differences in the incidence of seizures or pneumonia, or the number of hospital admissions. Although Bayley scores were comparable between the groups, the children of women who received ≥4 courses of steroids were more likely to have cerebral palsy or to die than were those whose mothers received placebo (9/161 or 5.5% in the ≥4 steroid courses group vs. 2/143 or 1.4% in the placebo group, P = 0.05; RR = 4.0 [0.9-18.2]). All but one of the children with cerebral palsy were born at 34 or more weeks of gestation. The investigators conclude that repeat doses of antenatal corticosteroids lack long-term benefit and may harm the infant.

Trial of Labor After One Previous Cesarean Delivery for Multifetal Gestation

To estimate success rates and risks with a trial of labor after one previous cesarean delivery for multifetal gestation compared with one previous cesarean delivery for a singleton pregnancy. Patients from the National Institute of Child Health and Human Development Maternal Fetal Medicine Units Network Cesarean Registry with one previous cesarean delivery and a current term singleton pregnancy were identified. Cases had one previous cesarean delivery for a multifetal pregnancy. Controls had one previous cesarean delivery for a singleton pregnancy. Of cases, 556 of 944 (58.9%) attempted a trial of labor. Of controls, 13,923 of 29,329 (47.5%) attempted a trial of labor. The trial of labor success rate was 85.6% among cases and 73.1% among controls (odds ratio 2.19, 95% confidence interval 1.72-2.78). Compared with trial of labor controls, cases had no statistically increased risk of transfusion, endometritis, intensive care unit admissions, uterine rupture, or perinatal complications. Cases in this analysis with a successful trial of labor were more likely to have previously had a successful vaginal birth after cesarean (37.1% compared with 14.1%, P<.001). Women with one previous cesarean delivery for a multifetal gestation have high trial of labor success rates and low complication rates.

Cordocentesis in multifetal pregnancies

To describe the experiences in diagnostic cordocentesis in twin pregnancies at midpregnancy The database and medical records of pregnant women attending Maternal Fetal Medicine Unit of the hospital for diagnostic cordocentesis at midpregnancy between January 1989 and September 2006 were retrospectively reviewed. During 17 years of experience, 4,241 cordocenteses at midpregnancy were performed for prenatal diagnosis, including 59 procedures in 30 multiple pregnancies (29 twins and 1 triplet). The mean gestational age at the time of cordocentesis was 19.5 +/- 1.6 weeks. Success rate of the samplings was 98.3% with one sample was maternal blood contamination. Averaged-time used of the procedures was 8.2 minutes (range 1-45 minutes). The procedure-related complications included transient bleeding at puncture site (8.5%) and transient fetal bradycardia (22.0%). The total fetal loss rate was 10.5% but there was no cordocentesis-related fetal loss (0.0%), defined as a fetal loss within 2 weeks after the procedure. This study may provide a new insight on the safety of cordocentesis in multifetal pregnancies at midpregnancy. The procedure-related fetal loss is not as high as reported in the past. This study suggests cordocentesis be a relatively safe and highly successful in obtaining fetal blood samples.

The National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network Beneficial Effects of Antenatal Repeated Steroids study: impact of repeated doses of antenatal corticosteroids on placental growth and histologic findings

In utero exposure to repeated doses of antenatal corticosteroids (ACSs) has been shown to reduce fetal growth. Our goal was to evaluate whether weekly betamethasone (R-ACS) alters placental growth and histologic findings. In a multicenter randomized controlled trial of R-ACS vs a single course of ACS followed by weekly placebo (S-ACS), placentas were weighed after removal of the membranes and umbilical cord. A single pathologist who was masked to study group and pregnancy outcomes performed histologic evaluation for placental calcifications, infarction, fibrin deposition, and hemorrhage or thrombus formation, acute and chronic chorioamnionitis, fibromuscular vascular hyperplasia, nucleated red blood cells, and villous crowding, edema, fibrosis, or fibrinoid necrosis. Findings were compared between study groups and according to the number of courses of ACS. One hundred ninety-four placentas were available for evaluation. Univariable analyses revealed no differences between study groups in any of the 19 evaluated histologic parameters between R-ACS and S-ACS groups overall or in analyses that were restricted to deliveries at < 32 or > or = 32 weeks of gestation. Calcifications were more common (P = .045) in the R-ACS group after controlling for other factors. Multivariable analysis revealed increasing gestational age at delivery, but not increasing ACS courses, to be associated with decreasing chorionic inflammation, villous edema, and fibrosis and with increasing villus crowding, fibrin deposition, and calcifications. Ninety-three placentas were weighed before formalin fixation. After controlling for delivery gestation and infant gender, placental weight was significantly lower in the R-ACS group (P = .017) and was related inversely to the number of ACS courses (P = .037). This finding was confirmed only for deliveries at > or = 32 weeks of gestation (525 vs 441 g for R-ACS and S-ACS group, respectively; P = .036). Repeated antenatal corticosteroid treatments in pregnancy are associated with decreased placental growth in a dose-dependent fashion, but not with evident differences in histologic markers of placental inflammation, ischemia, or infarction. Histologic placental abnormalities should not be attributed to repeated courses of corticosteroids.

Comparison of Maternal and Infant Outcomes From Primary Cesarean Delivery During the Second Compared With First Stage of Labor

About 1 in 4 primary cesarean deliveries take place during the second stage of labor. Not only is second-stage surgery technically more difficult, but the fetus is at risk of hypoxia-related morbidity. This prospective observational study of primary cesarean deliveries was carried out at 13 university centers that make up the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Of 11,981 primary cesarean deliveries, 9265 were done in the first and 2716 in the second stage of labor. Women in the latter group were likely to be older, nulliparous, and white, and they had a smaller body mass index at the time of delivery. In both groups, dystocia was the commonest indication for cesarean delivery. Second-stage deliveries were significantly longer than those done in the first stage of labor. Intraoperative complications were significantly more frequent when cesarean section was done in the second stage of labor because of higher rates of uterine atony, extension of a “T” or “J” uterine incision, and cystotomy. Women delivered in the second stage had slightly larger infants. Fetal injuries were more common in the second-stage group, but more infants in the first-stage group were admitted to intensive care for 24 hours or longer. The maternal composite index (endometritis, intraoperative surgical complications, blood transfusion, and/or wound complications) was slightly increased when cesarean section was done in the second stage of labor. The difference was significant after multivariable analysis, with an odds ratio of 1.21 and a 95% confidence interval of 1.07–1.37. In contrast, the neonatal composite outcome (5-minute Apgar score of 3 or less, neonatal death, admission to neonatal intensive care, intubation in the delivery room in the absence of meconium, and/or fetal injury) did not differ significantly between the 2 groups after multivariable analysis. Maternal—but not neonatal—morbidity appears to be marginally increased when primary cesarean section is performed in the second rather than in the first stage of labor. The investigators believe that a trial of labor extending into the second stage does not in itself increase the risk of an adverse maternal or neonatal outcome.

The National Institute of Child Health and Human Development Maternal-Fetal Medicine Unit Network Randomized Clinical Trial in Progress

It is recognized that women with gestational diabetes mellitus (GDM) who have significantly elevated fasting blood glucose levels are at increased risk for fetal macrosomia and perinatal morbidity if treatment is not provided (1,2). The association of milder forms of GDM with perinatal morbidity and mortality remains unclear, primarily because the condition is often confounded with other risk factors such as maternal obesity, age, and parity. Screening for GDM is recommended for most pregnant women, yet it is unknown whether there is a benefit to the identification and treatment of mild carbohydrate intolerance during pregnancy (3,4). The present report is an update of our previous description of a current ongoing randomized treatment trial for mild GDM (5). A randomized clinical trial of women with mild GDM (fasting glucose <95 mg/dl) is being undertaken that compares perinatal outcomes in those receiving diet therapy and insulin as required versus those randomized to no specific treatment. This study aims to clarify whether there is utility in identifying and treating women with a normal fasting glucose level who meet standard criteria for GDM. We plan to compare perinatal outcomes in women who have been randomized to diet and/or insulin therapy with women who have been randomized to no specific treatment. A randomized treatment trial of mild GDM will clarify whether identification and treatment of mild GDM reduce perinatal morbidity. This information will assist in determining appropriate thresholds for the treatment of GDM. Overall, with broader identification and aggressive treatment, perinatal mortality rates associated with GDM appear to be similar to the nondiabetic population (1). Several analyses of 20 years ago did document an increased stillbirth rate for GDM pregnancies that would qualify as preexisting diabetes according to World Health Organization criteria (6–9). Below this threshold, the extent to …

Comparison of Maternal and Infant Outcomes From Primary Cesarean Delivery During the Second Compared With First Stage of Labor

To compare maternal and neonatal outcomes when primary cesarean delivery is performed in the second stage of labor compared with the first stage. Between January 1, 1999, and December 31, 2000, a prospective observational study of primary cesarean deliveries was conducted at 13 university centers comprising the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. The primary outcomes of interest included a maternal composite (composed of at least one of the following: endometritis, intraoperative surgical complication, blood transfusion, or wound complication) and neonatal composite (which included at least one of the following: Apgar score of 3 or less at 5 minutes, neonatal death, neonatal intensive care unit admission, seizure, delivery room intubation in the absence of meconium, or fetal injury). A total of 11,981 cesarean deliveries were available for analysis: 9,265 were performed in the first stage and 2,716 in the second stage. Cesarean deliveries performed in the second stage were associated with longer operative times, epidural analgesia, chorioamnionitis, and higher birth weight (all P<.001). The maternal composite index was slightly increased in women undergoing cesarean delivery in the second stage of labor, primarily due to uterine atony, uterine incision extension, and incidental cystotomy. This difference was significant after multivariable analysis (odds ratio 1.21, 95% confidence interval 1.07-1.37). After multivariable analysis, the neonatal composite did not differ significantly between groups (odds ratio 0.96, 95% confidence interval 0.84-1.08). Cesarean delivery in the second stage of labor is associated with slightly increased maternal but not neonatal composite morbidity. II.

The Maternal-Fetal Medicine Units Cesarean Registry: Safety and Efficacy of a Trial of Labor in Preterm Pregnancy after a Prior Cesarean Delivery

The Maternal-Fetal Medicine Units Cesarean Registry: Safety and Efficacy of a Trial of Labor in Preterm Pregnancy after a Prior Cesarean Delivery

The Maternal-Fetal Medicine Units Cesarean Registry: Safety and efficacy of a trial of labor in preterm pregnancy after a prior cesarean delivery

The Maternal-Fetal Medicine Units Cesarean Registry: Safety and efficacy of a trial of labor in preterm pregnancy after a prior cesarean delivery

Decision-to-Incision Times and Maternal and Infant Outcomes

The goal of this observational study was to relate decision-to-incision intervals to maternal and fetal outcomes in women having emergency cesarean delivery at 13 university-based hospitals making up the National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Women having primary cesarean delivery over a 24-month period were prospectively enlisted. Indications for emergency section included umbilical cord prolapse, placenta abruption, placenta previa with hemorrhage, a nonreassuring fetal heart rate (FHR) pattern, and uterine rupture. Among 11,481 primary cesarean deliveries were 2808 performed for emergency indications. Approximately two thirds of these procedures (1814 or 65%) began within 30 minutes of the decision to operate. The most common indication was a nonreassuring FHR pattern. Decision-to-incision intervals of 30 minutes or less correlated significantly with more frequent fetal acidemia (an umbilical artery pH less than 7) and a more frequent need to intubate the infant in the delivery room. There were 8 neonatal deaths not associated with congenital malformations. Only one, a result of hypoxic ischemic encephalopathy, was associated with an interval exceeding 30 minutes. The same cause accounted for 2 neonatal deaths when the decision-to-incision interval was less than 30 minutes. There was no apparent association between the interval and rates of maternal complications, including endometritis, wound infection, and surgical injury. There was no indication of fetal compromise in 95% of infants delivered more than 30 minutes after the decision was made. Most infants delivered by emergency cesarean section do not exhibit adverse effects whether delivered less than or more than 30 minutes from the time the decision is made to proceed. Nearly one third of “emergency” cesarean deliveries in the present series were in fact begun after more than 30 minutes.

The use of progestational agents for preterm birth: Lessons from a mouse model

On the basis of the recent Maternal Fetal Medicine Unit Networks clinical trial, the American College of Obstetricians and Gynecologists supports the administration of 17-alpha hydroxyprogesterone caproate to high-risk patients. Because inflammation/infection is believed to be a contributing factor in many cases of preterm birth, it is imperative to understand the effect of 17-alpha hydroxyprogesterone caproate treatment in this clinical situation. Using a mouse model of localized intrauterine inflammation, we investigated the ability of progestational agents to prevent preterm birth. On gestational day 15 (E15), dams were assigned randomly to treatment with 17-alpha hydroxyprogesterone caproate, medroxyprogesterone acetate, or vehicle before intrauterine infusion of lipopolysaccharide. All dams were monitored for morbidity and preterm birth. Three separate sets of experiments were performed to assess different outcomes at 6, 24, and 96 hours. At 6 and 24 hours, C-reactive protein, interleukin-6, and interleukin-10 levels were measured in maternal serum by enzyme-linked immunosorbent assay. Pretreatment with 17-alpha hydroxyprogesterone caproate or medroxyprogesterone acetate before intrauterine lipopolysaccharide treatment significantly decreased the preterm birth rate, compared with lipopolysaccharide treatment alone. Medroxyprogesterone acetate treatment was more effective than 17-alpha hydroxyprogesterone caproate treatment in the prevention of preterm birth and resulted in live pups at term. Treatment with 17-alpha hydroxyprogesterone caproate was associated with significant maternal morbidity. In the setting of intrauterine inflammation, progestational agents decrease the preterm birth rate but can result in maternal morbidity. 17-Alpha hydroxyprogesterone caproate should not be used in patients who are suspected of having subclinical infection and/or acute preterm labor. The mechanisms by which progestational agents inhibit preterm birth warrants further investigations so that the use of this drug to appropriate populations could be pursued without undue fetal or maternal harm.

The Maternal-Fetal Medicine Units Cesarean Registry: Safety and efficacy of a trial of labor in preterm pregnancy after a prior cesarean delivery

This study was undertaken to compare success rates of vaginal birth after cesarean (VBAC) delivery, and uterine rupture as well as maternal/perinatal outcomes between women with preterm and term pregnancies undergoing trial of labor (TOL), and to compare maternal and neonatal morbidities in those women with preterm pregnancies undergoing a TOL versus repeat cesarean delivery without labor (RCD). Prospective 4-year observational study of women with a singleton gestation and a prior cesarean delivery at 19 academic centers. Clinical characteristics, maternal complications and VBAC delivery success for those with a preterm (24(0)-36(6) weeks) TOL, preterm RCD and term TOL (> or = 37 weeks) were analyzed. Among 3119 preterm pregnancies with prior cesarean delivery, 2338 (75%) underwent a TOL. 15,331 women undergoing TOL at term were also analyzed as a control group. TOL success rates for preterm and term pregnancies were similar (72.8% vs 73.3%, P = .64). Rates of uterine rupture (0.34% vs 0.74%, P = .03) and dehiscence (0.26% vs 0.67%, P = .02) were lower in preterm compared with term TOL. Thromboembolic disease, coagulopathy and transfusion were more common in women undergoing a preterm TOL than those at term. Among women undergoing a preterm TOL, rates of uterine dehiscence, coagulopathy, transfusion, and endometritis were similar to those having a preterm RCD. After controlling for gestational age at delivery and race, neonatal outcomes such as Neonatal Intensive Care Unit (NICU) admission, intraventricular hemorrhage, sepsis, and ventilatory support were similar in both groups except for a higher rate of respiratory distress syndrome in those delivered after a TOL. The likelihood of VBAC success after TOL in preterm pregnancies is comparable to term gestations, with a lower risk of uterine rupture. Perinatal outcomes are similar with preterm TOL and RCD. TOL should be considered as an option for women undergoing preterm delivery with a history of prior cesarean delivery.

Disruption of Interleukin-18, but Not Interleukin-1, Increases Vulnerability to Preterm Delivery and Fetal Mortality after Intrauterine Inflammation

Preterm birth is a major contributor of adverse perinatal outcome. Clinical data suggest that an inflammatory response is important in the process leading to preterm labor. By using a recently introduced mouse model of localized intrauterine lipopolysaccharide-induced inflammation, the effect of interleukin (IL)-18 gene disruption and/or IL-18 neutralization as well as combined IL-1alpha/beta gene disruption on inflammation-induced fetal loss was investigated. The frequency of preterm fetal loss was significantly higher in IL-18 knockout mice (58.9%) and in mice administered IL-18-binding protein (59.7%) compared to wild-type controls (34.7%). The rate of fetal loss was not affected by IL-1alpha/beta gene deficiency (38.7%). Decreased IL-18 protein expression combined with elevated IL-12 protein expression in uterine tissue of IL-18 knockout mice and IL-18-binding protein-treated animals was noticed. These data demonstrate that preterm pregnancy loss in response to intrauterine inflammation was enhanced by disruption of the IL-18 gene and/or IL-18 neutralization, events that may relate to exaggerated Th1 responses because of an increased IL-12/IL-18 ratio.

Lack of Concordance between the 75-g and 100-g Glucose Load Tests for the Diagnosis of Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is common and can have a substantial impact on fetal growth, birth weight, and morbidity. The American Diabetes Association recommends GDM testing with either a 3-h, 100-g glucose load (100 g) (criteria according to Am J Obstet Gynecol 1982;144:768-73) or a 2-h, 75-g glucose load (75g). We investigated the comparability of the 75 g and the 100g tests in the diagnosis of GDM. From January 1997 to December 1999, in 1061 consecutive Caucasian nonobese and nondiabetic pregnant women who attended the Maternal-Fetal Medicine Unit, we performed GDM testing with a 75-g load during 2 periods of pregnancy: early (16-20 weeks) and late (26-30 weeks). Because we assumed there would be few GBM cases in women with a 1-h plasma glucose <1300 mg/L in the 75 g test, we did not retest these women. We retested the remaining women with possible or diagnosed GDM with a 100-g load within a week. GDM was diagnosed in 41 of 227 women with the 100-g load and 15 of 227 with the 75-g load (11 concordant); the kappa index was 0.21. At 26-31 weeks of pregnancy, 484 of 976 women (49.9%) underwent both tests. GDM was diagnosed in 60 of 484 woman with the 100-g load and in 26 of 484 with the 75-g load (13 concordant); the kappa index was 0.18. Among women with possible GDM in both early and late periods of pregnancy, there was only weak diagnostic agreement between results determined with 75-g and 100-g glucose loads.

Decision-to-Incision Times and Maternal and Infant Outcomes

To measure decision-to-incision intervals and related maternal and neonatal outcomes in a cohort of women undergoing emergency cesarean deliveries at multiple university-based hospitals comprising the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. All women undergoing a primary cesarean delivery at a Network center during a 2-year time span were prospectively ascertained. Emergency procedures were defined as those performed for umbilical cord prolapse, placental abruption, placenta previa with hemorrhage, nonreassuring fetal heart rate pattern, or uterine rupture. Detailed information regarding maternal and neonatal outcomes, including the interval from the decision time to perform cesarean delivery to the actual skin incision, was collected. Of the 11,481 primary cesarean deliveries, 2,808 were performed for an emergency indication. Of these, 1,814 (65%) began within 30 minutes of the decision to operate. Maternal complication rates, including endometritis, wound infection, and operative injury, were not related to the decision-to-incision interval. Measures of newborn compromise including umbilical artery pH less than 7 and intubation in the delivery room were significantly greater when the cesarean delivery was commenced within 30 minutes, likely attesting to the need for expedited delivery. Of the infants with indications for an emergency cesarean delivery who were delivered more than 30 minutes after the decision to operate, 95% did not experience a measure of newborn compromise. Approximately one third of primary cesarean deliveries performed for emergency indications are commenced more than 30 minutes after the decision to operate, and the majority were for nonreassuring heart rate tracings. In these cases, adverse neonatal outcomes were not increased. II-2.