Tertiary Maternity Center Research Articles

Editor’s Choice

Editor’s Choice

Multiple Repeated Cesarean Deliveries: Operative Complications in the Fourth and Fifth Surgeries in Urgent and Elective Cases

To evaluate the maternal and neonatal risk related with multiple repeated cesarean sections. A case control study was conducted in a single tertiary maternity and children's center. The outcome of a study group including 122 pregnant women undergoing cesarean section for the fourth or fifth time was compared with a control group comprising 146 women sectioned for the second and third time. All multiple repeated cesarean sections were divided into urgent and elective groups to compare the outcome measures of demographic, neonatal, intra- and post-operative data. Compared with the control group, the study group had significantly lower birth weights (p=0.026), lower Apgar scores at 1 minute (p=0.0001) and 5 minutes (p=0.042), higher numbers of fetal death (p=0.03), higher rate of omentum adhesions (p =0.0001) and peritoneal adhesions (p=0.008), increased risk of cesarean hysterectomy (p = 0.014), increased need for transfusion (p = 0.018), and an increase in hospitalization days (p=0.005). Compared with the elective group, preterm birth incidence was higher (p = 0.01) and birth weight was lower (p=0.004) in the urgent group. The risk for myometrium herniation (p=0.018), need for drainage during operation (p=0.018), and post-operative fever (p =0.001) was also more common in the urgent group. Multiple repeated cesarean sections increase the risks for operative complications and poor perinatal outcomes. Patients must be informed about the related risks of multiple repeated cesarean sections and tubal ligation needs to be encouraged.

Predicting Fetal Asphyxia in Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is associated with significant perinatal morbidity and mortality. ICP-related prenatal complications include increased premature delivery, fetal distress, perinatal asphyxia, and intrauterine fetal loss. Levels of serum total bile acids (TBA) are typically elevated from 10- to 100-fold and may be used as a diagnostic criterion for ICP. An association between ICP and respiratory distress syndrome has been reported, and it has been suggested that scoring systems that include TBA level and exposure time may be useful to predict respiratory distress syndrome in neonates. This retrospective study investigated biochemical parameters that could be useful as potential predictors of fetal asphyxia in patients with ICP. The study was conducted between 2004 and 2008 at a tertiary care maternity center. A total of 187 cholestatic pregnancies in both primiparous (43; 23%) and multiparous (144; 77%) women were included in the study. Fetal asphyxia was defined as a mean 5 Apgar score of less than 7. A binary multivariate logistic regression model was used to identify independent variables that may help predict fetal asphyxia in ICP. Of the 187 cholestatic pregnancies, 36 (19.2%) resulted in asphyctic newborns at delivery. There were statistically significant differences between the asphyxiated and nonasphyxiated group in levels of TBA (42.4 ± 15.2 vs. 33.8 ± 12.9 μmol/L, P < 0.01), total cholesterol (279.0 ± 51.4 vs. 257.7 ± 51.6, P = 0.02), high-density lipoprotein (54.2 ± 15.9 vs. 61.3 ± 12.2, P = 0.01), and triacylglycerol (299.4 ± 94.6 vs. 260.4 ± 118.7, P = 0.03). In the multivariate model, independent variables that significantly predicted fetal asphyxia in ICP were TBA levels (odds ratio, 1.04; 95% confidence interval, 1.01–1.08, P = 0.03) and exposure time (odds ratio, 1.11; 95% confidence interval, 1.05–1.17, P < 0.01). These findings suggest that the most important predictive factors for fetal asphyxia in ICP are levels of TBA and exposure time.

The effects of booking body mass index on obstetric and neonatal outcomes in an inner city UK tertiary referral centre.

The aim of the study was to investigate the effects of booking body mass index (BMI) on obstetric and neonatal outcomes in an inner city UK tertiary referral maternity centre. The Guy's and St Thomas' Maternity and Gynaecology (Terranova Healthware) Database was studied. All women that delivered at St Thomas' during 2005 with normal and high BMI were included in the study. Subjects were divided into three groups: BMI 19-24.9 (normal); 25-29.9 (overweight) and 30 or greater (obese). Groups were compared using Stata Statistical software. The study included 3642 patients: 2169 normal, 945 overweight and 528 obese. Both overweight and obese groups had a statistically significant association with gestational diabetes (odds ratio [OR] 5.7 and 11.6), hypertension in pregnancy (including preeclampsia [ORs 1.5 and 2.4], preterm rupture of membranes (ORs 3.7 and 5.0) and preterm delivery (ORs 1.4 and 1.6). The rate for caesarean delivery was increased in both overweight and obese women (ORs 1.4 and 1.7). Obesity is an independent risk factor for adverse obstetric outcomes and is significantly associated with caesarean section delivery.

Extremely low birthweight infants at 3 years: A developmental profile

This study documents the neurodevelopmental outcome at 3 years of 52 of 55 extremely low birthweight (ELBW) survivors (survival rate 49%) born in a tertiary maternity centre from July 1985 through December 1988, and examines more closely the developmental profile of the neurologically normal survivors. At 3 years, 6 (12%) children had severe neurodevelopmental impairment (severe cerebral palsy, blindness, deafness or a General Quotient (GQ) < 70 on the Griffiths Scales), 11 (21%) had mild to moderate impairment and 35 (67%) had no neurosensory impairment and normal development (GQ > or = 85). Significant risk factors for severe impairment were stage 3 or 4 retinopathy of prematurity (odds ratio [OR] 21.5), treatment with postnatal steroids (OR 21), grade III or IV intraventricular haemorrhage (OR 11) and supplemental oxygen at 'term' (OR 6.4). The developmental profile of the 35 neurologically normal children revealed a significant weakness in eye and hand coordination skills and a relative strength in hearing and speech skills. Early recognition of this developmental profile may allow implementation of more appropriate preschool programmes for ELBW children.

Changing two-year outcome of infants weighing 500 to 999 grams at birth: A hospital study

Survival and neurodevelopmental outcome to 2 years were determined for two cohorts of infants weighing 500 to 999 gm at birth, born in a tertiary maternity hospital. Live births increased over time from an annual average of 48.7 in the first era (January 1977 to March 1982) to 64.6 in the second era (January 1985 to December 1987), largely from referrals of additional mothers with pregnancy complications. In the first era, 33.6% (86/256) of infants survived to 2 years; the survival rate improved significantly to 45.9% (89/194) in era 2. After adjustment for birth weight, the odds ratio for survival in era 2 versus era 1 was 1.39 (95% confidence interval = 1.12, 1.73; p less than 0.01). One known survivor in each era was not seen at 2 years of age. In the first era, 59.3% (51/86) of 2-year-old children were free of disability compared with 68.5% (61/89) in era 2 (NS), but the Mental Development Index of the Bayley Scales improved significantly, from 90.0 in era 1 to 98.0 in era 2. For infants weighing less than 800 gm at birth, not only did the 2-year survival rate improve, adjusted for birth weight (odds ratio = 1.53; 95% confidence interval = 1.06, 2.20; p less than 0.05), but there was also a significant reduction in neurologic disabilities in survivors (p = 0.03). For infants weighing 800 to 999 gm at birth, there was a significant improvement in the survival rate, adjusted for birth weight (odds ratio = 1.37; 95% confidence interval = 1.04, 1.79; p less than 0.05), but the rate of neurologic disabilities was unchanged. Increased survival in our tertiary maternity center was achieved without increasing the annual number of severely disabled 2-year-old survivors.

Longitudinal study of very low birthweight infants: impairments, health and distance growth to 14 years of age.

Of 456 consecutive infants born in a tertiary maternity centre in 1966-70 and of birthweight under 1501 g, 171 (37.5%) survived their primary hospitalization. Subsequently three children died and the outcome of 142 (90.5%) of the remaining children presumably still alive were reviewed at a mean age of 14.5 years. Four children had cerebral palsy although only one child was legally blind, 31.6% (48/152) had an existing or corrected visual impairment; visual impairments occurred significantly more frequently in those of birthweight under 1251 g or those born before 29 weeks gestation. Six children required hearing aids and three others were still epileptic. Four children were chronic asthmatics and one had rheumatoid arthritis. None had disabling malformations and there was no delay in pubertal changes. The distributions of weight, height and head circumference percentiles were not significantly different from a standard Australian population. For children in the cohort, weights and heights were under the 10th percentile in 13.4% and 14.1%, respectively. Of the 30 children with birthweights under the 10th percentile and who were reviewed as teenagers, only eight (26.7%) were still in this weight category.