Uncomplicated Spontaneous Vaginal Delivery Research Articles

FRI479 Resistance To Thyroid Hormone Due To Thyroid Hormone Receptor Alpha (THRA) Gene Mutation

Abstract Disclosure: J.O. Abdelkarim: None. S. Parveen: None. M.G. Jakoby: None. J. Fleischer: None. Introduction: Resistance to thyroid hormone (RTH) is a heritable disorder characterized by diminished response to triiodothyronine (T3). Most cases of RTH are due to mutations in the thyroid hormone receptor beta (THRB) gene (“RTH-beta”). Mutations in thyroid hormone receptor alpha (THRA) gene appear to be a rare cause of RTH (“RTH-alpha”), with the first case reported in 2012. We present a case of RTH-alpha in a patient confirmed to have a pathogenic THRA mutation. Clinical Case: A 38-year-old Caucasian male was referred to genetic clinic due to mild developmental delay, dyscalculia and mild autism spectrum disorder. He was born at term by uncomplicated spontaneous vaginal delivery. Parents first noticed developmental delays at age 5 y, though no evaluation occurred during childhood. As an adult, the patient completed seminary studies and was employed as a Catholic priest. An intellectual disability gene panel revealed a pathogenic variant of the THRA gene (c.1151G>A p.R384H). Both parents tested negative for the mutation. Examination was notable for obesity (183 cm, 186 kg, BMI 55.5), macrocephaly, hypertelorism, pectus excavatum and small hands with short digits. No thyroid anatomic thyroid abnormalities were appreciated on neck examination or ultrasonography. TSH was 1.860 mIU/L (0.358-3.740), free T4 0.71 ng/dL (0.76-1.46), and free T3 3.2 pg/mL (2.2-4.0). The patient had no symptoms of hypothyroidism, and supplemental thyroid hormone was deferred. Discussion: There are 29 reported THRA gene mutations and 32 cases of RTH-alpha reported in the peer reviewed literature. Common clinical features include mild-to-moderate intellectual impairment, low basal metabolic rate (BMR), mild skeletal dysplasia, normocytic anemia, bradycardia, consistent with high expression of THRA in brain, heart, gastrointestinal tract, skeletal muscle, and bone. TSH is normal to slightly increased, free T4 is low to low normal, and free T3 is normal to modestly elevated. This is the third reported case of the c.1151G>A missense mutation resulting in an arginine to histidine substitution at codon 384. Thyroid function tests conform to the pattern described for other cases of RTH-alpha. Like the other two patients with the R384H mutation, developmental delays occurred, though intellectual manifestations mitigated with time and the patient completed seminary studies without difficulty. Mitigation of phenotype with age has been reported in RTH-alpha mice with the R384C missense mutation. Short stature did not occur in this patient or the other R384H cases. Unlike other patients, this patient did not experience anemia or constipation. Macrocephaly is a common feature of the three R384H cases, but the patient’s other skeletal manifestations (e.g. pectus excavatum) were not reported. This case demonstrates the difficulty of recognizing THR-alpha and extends our understanding of the R384H phenotype. Presentation: Friday, June 16, 2023

Maternal Facial Nerve Palsy and a Perinatal Infection.

Maternal Facial Nerve Palsy and a Perinatal Infection.

Vaginal delivery in women with COVID-19: report of two cases

BackgroundDuring the ongoing global outbreak of COVID-19, pregnant women who are susceptible to COVID-19 should be highly concerned. The issue of vertical transmission and the possibility of neonatal infection is a major concern.Case presentationCase 1: A 35-year-old pregnant woman with a gestational age of 37 weeks and 6 days was admitted to our hospital at the point of giving birth. Except for the abnormalities in her chest CT image, she was asymptomatic. She had an uncomplicated spontaneous vaginal delivery, and her infant was discharged home for isolation. Because of the positive result of the maternal swabs for SARS-CoV-2 obtained on the 2nd day after sampling, we transferred the mother to the designated hospital and followed up with her by telephone interviews. Luckily, it was confirmed on February 23 that the newborn did not develop any COVID-19 symptoms after observation for 14 days after birth.Case 2: Another pregnant woman, with a gestational age of 38 weeks and 2 days, was also admitted to our hospital because of spontaneous labor with cervical dilation of 5 cm. Since she had the typical manifestations of COVID-19, including cough, lymphopenia, and abnormal chest CT images, she was highly suspected of having COVID-19. Based on the experience from case 1, we helped the mother deliver a healthy baby by vaginal delivery. On the 2nd day after delivery, the maternal nasopharyngeal swab result was positive, while the infant’s result was negative.ConclusionThere is still insufficient evidence supporting maternal-fetal vertical transmission for COVID-19-infected mothers in late pregnancy, and vaginal delivery may not increase the possibility of neonatal infection.

Spontaneous delivery is associated with increased endothelial activity in cord blood compared to elective cesarean section

ObjectivesIt is suggested that delivery whether spontaneous or by elective cesarean section is associated with an inflammatory reaction which may be modified by the type of delivery. Inflammatory reactions are associated with endothelial activation. The aim of our study was to assess endothelial biomarkers in cord and neonatal blood following different modes of delivery. Study designThe study group consisted of term healthy newborns after uncomplicated pregnancies and either spontaneous vaginal delivery (n = 39) or elective cesarean section (n = 20). Plasma soluble biomarkers were measured using multiplex magnetic bead immunoassay. The microvesicle count and number of surface antigen-specific microvesicles were determined by flow cytometry. ResultsWe found significantly increased concentrations of cord blood endothelial markers (sVEGFR1, Endothelin-1 and sVCAM1) and microvesicles (EPCR/CD201+, ICAM1/CD54+ and PECAM1/CD31+) in spontaneous vaginal delivery when compared to elective cesarean section. Irrespective of the delivery mode endothelial markers sVEGFR1, Endocan, Angiopoietin-2, VEGF, and sICAM1, were significantly increased in neonatal compared to cord blood. ConclusionWe found increased cord blood concentrations of endothelial markers and microvesicles following spontaneous vaginal delivery, which may reflect the natural activation of endothelial cells during labor. Following the delivery, most of the soluble markers increased, as a possible consequence of activation of neonatal innate immunity and postnatal cardiovascular transition.

Case Report: Retroperitoneal Abscess After Uncomplicated Spontaneous Vaginal Delivery [19H

INTRODUCTION: Retroperitoneal abscess following an uncomplicated vaginal delivery is uncommon and may be potentially life-threatening. We present a case of a multiparous 36 year old patient who developed a large retroperitoneal abscess following an uncomplicated vaginal delivery, requiring CT-guided fluid drainage and intravenous antibiotics. METHODS: Patient consent was obtained for this case report. Our patient is a 36 year old multiparous female who presented in spontaneous labor. She was febrile to 101.0 and started on empiric antibiotics. She underwent an uncomplicated spontaneous vaginal delivery with intact perineum without anesthesia. She remained afebrile and antibiotics were discontinued. Patient again developed fever to 102.5 prompting consult to infectious disease. Recommendation was made for broad spectrum antibiotics. She presented 3 weeks later with complaint of constipation, abdominal swelling, and pain. A palpable mass was noted, and patient was sent to the emergency department. CT scan showed heterogeneous fluid collection in the retroperitoneal left lower quadrant measuring 14.1 x 6.5 x 13.4 cm. Interventional radiology was consulted and she was taken for CT-guided drainage of fluid collection. Fluid culture resulted as Streptococcus pyogenes. IV antibiotics were adjusted based on culture and continued for 14 days. Follow up imaging demonstrated near-complete resolution of fluid collection. CONCLUSION: Diagnosis of a retroperitoneal abscess requires a high level of suspicion. In this case, we highlight the importance of postnatal follow-up and a low threshold for postpartum imaging. A multidisciplinary approach to treatment is important. Initiation of broad-spectrum antibiotics and drainage of the abscess should be arranged if diagnosis is made.

Draft Opioid-Prescribing Guidelines for Uncomplicated Normal Spontaneous Vaginal Birth.

Women who experience an uncomplicated vaginal delivery have acute intrapartum pain and variable pain in the immediate postpartum period. Although the Centers for Disease Control and Prevention (CDC) has urged clinicians to improve opioid-prescribing behavior, there are no published clinical practice guidelines for prescribing opioids during labor and delivery and at discharge for patients with uncomplicated normal spontaneous vaginal delivery. To address the knowledge gap regarding guidelines for pain management in this population, we used the national Premiere Health Care Database for deliveries of uncomplicated vaginal births from January 1, 2014, to December 31, 2016, to determine the prevalence of opioid administration. Among the 49,133 women who met inclusion criteria, 78.2% were administered opioids during hospitalization and 29.8% were administered opioids on the day of discharge. Descriptive statistics were generated to document the characteristics of the patients receiving opioids as well as the characteristics of hospitals administering opioids during inpatient labor and delivery and on discharge. Patient-level variables included age group, marital status, race, ethnicity, payer type, and length of stay. Hospital-level variables included bed size, geographic region, teaching status, and urbanicity status. These data were then presented in an electronic Delphi survey to 14 participants. The survey participants were obstetrician-gynecologists identified by the American College of Obstetricians and Gynecologists as being thought leaders in the obstetrics field and who had also demonstrated an active interest in the opioid epidemic and its effect on women's health. After the panelists viewed the opioid administration data, they were presented with an adapted version of the CDC's guidelines for opioid prescribing for chronic pain management. The eight adapted guidelines were constructed to be more relevant and appropriate for the inpatient normal spontaneous vaginal delivery population. After three rounds of the surveying process, seven of the eight adapted guidelines were endorsed by the survey participants. These seven draft consensus guidelines could now be used as a starting point to develop more broadly endorsed and studied guidelines for appropriately managing pain control for women with uncomplicated spontaneous vaginal birth.

Type of delivery is not associated with maternal depression.

Although many women experience depressive symptoms during the first year after childbirth, the relationship between type of delivery and maternal depression is not clear. The purpose of this study is to evaluate relationship between type of delivery and maternal depression, between 6 to 16months after childbirth. We performed a prospective cohort study of 558 low-socioeconomic status pregnant women without depression. All participants were recruited from primary care clinics of the public sector in three administrative districts in the Western area of the city of São Paulo, Brazil. Depressive symptoms were assessed using the Self-Report Questionnaire (SRQ-20). Type of delivery was classified as uncomplicated spontaneous vaginal delivery (UVD) (no episiotomy and no more than a first-degree perineal laceration), complicated vaginal delivery (CVD) (episiotomy or more than a second-degree perineal laceration), and cesarean delivery (CD). Data about type of delivery were extracted from medical charts. Crude and adjusted risk ratios with 95% confidence intervals were estimated using Poisson regression with robust variance estimates to examine the association between type of delivery with maternal depression. Among 482 women reassessed during 6 to 16months after delivery, 18% had symptoms of depression. According to the type of delivery, 250 (51.8%), 85 (21.7%), and 147 (30.5%) were UVD, CVD, and CD, respectively. There was no association between type of delivery and maternal depression. In comparison with women submitted to uncomplicated vaginal, women who had a cesarean or perineal trauma/episiotomy did not show greater risk of maternal depression, in the medium to long term after delivery.

A prospective cohort study on the prediction of fetal distress and neonatal status with arterial and venous Doppler measurements in appropriately grown term fetuses.

To assess the predictive power of the cerebro-placental ratio (CPR) and the venous-arterial index (VAI) for the development of intrapartum fetal distress (FD) and neonatal intensive care unit (NICU) admission. Fetal umbilical artery, middle cerebral artery and umbilical vein Doppler measurements were obtained before the active phase of labor in 311 singleton pregnancies at ≥37weeks. A continuous electronic fetal monitorization was applied, and an umbilical cord blood sample was obtained for each participant. FD and NICU admission were the primary outcomes. Labor was concluded as uncomplicated spontaneous vaginal delivery (SVD) in 261 (83.9%) cases. The 22 (7.1%) FD cases were subdivided into FD with NICU admission (n: 7; 2.3%) and without NICU admission (n: 15; 4.8%). Six out of 7 (85.8%) FD with NICU admission cases were from nulliparous pregnancies. The combinatory indices (VAI and CPR) reached the highest sensitivity (31.8%) and negative predictive value (94.7%). None of the fetuses, distressed or non-distressed, with CPR≤10th percentile was born with a cord pH<7.20. FD frequency was increased in fetuses with a low CPR or low VAI. However, the Doppler patterns were heterogeneous in both subgroups: FD with and without NICU admission. FD seems to be a common endpoint of different circulatory-metabolic disturbances. Parity affects the FD frequency in a manner related but not limited to fetal arterial and venous circulation. Low CPR could be a part of the adaptive mechanisms providing metabolic preparedness for hypoxic episodes.

Demographic characteristics and pregnancy outcomes in adolescents - Experience from an Australian perinatal centre.

Adolescent pregnancy is defined as pregnancy in girls aged 10-19years and can be associated with increased risks. To investigate obstetric and perinatal outcomes in a cohort of adolescent girls from a major Australian tertiary centre. This was a nine-year retrospective cohort study of women who birthed at the Mater Mother's Hospital (MMH) in Brisbane, Australia between 1 January 2007 and 31 December 2015. The adolescent cohort was aged <19years and the control group was aged 20-24years. Over the study period the total study cohort comprised 8904 women. Of these, the adolescent cohort consisted of 1625 girls (18.2%) and the control group consisted of 7279 women (81.8%). Adolescents were more likely to be nulliparous, single, of Indigenous ethnicity or to have refugee status. They had higher rates of smoking, asthma, diabetes mellitus and thyroid disease. They were more likely to have an uncomplicated spontaneous vaginal delivery but were less likely to have an intact perineum and had higher rates of pre-term delivery and low birth weight babies. There were no differences in rates of postpartum haemorrhage. Teenage pregnancy results in poorer obstetric and perinatal outcomes. A focus on optimising maternal health care and providing culturally appropriate antenatal and intrapartum care is imperative to improving outcomes.

Acute septic arthritis of the right sacroiliac joint following uncomplicated spontaneous vaginal delivery at term: A case report

Acute septic arthritis of the right sacroiliac joint following uncomplicated spontaneous vaginal delivery at term: A case report

Case 2: Hyperbilirubinemia at Age 4 Days in an African American Infant

A male African American infant is born at term to a gravida 4 now para 3 mother by uncomplicated spontaneous vaginal delivery after an unremarkable prenatal course. His Apgar scores are 9 and 9 at 1 and 5 minutes, respectively, and his birth weight is 3,515 g. Before 48-hour discharge, his total bilirubin level is 14.2 mg/dL (242.9 μmol/L). He is discharged home feeding well with formula. On the day of discharge, his weight is down 2.7% (3,420 g) from his birth weight. At his follow-up visit on the fourth day after birth, he is noted to have scleral icterus and jaundice down to his knees. His weight has increased from discharge to 3,435 g. A slightly hemolyzed heelstick total bilirubin measurement is 25.2 mg/dL (431.0 μmol/L) (direct component, 0.2 mg/dL [3.4 μmol/L]), and he is admitted for treatment of hyperbilirubinemia. Before admission, his parents report that he was taking 2 oz of formula every 2 hours and was producing yellow transitional stool with nearly every feeding. He has an older brother who had a history of jaundice that required phototherapy for 1 week, with no intravenous immunoglobulin (IVIG) or exchange transfusion required. Family history was negative for hemoglobinopathies, glucose-6-phosphate dehydrogenase, or anemia. His admission vital signs are as follows: temperature, 98.8°F (37.1°C); pulse, 128 beats per minute; respirations, 44 breaths per minute; oxygen saturation, 100% on room air; …

Maternal adaptations in preparation for parturition predict uncomplicated spontaneous delivery outcome

The objective of the study was to define maternal tissue adaptations in pregnancy associated with uncomplicated spontaneous vaginal delivery using anatomical and biological outcomes. Nulliparous gravidas were prospectively enrolled in the first trimester at 2 institutions. Demographic and delivery data were chart abstracted. Vaginal elastase activity (units per milligram of protein) and Pelvic Organ Prolapse Quantification measurements of pelvic organ support were obtained in the first and third trimesters. A subset underwent 3-dimensional ultrasound measures of levator hiatus. Uncomplicated spontaneous vaginal delivery (VD) was defined as no cesarean, forceps, vacuum, shoulder dystocia, third- or fourth-degree perineal laceration, or prolonged second stage labor. We enrolled 173 women in their first trimester, 50 of whom had ultrasounds. Mean age was 25.5 ± 5.5 years with a body mass index of 28.0 ± 7.3 kg/m(2). Sixty-seven percent were white/Caucasian, 27% black/African American, and 6% Hispanic/Latina. Mean delivery gestational age was 38.5 ± 2.9 weeks, with 23% delivering by cesarean and 59% achieving uncomplicated spontaneous VD. Vaginal support changed significantly over trimesters with posterior vaginal and hiatal relaxation, vaginal lengthening, and increased levator hiatus area during strain. Women achieving uncomplicated spontaneous VD demonstrated significantly greater relaxation on third-trimester Pelvic Organ Prolapse Quantification for anterior, apical, and hiatal measures than those without uncomplicated spontaneous VD. Higher first-trimester vaginal elastase activity was strongly associated with uncomplicated spontaneous VD (geometric mean activity 0.289 ± 0.830 U/mg vs -0.029 ± 0.585 U/mg, P = .009). Higher first-trimester elastase, younger age, lower first-trimester body mass index, and more third-trimester vaginal support laxity in points C and GH were predictive of VD success. Significant maternal adaptations occur in the vagina during pregnancy, presumably in preparation for vaginal delivery. Greater adaptation, including vaginal descent and higher first-trimester elastase activity, is associated with an increased likelihood of uncomplicated spontaneous VD.

Assessment of factors affecting afterpain in multiparous women delivered in Mashhad 17-Shahrivar Hospital, Mashhad, Iran

Background: Afterpain is a common phenomenon after vaginal delivery. Any factor that causes a delay in the process of uterus sub involution and consequently returning its size to pre-pregnancy status could affect the severity of afterpain. This study aimed to investigate the factors related to afterpain in multiparous women delivered in 17-Shahrivar Hospital, Mashhad, Iran. Methods: In this descriptive study 210 multiparous women during 2-4 hours after uncomplicated spontaneous vaginal delivery with moderate or severe afterpain were conveniently selected and included in the study. Afterpain was measured each hour during the first 12 hours of postpartum period using Visual Analogue Scale (0-100 mm). The duration of lactation and ambulation, the need for any medication to relieve afterpain and also vital signs were recorded during this period. Data were analyzed with SPSS Version 14, using t Student and correlation test. Results: The mean score of afterpain severity was 55.1±16.7. There was a positive correlation between the number of pregnancies and the duration of breastfeeding with mean score of afterpain. Also the length of ambulation decreased the afterpain intensity. However, the intensity of afterpain had no significant relationship with stimulation with oxytocin in labor, prescription of methyl ergonowin and also oxytocin after delivery. Conclusion: Considering that longer duration of breast feeding and ambulation in early postpartum period could decrease afterpain, it is suggested to encourage postpartum mothers to begin breast feeding and ambulation as soon as possible after birth.

Antenatal identification of factor VII Padua during a healthy pregnancy: implications for labor and delivery

Abstract We present a case in which a 28-year-old pregnant woman (para 1) was suspected to have inherited factor VII (FVII) deficiency following investigation for recurrent mild easy bruising. However, this was ruled out by identification of a rare FVII variant not associated with an increased bleeding risk. This allowed usual obstetric care to proceed without any restrictions, facilitating an uncomplicated spontaneous vaginal delivery at term.

Intracranial haemorrhage: an incidental finding at magnetic resonance imaging in a cohort of late preterm and term infants

Intracranial haemorrhage (ICH) in term newborns has been increasingly recognised but the occurrence in late preterm infants and the clinical presentation are still unclear. To investigate the appearance of intracranial haemorrhage at MRI in a cohort of infants born at 34weeks' gestation or more and to correlate MRI findings with neonatal symptoms. We retrospectively reviewed neonatal brain MRI scans performed during a 3-year period. We included neonates ≥34weeks' gestation with intracranial haemorrhage and compared findings with those in babies without intracranial haemorrhage. Babies were classified into three groups according to haemorrhage location: (1) infratentorial, (2) infra- and supratentorial, (3) infra- and supratentorial + parenchymal involvement. Intracranial haemorrhage was observed in 36/240 babies (15%). All of these 36 had subdural haemorrhage. Sixteen babies were included in group 1; 16 in group 2; 4 in group 3. All infants in groups 1 and 2 were asymptomatic except one who was affected by intraventricular haemorrhage grade 3. Among the infants in group 3, who had intracranial haemorrhage with parenchymal involvement, three of the four (75%) presented with acute neurological symptoms. Uncomplicated spontaneous vaginal delivery was reported in 20/36 neonates (56%), vacuum extraction in 4 (11%) and caesarean section in 12 (33%). Babies with intracranial haemorrhage had significantly higher gestational age (38 ± 2weeks vs. 37 ± 2weeks) and birth weight (3,097 ± 485g vs. 2,803±741g) compared to babies without intracranial haemorrhage and were more likely to be delivered vaginally than by caesarian section. Mild intracranial haemorrhage (groups 1 and 2) is relatively common in late preterm and term infants, although it mostly represents an incidental finding in clinically asymptomatic babies; early neurological symptoms appear to be related to parenchymal involvement.

Breast Abscess and Community-Acquired Resistant Staphylococcus aureus: Case Report and Literature Review

Abstract Background: Mastitis is a complication that develops in 1%–24% of breastfeeding women. Breast abscesses complicate mastitis in 5%–11% of cases in the first 12 weeks after birth with Staphylococcus aureus being the most common microorganism retrieved from from breast abscesses. A small number of mastitis cases are caused by community-acquired methicillin-resistant S. aureus (CA-MRSA). Case: The patient was a 24-year-old, gravida 1, para 1, who had an uncomplicated spontaneous vaginal delivery 21 days prior to her first consultation regarding acute mastitis that had been treated with dicloxacillin. She returned febrile with an abscess and she was admitted to a hospital for intravenous therapy with vancomycin and an incision and drainage. Cultures revealed methicillin-resistant S. aureus that was sensitive to the chosen antibiotics. Ten days later, her abscess was drained and oral levofloxacin was prescribed. Results: This patient's mastitis and complications were finally resolved. Her newborn was n...

Emergency laparoscopic sigmoid colectomy for perforation secondary to intrauterine contraceptive device

A 27-year-old female was admitted as an emergency by the on-call gynaecology team. Eight weeks earlier, she had an uncomplicated spontaneous vaginal delivery. A copper intrauterine device (Nova-T 3...

Policy for Prevention of a Retained Sponge after Vaginal Delivery

Background. Policies for sponge count are not routine practice in most labor and delivery rooms. Ignored or hidden retained vaginal foreign bodies has potentially significant health care morbidity. Case. This was a case of a retained vaginal sponge following an uncomplicated spontaneous vaginal delivery. Delivery room policy resulted in the discovery of the sponge on X-ray when an incorrect sponge count occurred and physical exam did not find the sponge. Conclusion. This emphasizes the use of protocols to enhance patient safety and prevent medical error.

Severe Myelosuppression and MRSA Infection as the Presentation of Perinatal HIV Infection

Severe Myelosuppression and MRSA Infection as the Presentation of Perinatal HIV Infection

Uncomplicated Vaginal Delivery Following Midurethral Sling

: Delivery mode following midurethral sling remains controversial. There are no formal guidelines as to the preferred mode of delivery following midurethral sling. : A 33-year-old gravida 2 para 2 underwent midurethral sling placement 16 months after the delivery of her first child for severe stress urinary incontinence (SUI). She conceived 2 months postprocedure and had an uneventful antepartum course. She remained without any SUI and delivered via uncomplicated spontaneous vaginal delivery at 38 weeks' gestation. One year after her delivery, she was still free of SUI symptoms. : Midurethral sling placement may be a valid treatment option for patients with stress incontinence even if they are contemplating future pregnancies and subsequent vaginal delivery.