Biomedical subjects
Robert J Gauthier
Publications and source records attributed to Robert J Gauthier.
Twin delivery after a previous caesarean: a twelve-year experience.
OBJECTIVES: To compare maternal and neonatal morbidities between trial of labour (TOL) and elective Caesarean section in women with twin pregnancies who have had a prior Caesarean. METHODS: An observational study was conducted of women with a prior Caesarean who delivered twins at 28 weeks gestation or greater in Ste-Justine Hospital between 1988 and 2001. Maternal and neonatal outcomes were compared between women who had a TOL (group 1) and those who had an elective Caesarean delivery (group 2). RESULTS: Twenty-six women and 52 fetuses were included in group 1 and compared to the 71 women and 142 fetuses in group 2. Maternal age, gestational age, and birth weight were comparable in both groups. In group 1, 22 (85%) out of 26 women delivered twin A vaginally and 19 (73%) delivered both vaginally. There was no significant difference in the umbilical artery cord pH, Apgar score, ventilatory support, and admission to the neonatal intensive care unit between the 2 groups. There was also no significant difference in the rate of postpartum maternal fever or decrease of serum hemoglobin between the 2 groups, but the median hospital stay was higher in the group with elective Caesarean (5.0 vs. 3.0 days, p <0.001). There were no uterine ruptures or other major complications in either group. CONCLUSION: There were no significant differences in maternal and neonatal morbidity outcomes between births by trial of labour and by elective Caesarean, in twin pregnancies after a prior Caesarean section. A trial of labour is associated with a shorter hospital stay.
Sublingual nitroglycerin versus intravenous ritodrine as tocolytic for external cephalic version: a double-blinded randomized trial.
OBJECTIVE: The purpose of this study was to compare the efficacy of sublingual nitroglycerin with that of intravenous ritodrine as a tocolytic agent for external cephalic version in nulliparous women. STUDY DESIGN: We performed a double-blinded, randomized trial. Nulliparous patients, between 36 and 40 weeks of gestation, were assigned randomly to receive either (1) an intravenous infusion of ritodrine (111 microg/min) for 20 minutes, followed by two puffs of sublingual placebo or (2) an intravenous infusion of sodium chloride 0.9% (placebo) for 20 minutes, followed by two puffs of sublingual 0.4 mg of nitroglycerin. Three minutes after the administration of the sublingual spray, an external cephalic version was attempted. The rate of successful external cephalic version and side effects was compared between groups. RESULTS: Of 74 randomly assigned patients, 38 patients received intravenous ritodrine, and 36 patients received sublingual nitroglycerin. Although not statistically significant, the rate of the successful external cephalic version was higher in the ritodrine group compared with the nitroglycerin group (45% vs 25%, P =.075). The rate of headaches was higher in patients who received nitroglycerin (28% vs 8%, P =.02). Mean blood pressure and maternal heart rate were lower in the nitroglycerin group 10 minutes after the administration of the medication. However, there was no significant difference in the rate of palpitations, hypotension, or fetal bradycardia between the two groups. CONCLUSION: When compared with intravenous ritodrine, sublingual nitroglycerin was associated with a higher rate of headache, lower blood pressure, and a trend toward a lower rate of successful external cephalic version.
Neonatal morbidity associated with uterine rupture: what are the risk factors?
OBJECTIVE: The purpose of this study was to evaluate factors associated with severe metabolic acidosis or death in a situation of uterine rupture. STUDY DESIGN: A retrospective study was performed with review of charts and electronic monitoring strips. RESULTS: Between November 1988 and November 2000, a total of 23 cases of complete uterine rupture were identified from among 2233 trials of labor after a previous low transverse cesarean delivery. Nine neonates (39.1%) had severe metabolic acidosis (pH < 7.0); among these, hypoxic-ischemic encephalopathy was diagnosed in 3 neonates and another neonate died. Placental or fetal extrusion or both were associated with severe metabolic acidosis (P <.001) but not with the other factors (birth weight, induction of labor, use of oxytocin, use of epidural, and cervix dilatation). Two newborns with severe acidosis had impaired motor development even with an intervention time less than 18 minutes from the onset of prolonged deceleration to delivery. CONCLUSION: When uterine rupture occurs, placental or fetal extrusion was the most important factor associated with severe metabolic acidosis. Prompt intervention did not always prevent severe metabolic acidosis and neonatal morbidity.
The impact of a single-layer or double-layer closure on uterine rupture.
OBJECTIVE: Our purpose was to measure the impact of a single-layer or double-layer closure on uterine rupture at subsequent delivery. STUDY DESIGN: This is an observational cohort study of all women undergoing a trial of labor from 1988 to 2000 in a tertiary care center, after a single low transverse cesarean delivery. Factors most highly associated with uterine rupture were identified by using univariate regression analysis. Multivariate logistic regression analysis was used to adjust for selected confounding variables. RESULTS: Of the 2142 women who met the study criteria, 1980 (92.4%) had maternal records and original operative reports reviewed. After adjustments were made for confounding variables, the odds ratio for uterine rupture in women with a single-layer closure was 3.95 (95% CI, 1.35-11.49). CONCLUSION: A single-layer closure of the previous lower segment incision was the most influential factor and was associated with a 4-fold increase in the risk of uterine rupture compared with a double-layer closure.
Interdelivery interval and uterine rupture.
OBJECTIVE: The purpose of this study was to measure the impact of the interdelivery interval on uterine rupture during subsequent delivery. STUDY DESIGN: An observational cohort study was performed to assess the rate of uterine rupture in women with a previous low transverse cesarean delivery and no previous vaginal delivery who undergo a trial of labor from 1988 to 2000 in a tertiary care center. The rate of uterine rupture was measured for each of the following interdelivery intervals: 36 months of gestation. Multivariate logistic regression analysis was used to adjust for selected confounding variables. RESULTS: Of the 1527 women who met the study criteria, the rate of uterine rupture was 4.8% for patients with an interdelivery interval of 36 months of gestation (P =.04). After adjustment for the confounding variables, the odds ratio for uterine rupture in women with an interdelivery interval of 24 months of gestation.