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PubMed1994

Premature delivery of small versus appropriate-for-gestational-age neonates. A comparative study of maternal characteristics.

Prematurity and growth retardation of the fetus are major factors affecting perinatal outcome. The purpose of this study was to compare maternal characteristics of 63 women who delivered a preterm, small-for-gestational-age (SGA) neonate with those of 63 women matched for parity and gestational age who delivered a preterm, appropriate-for-gestational-age (AGA) neonate. All women delivered at the Soroka Medical Center between January 1, 1985, and December 31, 1990. Mothers of SGA neonates were more likely than those of AGA neonates to be over the age of 35 years (P = .043), to have hypertensive disorders and oligohydramnios (P < .001), to have induced labor (P < .001) and to deliver by cesarean section (P < .001). In addition, they had a higher rate of morbidity in the puerperium (P = .015) and were more likely to have longer hospitalization (P = .002). In contrast, previous preterm deliveries were significantly more common in the AGA group than in the SGA group (P = .034). The results of this study indicate that women who deliver preterm SGA neonates belong to a special subgroup with unique characteristics in comparison to those who deliver preterm AGA neonates.

Adolescent↗

PubMed2001

Trial of labor after 40 weeks' gestation in women with prior cesarean.

OBJECTIVE: To compare outcomes in women with prior cesareans delivering at or before 40 weeks' gestation with those delivering after 40 weeks. METHODS: We reviewed labor outcomes over 12 years at one institution for women with one prior cesarean and no other deliveries who had a trial of labor at term. We analyzed the rates of symptomatic uterine rupture and cesarean for term deliveries before or after 40 weeks and stratified for spontaneous and induced labor. Potential confounding by birth weight was controlled using logistic regression. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Of 2775 women with one prior scar and no other deliveries, 1504 delivered at or before 40 weeks and 1271 delivered after 40 weeks. For spontaneous labor, rupture rate at or before 40 weeks was 0.5% compared with 1.0% after 40 weeks (P =.2, adjusted OR 2.1, CI 0.7, 5.7). For induced labor, uterine rupture rates were 2.1% at or before 40 weeks and 2.6% after 40 weeks (P =.7, adjusted OR 1.1, CI 0.4, 3.4). For spontaneous labor, rate of cesareans during subsequent trials of labor at or before 40 weeks was 25% compared with 33.5% after 40 weeks (P =.001, adjusted OR 1.5, CI 1.2, 1.8). For induced labor, rate of cesareans during subsequent trials of labor at or before 40 weeks was 33.8% compared with 43% after 40 weeks (P =.03, adjusted OR 1.5, CI 1.1, 2.2). CONCLUSION: The risk of uterine rupture does not increase substantially after 40 weeks but is increased with induction of labor regardless of gestational age. Because spontaneous labor after 40 weeks is associated with a cesarean rate similar to that following induced labor before 40 weeks, awaiting spontaneous labor after 40 weeks does not decrease the likelihood of successful vaginal delivery.

Adult↗

PubMed1976

Actions of the uterine relaxant, fenoterol, on uteroplacental hemodynamics in human subjects.

The action of fenoterol, a uterine relaxant of the adrenergic beta-mimetic group of drugs, has been investigated on placental, myometrial, and cardiac blood pools. 113mIndium was injected intravenously and the blood pools were measured by recording gamma activity externally. In eight cases with oxytocin-induced labor, fenoterol inhibited the typical blood pool changes of labor, i.e., contraction-synchronized decrease of placental and myometrial blood pools with increase in cardiac blood pool. Furthermore, fenoterol produced an increase in placental and myometrial pools with corresponding decrease of cardiac blood pool. These changes were observed consistently. In four other cases, of which three had spontaneous labor, similar effects were observed. The possible mechanisms of hemodynamic action of fenoterol, with reference to uterine relaxation, are discussed.

Adult↗

PubMed1980

Intravenous prostaglandin E2 and 16-phenoxy prostaglandin E2 methyl sulfonylamide for induction of fetal death in utero.

The efficacy of intravenously administered prostaglandin E2 (PGE2) compared to that of intravenously administered 16-phenoxy-17,18,19,20 tetranor prostaglandin E2 methyl sulfonylamide (SHB 286) for termination of fetal death in utero was evaluated in 20 pregnant women from 14 to 38 weeks' gestation. Ten subjects received 1 microgram of PGE2 per minute intravenously. This rate of infusion was doubled at hourly intervals up to 8 microgram per minute. Ten subjects received 0.25 microgram of SHB 286 per minute. This rate of infusion was doubled at hourly intervals up to 2 microgram per minute. It appears that the dosage schedules of PGE2 and SHB 286 were equally effective in inducing labor. Cumulative expulsion rates and mean induction times were similar in both groups. Rates of emesis were low in both groups. Either fever greater than 38.0 degrees C, or shivering, or phlebitis at the site of infusion was observed in three patients treated with PGE2 but in no patient receiving SHB 286.

Adult↗

PubMed1993

Failure of prostaglandin induction in an obstructive müllerian abnormality.

Failure of prostaglandins E2 and F2 alpha to induce labor for intrauterine fetal death is infrequent. The factors contributing to these failures remain unclear. We describe a case of failed induction with the use of a combination of vaginal prostaglandin E2 and systemic prostaglandin F2 alpha in a 24-week intrauterine fetal death in association with a noncommunicating rudimentary uterine horn. The implications of this müllerian abnormality for theories of parturition are discussed.

Adult↗

PubMed1977

Uterine priming with oral prostaglandin E2 prior to elective induction with oxytocin.

Fifty pregnant women at term, with a cervix unfavorable for induction, were electively induced with intravenous oxytocin after priming with either oral prostaglandin E2 or a placebo. Oral PGE2 was effective in increasing the Bishop score and in inducing labor prior to the induction, but did not increase the incidence of successful inductions.

Administration, Oral↗

PubMed1997

Extemporaneous preparation of misoprostol gel for cervical ripening: a randomized trial.

OBJECTIVE: To compare the safety and efficacy of intravaginal misoprostol gel with that of tablets for ripening the cervix and inducing labor in women with unfavorable cervices. METHODS: Four hundred sixty-seven gravidas were randomized to receive misoprostol tablets (n = 234) or misoprostol gel (n = 233). The gel was prepared in the antepartum unit immediately before use by dissolving the tablet in 1 mL normal saline and mixing with 4 mL hydroxyethylcellulose gel. In both groups, a 50-microgram dose was applied intravaginally every 8 hours for two doses, then increased to 100-microgram for a total of six applications or 500 micrograms. RESULTS: The mean interval in hours from drug administration to start induction or labor (13.8 versus 18.2) and delivery (22.4 versus 29.0) was significantly less in the tablet group than in the gel group (P < .01 for both). Oxytocin and epidural use and the mean number of misoprostol insertions (1.4 versus 1.9) were lower in the tablet group than in the gel group (P < .05 for all). The incidences of tachysystole (13.7 versus 7.3%) and hyperstimulation (15.8 versus 7.7%) were significantly higher in the tablet group than in the gel group. Cesarean delivery rates and neonatal outcomes were similar between the groups. CONCLUSION: Intravaginal misoprostol gel is associated with fewer uterine contractile abnormalities than the tablet form of the drug but results in a slower time to labor or delivery.

Administration, Intravaginal↗

PubMed2002

Elective induction: an analysis of economic and health consequences.

OBJECTIVE: Our purpose was to assess economic and health consequences of elective induction at term. STUDY DESIGN: A decision-tree model incorporating a Markov analysis was used to compare the decision either to electively induce labor at term or expectantly manage the pregnancy until 42 weeks' gestation. Main outcome measures, stratified by parity, cervical ripeness, and gestational age at induction, were number of cesarean deliveries and costs to the health care system. RESULTS: By use of baseline estimates, induction at any gestational age, regardless of parity and cervical ripeness, required expenditures from the medical system. Although never cost saving, inductions were less expensive at later gestational ages, for multiparous patients, and for those women with a favorable cervix. Sensitivity analysis demonstrated a robust model. CONCLUSIONS: Elective induction of labor at term is not cost saving and results in a large excess of cesarean deliveries. Costs are significantly altered by the timing of the induction, parity, and cervical ripeness.

Cervical Ripening↗

PubMed1998

Differences in the in vitro sensitivity of ovine myometrium and mesometrium to oxytocin and prostaglandins E2 and F2alpha.

We compared the in vitro response to oxytocin, prostaglandin (PG)E2, and PGF2alpha of myometrium and mesometrium from six ovariectomized ewes and 53 ewes at 106-145 days gestational age (dGA), including 14 ewes in spontaneous or betamethasone-induced labor. Myometrial baseline activity increased from 217+/-27 mN/cm2 of cross-sectional area (mean +/-SEM) in ovariectomized ewes to a plateau of 696+/-39 mN/cm2 at 126-135 dGA. No gestation-related changes were observed in mesometrial baseline activity. Myometrial, but not mesometrial, maximum tension in response to agonists increased with gestation to a plateau at 126-135 dGA. The pD2 (negative logarithm of the EC50) values for oxytocin were similar in both tissues and did not change with gestation. During pregnancy, the myometrial pD2 of both PGs was one order of magnitude higher than the mesometrial pD2. The results indicate an increase in myometrial uterotonic receptor-mediated activity that precedes labor with no increase at labor, suggesting that in sheep, activation of the basic mechanisms responsible for strength of myometrial activity at labor occurs by 135 dGA. The greater sensitivity of the myometrium than the mesometrium to PGs supports a major role for intrauterine paracrine factors in regulating myometrial contractility.

Animals↗

PubMed2004

Misoprostol: a quarter century of use, abuse, and creative misuse.

Misoprostol is a prostaglandin E1 analog originally intended for use to prevent NSAID-induced gastric ulcers. However, because of its cervical ripening and uterotonic property, misoprostol has become one of the most useful drugs in obstetrics and gynecology. Misoprostol has proven to be a very convenient and flexible drug because of its formulation as a tablet that is stable and that can be administered orally, rectally, vaginally and by the sublingual route. Beginning with its abuse for illegal abortion in the late 1980s, misoprostol has quickly become established as one of the most effective drugs for terminating pregnancies in the first and second trimesters, as well as for inducing labor in the third trimester. Its use for routine prevention of postpartum hemorrhage has not been so successful, partly as the high doses required for this indication often result in troublesome side effects. Despite the large body of medical evidence about its efficacy and relative safety, the use of misoprostol in pregnant women remained off-label until the spring of 2002.

Abortifacient Agents, Nonsteroidal↗

PubMed2005

Comparison of extraamniotic Foley catheter and intracervical prostaglandin E gel for preinduction cervical ripening.

BACKGROUND: The success of induced labor depends on the degree of ripening of cervix. Pharmacological preparations are in widespread use for cervical ripening but are not free from side-effects and complications. Mechanical methods, i.e. the use of Foley catheter balloon, though effective have not gained much popularity because of the fear of infection. Therefore, this study has been conducted to prove the efficacy and safety of extraamniotic Foley catheter balloon and to compare it with intracervical prostaglandin E2 (PGE2) gel. METHODS: The randomized prospective study was conducted in the Department of Obstetrics and Gynecology and Medical Microbiology of Nehru Hospital. Hundred women attending the labor ward for induction of labor were divided into two groups: Group A--Foley catheter, Group B--PGE2 gel. Cervical swabs before and after the insertion of ripening agents were taken for culture studies. Placental membranes were also sent for culture. Labor outcome, side-effects, and complications were compared in both the groups. The statistical methods used were Student's compared t-test, Chi-square test, and Wilcoxon-Mann-Whitney test. RESULTS: Foley catheter proved to be a very effective preinduction ripening agent for unfavorable cervix compared with PGE2 gel, as is evident by the mean Bishop score at 12 h (P<0.001). Preparation delivery interval was significantly shorter (P<0.05) in women who underwent cervical ripening with Foley catheter balloon than with the PGE2 gel. No clinical evidence of chorioamnionitis was present in both the groups. CONCLUSION: This study concludes that extraamniotic Foley catheter balloon is an effective, safe, simple, low-cost, reversible, non-pharmacological mechanical method of preinduction cervical ripening.

Administration, Intravaginal↗

PubMed1984

Serum cortisol levels of maternal vein, umbilical artery, and umbilical vein classified by mode of delivery.

We measured maternal venous (MV), umbilical arterial (UA), and umbilical venous (UV) cortisol levels of 180 pregnancies at term. The cortisol level of MV was higher than that of UA and UV in all deliveries. The cortisol levels of three samples had no difference between the induced labor group and the spontaneous onset of labor group regardless of delivery mode. In spontaneous vaginal delivery the cortisol levels of three individual samples were significantly higher in primipara than in multipara. The positive correlations were observed in any modes of deliveries between the cortisol levels of MV and UA, and MV and UA and UV. These data suggest that the fetus may produce cortisol by itself and maternal cortisol may inflow to the fetus.

Breech Presentation↗

PubMed1996

Placental proopiomelanocortin gene expression, adrenocorticotropin tissue concentrations, and immunostaining increase throughout gestation and are unaffected by prostaglandins, antiprogestins, or labor.

The objective of this study was to demonstrate the ontogeny of POMC gene expression, the distribution of immunoreactive ACTH, and tissue peptide content within the placenta and fetal membranes and to investigate the regulatory effects of PGs and progesterone during the first trimester and of labor at term. Tissues were collected from the following groups: 1) women undergoing first trimester (gestation 5-12 weeks) therapeutic abortion (by suction curettage with and without the synthetic PGE1 analogue, gemeprost administered vaginally 2-4 h before the procedure or with 600 mg mifepristone 48 h before receiving 1 mg gemeprost vaginally); 2) women undergoing second trimester therapeutic abortion (600 mg mifepristone; 1 mg gemeprost); 3) in association with delivery at term by spontaneous labor; 4) induced labor; or 5) elective caesarean section. ACTH was immunolocalized to the placental cytotrophoblasts in the first trimester and to the syncytiotrophoblasts in the second and third trimester. The intensity of the staining increased with advancing gestation. ACTH immunoreactivity also was localized in the epithelial layer of the amnion, the reticular layer of the chorion, and the decidual stroma. ACTH content measured by RIA in placental extracts increased significantly in the third trimester. In situ hybridization demonstrated expression of POMC messenger RNA in syncytiotrophoblasts and cytotrophoblasts from the first trimester and also demonstrated a significant increase in POMC gene expression with advancing gestation. The localization and staining intensity for ACTH and POMC gene expression were not affected by the administration of PGs or mifepristone or by labor at term. These data demonstrate the localization of ACTH immunoreactivity within the placenta throughout pregnancy, supporting the hypothesis that the placenta may activate and maintain the maternal and/or fetal hypothalamo-pituitary-adrenal axis throughout pregnancy.

Adrenocorticotropic Hormone↗

PubMed1995

The outcome of post-term pregnancy. A comparative study.

The aim of this study was to evaluate whether prolonged pregnancy was associated with dangers to the fetus, and to assess the incidence of cesarean section as well as fetal distress. The outcome for mother and baby in both groups of patients with post-term pregnancies was generally good. Furthermore, the improvement of prognosis for postdate pregnancy is due to the availability of electronic fetal monitoring and ultrasound, making possible the identification of fetal distress, as well as the use of prostaglandin to ripen a stubborn cervix, and induce labor successfully in most cases. Consequently, we feel that fetal jeopardy with continued intrauterine existence, as well as the excellent results of induction of labor, justify the active approach. The routine induction of labor in postdate pregnancy may reduce perinatal morbidity, as indicated in previous reports [2], and confirmed in this study.

Case-Control Studies↗

PubMed1994

Uterine rupture. A seat belt hazard.

A case is described of a uterine rupture resulting from a car accident occurring in a woman who was wearing a seat belt as generally recommended. The rupture was initially not recognised and only became apparent after attempts to induce labor which led to expulsion of the fetus into the abdominal cavity.

Accidents, Traffic↗

PubMed1997

Risk of retained placenta: multivariate approach.

BACKGROUND: To identify important covariates related to retained placenta using logistic regression analysis. METHODS: The study was carried out in the King Khalid University Hospital, Saudi Arabia, and involved 114 women who had retained placenta, and 116 women with normal deliveries. Chi-square test and logistic regression analysis were used for analysis of data. Adequacy of predictor variables was examined using indices of sensitivity and specificity and plots of probability histograms for prediction of retained placenta among patients and controls. RESULTS: Logistic regression analysis highlighted multiparity, induced labor, small placenta, and large amount of blood loss to be significantly associated with retained placenta. In addition, high pregnancy number, previous injury to uterus, and pre-term labor related significantly to retained placenta. Predictor variables had sensitivity of 65.5% and 87.9% specificity and achieved 77% overall correct classification. CONCLUSIONS: These findings could be used to develop a predictive procedure for identifying high-risk cases of retained placenta.

Case-Control Studies↗

PubMed1998

[Stripping membranes at term. Review of randomized trials].

Stripping the membranes at term is a method for inducing labor. This method is currently performed but not well analyzed. Most trials were published after 1990 and the half of them since 1996. Seven of the nine randomized trials recently published showed the efficacity of stripping of the membranes performed between 38 and 42 weeks. It seems to become more efficient after 40 weeks. In these trials, increased of maternal (cesarean section rate, chorioamniotitis, premature rupture of membranes) or neonatal morbidity cannot be found. However, in these trials included populations are not enough large to conclude. Given the absence of large studies, it seems unjustified to repeat this intervention.

Female↗

PubMed1976

Intra-amniotic use of urea and prostaglandin F2 alpha to induce labour in pregnancies complicated by death of the fetus.

A simple, safe and efficient method of inducing labor in patients in whom pregnancy is complicated by intrauterine death of the fetus is described. The technique involves a single intra-amniotic infusion of 30 mg of prostaglandin F2alpha with 60 g of urea. Fourteen pregnancies complicated by intra-uterine fetal death (ranging in duration from 1 to 7 1/2 weeks) were successfully terminated by this method. Side-effects and complications were minimal. It is submitted that this method provides the obstetrician with a valuable addition to his therapeutic armamentarium. If correctly employed, it provides rapid delivery with minimal risk of discomfort to the patient.

Amnion↗