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PubMed2001

Caesarean section rate for maternal indication in sub-Saharan Africa: a systematic review.

INTRODUCTION: Rates of caesarean sections in more-developed countries have been rising since 1970, and vary greatly between less-developed countries. Present estimates, based on data from more-developed countries need to be validated with data from less-developed countries. We estimated the need for caesarean section for maternal indication in a population of pregnant women in west Africa (MOMA survey). METHODS: The expected caesarean section rate was calculated from the rate of obstetric risk in the MOMA population, and rates of caesarean section in published work. FINDINGS: Three-quarters of women from hospitals of sub-Saharan Africa were delivered by caesarean section for maternal reasons. Such intervention was needed for six main reasons, protracted labour, abruptio placentae, previous caesarean section, eclampsia, placenta praevia, and malpresentation. Although the observed rate of caesarean section in west African women is 1.3%, our results, combined with those of published work suggest a range of 3.6-6.5% (median, 5.4%). INTERPRETATION: Our method might not be strictly accurate, but it is simple and provides informative findings that can help policy makers and health planners in sub-Saharan Africa to design and follow up programmes to reach the optimum caesarean section rate. Moreover, application of this method to hospital data could improve practitioners' assessments in these countries.

Africa South of the Sahara↗

PubMed1997

Randomised controlled trial of ketanserin and aspirin in prevention of pre-eclampsia.

BACKGROUND: Pre-eclampsia is associated with extensive endothelial-cell damage and platelet activation, resulting in lower production of vasodilator prostaglandins and increased release of the vasoconstrictors thromboxane A2 and serotonin. Damage to endothelial-cell serotonin-1 receptors leaves vasoconstriction and platelet aggregation mediated by serotonin-2 receptors unopposed. We investigated the role of ketanserin, a selective serotonin-2-receptor antagonist, in lowering the rate of pre-eclampsia among pregnant women with mild to moderate hypertension. METHODS: We recruited 138 pregnant women into a double-blind, randomised, placebo-controlled trial. They had diastolic blood pressure persistently more than 80 mm Hg before 20 weeks' gestation. 69 women received ketanserin and 69 received placebo. Both groups also received aspirin. Patients were initially given two tablets daily, increased to four tablets daily in diastolic blood pressure was more than 90 mm Hg. Primary outcomes were the development of pre-eclampsia and severe hypertension, and perinatal mortality. FINDINGS: There were significantly fewer cases of pre-eclampsia (two vs 13; relative risk 0.15 [95% CI 0.04-0.66], p = 0.006) and severe hypertension (six vs 17; p = 0.02) in the ketanserin than in the placebo group. There was also a trend towards less perinatal mortality (one vs six deaths) but this was not significant (p = 0.28). Rates of abruptio placentae and pre-eclampsia before 34 weeks' gestation were lower in the ketanserin group, and mean birthweight was significantly higher. INTERPRETATION: We found an association between the addition of ketanserin to aspirin and a decrease in the number of cases of pre-eclampsia and severe hypertension, as well as improved pregnancy outcome among patients with mild to moderate midtrimester hypertension.

Adult↗

PubMed1996

Clinical course of premature rupture of the membranes.

Premature rupture of the membranes (PROM), defined as rupture of the membranes before the onset of labor, is a common obstetric event occurring in 10% of pregnancies. Most of the time this occurs at or beyond 37 weeks' gestation with only 10% of PROM occurring at less than 37 weeks' gestation. The natural course of PROM is labor, and at term this is associated with a low rate of complications for the mother and the fetus. At less than 37 weeks' gestation PROM places the mother and the fetus at increased risk of short-term and long-term morbidity and mortality. Several factors related to preterm premature rupture of the membranes (PROM) add risk to the pregnancy and include premature delivery, infection in the mother and the fetus, effects of prolonged oligohydramnios on fetal development, abruptio placenta, prolapsed cord, and fetal malposition. Since the 1970s expectant management has been the standard treatment for PROM; however, in the majority of patients, this strategy results in the delivery of a preterm infant. In addition, controversy exists over the gestational age at which expectant management should be abandoned and active interventions to effect delivery pursued. This article discusses the natural history of PROM, the outcome of expectant management in PROM, and maternal and fetal outcomes in these patients. The emphasis of this discussion is on the preterm fetus.

Female↗

PubMed1996

Premature rupture of the membranes: neonatal consequences.

Premature rupture of the membranes (PROM), membrane rupture before the onset of labor, occurs in 2% to 18% of pregnancies. The time from PROM to delivery (latency) is usually less than 48 hours in term pregnancy. Therefore, the risks of PROM at term are related to fetal distress, prolapsed cord, abruptio placenta, and rarely, infection. Preterm PROM (pPROM), PROM before 37 weeks' gestation, accounts for 20% to 40% of PROM, and the incidence is doubled in multiple gestations. The latency period in pPROM is inversely related to the gestational age thereby increasing the risks of oligohydramnios and infection in very premature infants and their mothers. Because pPROM is associated with 30% to 40% of premature births, pPROM is also responsible for the neonatal problems resulting from prematurity. This review examines the impact of PROM on the neonate including fetal distress, prematurity, infection, pulmonary hypoplasia, and restriction deformations.

Female↗

PubMed1983

Rupture of the uterus with DIC.

Rupture of the uterus is an uncommon obstetric emergency that usually occurs after 36 weeks gestation in a woman with a previous cesarean section. Complete rupture of the uterus with extrusion of the fetus into the peritoneal cavity is associated with high fetal mortality and with hypovolemic shock in the mother. Incomplete ruptures are less catastrophic and are often found incidentally at routine elective cesarean section. Management of uterine rupture consists of prompt recognition, rapid replacement of maternal blood volume, and early laparotomy and hysterectomy or, in selected cases, uterine repair. Disseminated intravascular coagulation has been reported in association with such obstetrical emergencies as abruptio placentae, intrauterine fetal demise, septic abortion, and amniotic fluid embolism. We report a case in which there was clinical and laboratory evidence of DIC in a patient with uterine rupture. The patient was successfully managed with prompt hysterectomy and replacement of coagulation factors.

Adult↗

PubMed1992

Pregnancy in patients on chronic ambulatory peritoneal dialysis.

Both conception and successful completion of pregnancy are rare occurrences in female patients on chronic renal replacement therapy. Only a handful of successful pregnancies and deliveries have been reported in patients receiving hemodialysis (HD). Even less common are reports of successful pregnancy and delivery in patients receiving chronic ambulatory peritoneal dialysis (CAPD). Among the more common causes of fetal loss are abruptio placentae and other causes of spontaneous miscarriage. We report here three cases of pregnancy in patients on CAPD; two of these pregnancies progressed successfully to spontaneous delivery, while the third terminated during an episode of acute peritonitis. Furthermore, we have reviewed the literature concerning the outcome of pregnancy in the dialysis population on CAPD.

Adult↗

PubMed1987

Pregnancy in women requiring dialysis for renal failure.

Pregnancy is an unusual occurrence in women with end-stage renal disease. When it occurs, spontaneous abortion, stillbirth, and neonatal death end 75% to 80% of the pregnancies. The mother is at risk for hypertension and abruptio placentae. The fetus is at risk for prematurity and growth retardation. Surviving infants appear to be normal. This report outlines the problems in 37 pregnancies (22 in the reported literature and 15 not yet reported). It outlines strategies for improving the chances of survival of the infant.

Female↗

PubMed2000

Hyperhomocysteinemia and pregnancy--review of our present understanding and therapeutic implications.

Homocysteine results from the transmethylation of methionine. Its metabolism depends primarily on three enzymes and several vitamin cofactors. Genetic abnormality in these enzymes or deficiency of these vitamins lead to hyperhomocysteinemia (HHCh). HHCh is usually biologically defined by a fasting value >15 micromol/l. HHCh belongs among the congenital hypercoagulable states and is a long-known vascular disease risk factor. The discovery that HHCh may also be responsible for several pregnancy complications has only recently been made. Studies in this area are still scarce and report on limited numbers of patients. It nevertheless appears clear that HHCh is associated with the syndromes of repeated miscarriage, pre-eclampsia, placenta abruptio, thromboembolic events, neural tube defects, and perhaps with fetal death-in-utero and intra-uterine growth retardation. Supplementation with vitamin B9 can reduce plasma HC levels, and is thus recommended in patients with HHCh. The prevention of thromboembolic events during pregnancy by anticoagulant treatment is also desirable in these patients.

Abortion, Habitual↗

PubMed2001

Doppler velocimetry and thrombophilic screening at middle trimester of gestation: preliminary data.

OBJECTIVE: To establish whether asymptomatic normotensive pregnant women with an abnormal uterine Doppler velocimetry, have haematological changes characteristic of congenital or acquired thrombophilia, and whether this information improve predict in pregnancy complications. STUDY DESIGN: A prospective study involved the enrolment of 30 healthy normotensive pregnant women between the 23rd and 27th week of gestation, subdivided into group A (normal uterine Doppler velocimetry) and group B (abnormal uterine Doppler velocimetry). Besides uterine velocimetry (resistence index and presence/absence of notch), at enrolment in the study the PI of the umbilical artery and of the middle cerebral artery were measured, in addition to the usual foetal biometric parameters (biparietal diameter and abdominal circumference). Contemporaneously, a 20 ml blood sample was taken for the dosage of protein C, protein S, antithrombin III, activated protein C resistance, antiphospholipid antibodies and platelet functionality. Subsequently, for all the remaining period of the pregnancy, data were collected relating to the onset of any materno-foetal complications and modality of delivery, as well as neonatal data up to the first 20 days of life. RESULTS: The incidence of adverse perinatal outcomes (pre-eclampsia, gestational hypertension, abruptio placentae, endouterine foetal death, preterm birth, caesarean section because of maternal or foetal problems, APGAR score lower than 7 at the 5th minute of life, small for gestational age) resulted as being 75% in group B versus 11% in group A (P<0.001). The mean gestational age at delivery was 34 weeks (range 27-41) in group A versus 39 weeks (range 37-42) in group B (P<0.001). No difference emerged as to either the mean activity in the plasma levels of the coagulation protein studied in patients with normal and abnormal uterine velocimetry. The same consideration is also true if the population is analysed in relation to the lesser or greater seriousness of the Doppler velocimetry abnormalities. Subdividing the patients in relation to the absence and to the presence of unfavourable perinatal outcomes, the thrombophilic indices appear to be substantially comparable. CONCLUSION: Uterine Doppler velocimetry, carried out between the 24th and the 26th week of pregnancy, proves its validity by identifying a population at high risk of adverse perinatal outcomes. In contrast, the investigations carried out on the haematological abnormalities characteristic of thrombophilia do not reveal any significant differences, either between patients with normal and those with abnormal velocimetry, or between patients with adverse perinatal outcomes and those without. It is thus unlikely that these preliminary data will lead to an improvement in the clinical reliability of uterine velocimetry.

Adult↗

PubMed1998

Isolated hydramnios at term gestation and the occurrence of peripartum complications.

OBJECTIVE: To determine if hydramnios at term gestation is an independent risk factor for poor pregnancy outcome and perinatal death. STUDY DESIGN: The study population consisted of 60,702 patients with singleton gestation who delivered at term (>37 weeks). Patients were classified into two groups according to the presence or the absence of hydramnios. Hydramnios was diagnosed in the presence of an amniotic fluid index greater than 25 cm or of a maximum vertical pocket of amniotic fluid of at least 8 cm or by subjective assessment. Logistic regression analysis was used to evaluate the unique contribution of hydramnios to fetal death and to perinatal and maternal morbidity. RESULTS: The prevalence of hydramnios was 1211/60,702 (2%). Patients with hydramnios had a higher incidence of complications than those with a normal amount of amniotic fluid: cesarean section (22.8 vs. 8.5%, P<0.01), antepartum death (0.6 vs. 0.2%, P<0.005), postpartum death (2.8 vs. 0.4%, P<0.01), abruptio placenta (0.9 vs. 0.3%, P<0.001), fetal distress (6.1 vs. 3.65%, P<0.0015), meconium-stained amniotic fluid (17.8 vs. 15%, P<0.001), low Apgar score at 5 min (2.95 vs. 1%, P<0.01), malpresentation (6.8 vs. 2.9%, P<0.01), clinical chorioamnionitis (0.3 vs. 0.1%, P<0.05), prolapse of cord (2.2 vs. 0.3%, P<0.01), and large-for-gestational-age infant (LGA) (23.8 vs. 8.1%, P<0.01). When adjusted for confounding variables, the presence of hydramnios remained strongly associated with perinatal mortality (odds ratio 5.5 (95% CI 3.2-9.3)) and neonatal and maternal morbidity (odds ratios 2.1 (CI 1.1-3.7) and 2.3 (CI 1.9-2.7), respectively). CONCLUSIONS: (1) Hydramnios at term is an independent risk factor for perinatal death; (2) Fetal surveillance is warranted in patients with hydramnios even in the absence of other known risk factors for adverse pregnancy outcome.

Adult↗

PubMed1998

Pregnancy outcome after repeated blunt abdominal trauma.

During a four-year period, five of 49671 parturients were admitted on a prospective study protocol for repeated direct blunt abdominal trauma due to falls during pregnancy. Preterm contractions were noted in three patients one of which delivered preterm. No delayed abruptio placentae, intrauterine growth restriction or antepartum death were encountered. All patients delivered spontaneously. Repeated blunt abdominal trauma occurs rarely in pregnancy. Routine hospitalised surveillance in the absence of vaginal bleeding or uterine contractions may not be warranted.

Abdominal Injuries↗

PubMed1979

Shock in pregnancy: pathophysiology and morphologic findings.

Sepsis and non-septic shock in pregnancy show characteristic modifications which are caused a) by physiologic changes in hemostasis primarily in the third trimester of pregnancy, b) by etiologic distinctions of shock regarded as pregnancy-specific, c) by hemodynamic changes in the circulation during pregnancy, d) by the ability of the healthy, young organism to compensate adequately. In the dead fetus syndrome and in non-septic shock, i.e., in amnionic fluid embolism and in abruptio placentae, the clinical picture is often governed by marked secundary fibrinolysis. Retroplacental hematoma, the characteristic feature of premature placental separation, remains controversial as either the cause or sequela of the hemostatic disorder. Etiologic, pathogenetic, and morphologic similarities exist between septic abortion, chorioamnionitis, and puerperal sepsis, but the varying response of the maternal organism during the course of pregnancy leads to different clinical and morphologic pictures. Due to a decrease in fibrinolytic activity as a consequence of pregnancy, the hypercoagulability state in a septic endotoxic shock predisposes the kidneys to bilateral renal cortical necrosis, principally in the amnion infection syndrome.

Abortion, Septic↗

PubMed2006

[Abdominal trauma during pregnancy: Pertinence of monitoring elements].

OBJECTIVE: The objective of this study is to evaluate current means of monitoring of pregnant women victims of abdominal trauma and to determine whether systematic hospitalization is warranted. MATERIAL: and methods. This was a retrospective study of pregnant women who consulted the Nantes hospital during a three-year period for abdominal trauma during pregnancy. Four principal means of monitoring (examination, fetal heart rate or ERCF, ulstrasonography, Kleihauer test) were evaluated according to the fetal outcomes. RESULTS: Ninety-five patients were including in the study. The abdominal trauma resulted from a traffic accident for 49 patients (51%), a fall for 39 patients (41%) and high-energy trauma for 7 patients (8%). Three patients (3%) presented fetal complications: one fetal death, one fetal porencephaly, one premature birth at 34 weeks gestation for premature rupture of the membranes and abruptio placentae. These three women were traffic accident victims who also suffered extra-abdominal trauma. Ultrasonographic signs (npv=99%) and anomalies foetal monitoring (npv=98%) were also observed in two cases (fetal death and premature birth). The porencephaly was fortuitously discovered 3 weeks after trauma at a routine ultrasound. The Kleihauer test remained negative in all patients. The other traumas did not give lead to fetal complications. The incidence of premature births did not increase after trauma. Fetal outcome was good when monitoring parameters were normal at admission. CONCLUSION: Ultrasonography and fetal heart rate monitoring enable proper assessment of fetal well-being but only have predictive value if they are negative. A negative Kleihauer test, useful for Rh negative patients to determine the amount of anti-D antibody to inject, does not provide any information about fetal outcome when it is negative. The complications observed were related only to traffic accidents. Hospitalization is probably not very useful when monitoring elements are normal at admission and when the women has suffered mild trauma.

Abdominal Injuries↗

PubMedDate not supplied

Folate economy in pregnancy.

Pregnant women are prone to becoming folate deficient because there is a significant increase in folate requirement during pregnancy and folate intakes of pregnant women are often insufficient. Reduced folate levels in blood and neutrophilic hypersegmentation reflect a negative folate balance. Possible consequences of a low maternal folate status may be pregnancy complications such as abortion, abortus imminens, abruptio placentae, and congenital malformations. The role of folic acid in the etiology of neural tube defects has been discussed for decades. The importance of an adequate maternal folate status in the prevention of neural tube defects has been demonstrated by observational and controlled intervention trials. However, the mechanism of the protective effect of periconceptional folate supplementation is not completely understood. Metabolic disorders are probably involved in the pathogenesis of neural tube defects so that a relative folate shortage rather than folate deficiency seems to be responsible for the disturbed neural tube development, which can be compensated for by a higher folate intake.

Female↗

PubMed1995

The pharmacological prevention of pre-eclampsia.

The disparate results reported in the literature on the effects of low dose aspirin in preventing pre-eclampsia might be caused by non-compliance in the more recent large trials in low-risk patients. All the earlier small trials were done on identified high-risk patients who consider themselves as patients, as do their doctors. Compliance in these patients will be very high. In fact, the only study in healthy subjects in which aspirin intake was controlled for (Hauth et al 1993) showed a marked reduction in the incidence of pre-eclampsia. However, the recent large trials have demonstrated, without any doubt, that low dose aspirin is not a miracle drug. The combined literature points at a 25% reduction in the incidence of pre-eclampsia in association with the use of aspirin (Collins, 1994). The correct indication for the use of low-dose aspirin appears to be the patient that is at very high risk of developing early-onset (less than 32 weeks gestation) pre-eclampsia. Since early-onset pre-eclampsia can begin at any time after 20 weeks gestation, it is necessary to initiate low-dose aspirin therapy early in pregnancy, preferably at 10-14 weeks gestation. The results of the recent large trials emphasize the need for a reliable, sensitive method of predicting or detecting pre-eclampsia at a very early gestational age (Dekker and Sibai, 1991). Valensise et al (1993) recently confirmed earlier studies (McParland et al, 1990) on the useful combination of uteroplacental Doppler flow velocimetry and aspirin in low-risk primigravidae. Results from current large-scale trials, such as the ECPPA, the BLASP, the WHO Jamaica and the second NICHHD studies, will be available in the near future. The results of especially the second NICHHD study on low-dose aspirin, in more than 2000 high-risk women (previous pre-eclampsia/eclampsia, chronic hypertension, class B to F diabetes or multiple gestation), will hopefully give us a more definitive picture on the potential benificial effects of low-dose aspirin in high-risk patients. The effect of aspirin on placental TXA2 deserves further studies. It might be that the optimal level to inhibit placental TXA2 and lipid peroxide production is actually higher than the minimal effective doses of aspirin that are needed to inhibit platelet TXA2 production (Walsh, 1994). Low-dose aspirin appears to be safe for the fetus and neonate. If there is an increased risk of abruptio placentae, this risk appears to be minimal. The final word on the use of low-dose aspirin has not yet been reached; however, we may be getting closer to profiling patients for whom the therapy may be efficacious and beneficial to both mother and fetus. Further studies are also necessary on combinations of aspirin and other antithrombotic drugs, such as heparin or ketanserin (Tanaka et al, 1993; Bolte et al, 1994; North et al, 1994). North et al (1994) demonstrated that treatment of women with severe renal disease with heparin plus aspirin reduced the prevalence of superimposed pre-eclampsia, compared with no treatment or aspirin alone. Next to low-dose aspirin, there appear to be several new and promising pharmaceutical approaches for reducing the consequences of EC dysfunction. Among these are selective TXA2-synthetase or TXA2-receptor antagonists, Serotonin2-receptor blockers, stable PGI2 analogues and NO donors.

Aspirin↗

PubMed1988

Cerebral handicap in full-term neonates related to the mechanical forces of labour.

Sometimes the relationship between peripartum events and neonatal CNS injury is obvious: for example, following complete abruptio placentae or umbilical cord prolapse and occlusion with a delay of many minutes before delivery of the baby. These circumstances are, of course, rare in modern obstetrics. Usually, when a neonate develops neurological injury, a host of various potentially adverse peripartum factors are assumed to be the aetiology, but without definitive evidence. Among these latter factors are those we have focused on in this paper: the mechanical forces exerted on the fetal head during labour when the full-term fetus is in cephalic presentation. The mechanical events during the first stage of labour are reviewed, showing how uterine contractions result in cervical dilatation and descent and rotation of the fetal head. The consequences of these forces on the fetal intracranial pressure and blood flow are discussed: FHR remains normal up to a certain pressure threshold, above which decelerations occur. In other words, excessive pressures applied to the fetal head, either spontaneously (e.g. uterine tetany) or iatrogenically (e.g. traumatic forceps delivery or excessive fundal pressure) can increase fetal intracranial pressure to such a degree as to result in significant decreases in cerebral blood flow that are associated with fetal heart rate decelerations. Even when decelerations are simultaneous to contractions, decelerations cannot be considered as reflex and innocuous, as they are indeed associated with a decreasing cerebral blood flow. They must therefore be considered and evaluated in the management of labour. Cord compression and functional modifications of intervillous space by mechanical forces may further compromise the biological status of the fetus, leading to severe asphyxia. Neurological evaluation of the neonate within the first few days after delivery is currently the only way to provide the obstetricians with information on the possible consequences of an abnormal labour. The assessment of normality of the CNS in the neonate born at term, and its value in predicting late outcome are discussed. When abnormalities are detected after one or repeated assessments, abnormal neurological signs and symptoms are classified into three grades at the end of the first week. According to our data, a good correlation exists between this neonatal grading of cerebral dysfunction and late outcome. A careful evaluation of fetal head deformation, extensive caput succedaneum, and extensive retinal haemorrhages can help to interpret an abnormal labour retrospectively.(ABSTRACT TRUNCATED AT 400 WORDS)

Asphyxia Neonatorum↗

PubMed2002

Hysteroscopic resection of a cervical ectopic pregnancy.

A 32-year-old woman who had a history of abruptio placentae and cesarean section with her first pregnancy experienced vaginal hemorrhage 6 weeks after her last menstrual period. Clinical examination and ultrasound findings were consistent with cervical ectopic pregnancy. The gestation was hysteroscopically resected with the aid of the rollerbar.

Adult↗

PubMed2002

[Criteria of pregnancy termination in women with preeclampsia].

Preeclampsia remains an important cause of maternal and neonatal mortality and morbidity. Delivery is always the appropriate therapy for the mother but may be responsible for neonatal adverse outcomes, particularly when it occurs at less than < 34 weeks' gestation. In women with severe preeclampsia at < 34 weeks expectant management to improve neonatal mortality and morbidity may be performed under close monitoring of both the mother and the fetus. Any severe condition of the mother (HELLP syndrome, abruptio placentae, eclampsia) or the fetus (abnormal fetal heart rate) should lead to prompt delivery. In women with mild preeclampsia, expectant management should be performed until 38 weeks gestation.

Delivery, Obstetric↗