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PubMed1990

Preterm delivery: a risk factor for retained placenta.

The purpose of this study was to determine whether preterm delivery, with and without intraamniotic infection, is a risk factor for retained placenta. This complication occurred more frequently in women with preterm vaginal delivery than in women with term vaginal delivery (9.1% [21/231] vs 1.1% [6/561]; p less than 0.00001; odds ratio = 9.25). There was no significant difference in the prevalence of retained placenta between women with preterm labor and intact membranes and those with preterm premature rupture of membranes (8% [10/125] vs 10.4% [11/106]; p greater than or equal to 0.05). A positive amniotic fluid culture or clinical chorioamnionitis was not associated with a higher incidence of retained placenta. This study indicates that preterm delivery is associated with an increased risk of complications of the third stage of labor.

Adult↗

PubMed1992

Tumor necrosis factor in preterm and term labor.

OBJECTIVE: Our objective was to determine if labor (term and preterm) and microbial invasion of the amniotic cavity were associated with changes in amniotic fluid concentrations of tumor necrosis factor. STUDY DESIGN: Amniotic fluid was retrieved by transabdominal amniocentesis from 269 women in the following groups: midtrimester (n = 38), preterm labor with intact membranes (n = 52), preterm premature rupture of membranes (n = 74), term in active labor (n = 84), and term not in labor (n = 21). Fluid was cultured for aerobic and anaerobic bacteria and for Mycoplasma species. Tumor necrosis factor was measured with a commercially available enzyme-linked immunosorbent assay validated for amniotic fluid (sensitivity 60 pg/ml). RESULTS: Amniotic fluid from pregnant women in the second and third trimesters who were not in labor did not contain tumor necrosis factor. Among women in preterm labor, 92.3% (12/13) of patients with a positive amniotic fluid culture had detectable tumor necrosis factor in the amniotic fluid (median 820 pg/ml, range less than 60 to 2340 pg/ml). In contrast, only 10.2% (4/39) of women with a negative amniotic fluid culture had detectable tumor necrosis factor. Histopathologic chorioamnionitis was found in all patients who had a positive amniotic fluid culture, and tumor necrosis factor was detectable in the amniotic fluid of all but one of these patients. Among women in active labor at term, 25% (21/84) had detectable tumor necrosis factor in the amniotic fluid. Tumor necrosis factor was detected more frequently in the amniotic fluid of patients with a positive amniotic fluid culture than in patients with a negative culture (46.6% [7/15] vs 20.2% [14/69], p = 0.047). Amniotic fluid concentrations of tumor necrosis factor were significantly higher in patients with preterm premature rupture of membranes, labor, and a positive amniotic fluid culture than in the other subgroups of patients with preterm premature rupture of membranes. CONCLUSION: Parturition in the setting of microbial invasion of the amniotic cavity is associated with activation of the cytokine network as demonstrated by the detection of tumor necrosis factor in human amniotic fluid.

Adult↗

PubMed1992

Infection and labor. VII. Microbial invasion of the amniotic cavity in spontaneous rupture of membranes at term.

OBJECTIVE: The purpose of this study was to determine the frequency, microbiologic characteristics, and clinical significance of microbial invasion of the amniotic cavity in women with premature rupture of membranes at term. STUDY DESIGN: Amniocentesis was performed in 32 women with term premature rupture of membranes and amniotic fluid cultured for aerobic and anaerobic bacteria and Mycoplasmas. RESULTS: The prevalence of positive amniotic fluid cultures was 34.3% (11/32). The most common isolates were Ureaplasma urealyticum, Peptostreptococcus sp., Lactobacillus sp., Bacteroides fragilis, and Fusobacterium sp. Clinical chorioamnionitis occurred only in one patient with a positive amniotic fluid culture. Her neonate had ophthalmitis. Three patients (9.4%) had endometritis. Among women who were delivered vaginally, those with a positive amniotic fluid culture had a significantly higher rate of endometritis than those with a negative culture (33% [3/9] vs 0% [0/20], respectively, p = 0.023). CONCLUSIONS: These data indicate that microbial invasion of the amniotic cavity occurs in approximately one third of patients with preterm premature rupture of membranes. Microbial invasion of the amniotic cavity is a risk factor for endometritis in women with term premature rupture of membranes.

Amnion↗

PubMed1993

Double-blind; placebo-controlled trial of piperacillin prophylaxis in preterm membrane rupture.

OBJECTIVE: We attempted to test whether antibiotic therapy prolongs pregnancy in preterm premature rupture of membranes, because preterm premature rupture of membranes is frequently associated with chorionic-decidual infection. STUDY DESIGN: Women with preterm premature rupture of membranes and a singleton gestation at 24 to 34 completed weeks were randomized to receive either piperacillin 3 gm or placebo intravenously every 6 hours for 72 hours and were managed conservatively until spontaneous delivery, chorioamnionitis, or fetal distress. RESULTS: Between January 1987 and January 1992, a total of 75 patients were randomized to receive piperacillin (n = 38) or placebo (n = 37). There were no differences between the piperacillin group and the placebo group in mean gestational age at randomization (30.2 +/- 3 vs 30.3 +/- 2.9 weeks). However, a greater number of patients had pregnancy prolonged beyond 7 days (42.1% vs 10.8% p = 0.005) and the mean latency period was significantly prolonged (11.4 +/- 18.8 vs 6.1 +/- 13.6 days, p = 0.001) in the piperacillin group compared with the control groups. CONCLUSIONS: Use of intravenous piperacillin for 72 hours in preterm premature rupture of membranes significantly prolongs the latency period between membrane rupture and delivery.

Adult↗

PubMed1993

Antibiotics in the treatment of preterm labor.

OBJECTIVE: Clinical evidence for a relationship between chorioamnionitis and the onset of preterm labor, supported by well developed biochemical models of that interaction, motivated a review of prospective, randomized trials of antibiotic use in its prevention. STUDY DESIGN: A literature search was made of antibiotic trials applied to women at risk for preterm labor and with a clinical diagnosis of preterm labor after premature preterm rupture of membranes. A review of two retrospective case-control studies conducted on pregnant women with positive cultures for Chlamydia trachomatis is also included. RESULTS AND CONCLUSION: Results of antibiotic use in women with preterm premature rupture of membranes supports significant prolongation of the interval from rupture of membranes to delivery and improvement and neonatal outcome in treated patients.

Anti-Bacterial Agents↗

PubMed1994

Nitric oxide metabolites and preterm pregnancy complications.

OBJECTIVE: Intraamniotic infection may play a significant role in preterm labor and premature rupture of membranes. Synthesis of nitric oxide and its metabolites nitrite and nitrate purportedly are increased in infection. This project was designed to evaluate whether plasma or urine nitrate concentrations are increased in patients with either preterm labor or premature rupture of membranes in comparison with pregnant controls. STUDY DESIGN: A total of 42 patients between 24 and 35 weeks' gestation (20 with preterm labor; 14 with premature rupture of membranes, and 8 with premature rupture of membranes and contractions) and 35 additional patients without preterm labor or premature rupture of membranes (controls) had blood and urine collected for nitrate determination. Nitrate was reduced to nitrite and quantitated with the Griess reagent. RESULTS: The urine nitrate concentrations were significantly higher only in the preterm labor group compared with the control group (1.23 +/- 0.22 vs 0.67 +/- 0.05 mumol/mg creatinine, p < 0.05). The plasma nitrate level, however, was significantly higher in both the preterm labor and the premature rupture of membranes groups compared with the control group (52.47 +/- 10.11 and 40.05 +/- 5.38 mumol/L vs 16.29 +/- 2.89 mumol/L, p < 0.05). However, the concentrations of nitrate in the urine or plasma did not correlate with time from admission to delivery (p > 0.2). Finally, the presence of positive cervical or urine cultures, a clinical examination consistent with chorioamnionitis, or a maternal temperature > 100.4 degrees F was not associated with higher levels of nitrates in this small series of patients. CONCLUSION: Patients with preterm labor or premature rupture of membranes do have increased nitrate concentrations; however, this increased concentration is not predictive of impending delivery but may indicate that a subclinical infectious process is occurring.

Analysis of Variance↗

PubMed1995

Inhibition of neutrophil oxidative burst and phagocytosis by meconium.

OBJECTIVE: Meconium in amniotic fluid has been associated with an increased prevalence of chorioamnionitis. In an effort to delineate the mechanism of this association, we determined the effect of meconium on the neutrophil's capacity for phagocytosis and microbial killing by oxidative burst in vitro. STUDY DESIGN: Sterile meconium samples were obtained from four fetuses at the time of breech delivery and were then pooled and lyophilized. Neutrophils were purified from whole blood of each of 13 pregnant nonlaboring patients. Phagocytosis and the oxidative burst of neutrophils in the presence and absence of meconium were assessed by single-cell analysis with flow cytometry. Phagocytosis was measured as the mean fluorescence intensity produced after 30 minutes of incubation with fluorescein-labeled Escherichia coli. Oxidative burst was measured as the mean fluorescence intensity resulting from the oxidation of internalized reduced dichlorodihydrofluorescein after 15 minutes of stimulation with phorbol myristate acetate. Oxidative burst was expressed as the neutrophil oxidative index and the net fluorescence intensity. Neutrophil oxidative index was equivalent to the quotient of the mean fluorescence intensity for phorbol myristate acetate-stimulated and unstimulated cells. Net fluorescence intensity was equivalent to the absolute difference between stimulated and unstimulated cells. RESULTS: Exposure of neutrophils to light and very light meconium each resulted in significantly lower mean neutrophil oxidative index compared with unexposed controls (3.2 +/- 4.9 and 4.2 +/- 5.9 vs 16.2 +/- 7.5, p = 0.00002 and p = 0.0007, respectively) and significantly lower mean net fluorescence intensity than that of control cells (112 +/- 220 and 188 +/- 294 vs 613 +/- 328, p = 0.0001 and p = 0.005, respectively). Phagocytosis was significantly impaired in the presence of moderate meconium compared with control cells (2239 +/- 393 vs 4645 +/- 2071, p = 0.0001). Light meconium did not significantly affect phagocytosis. CONCLUSION: Meconium has significant effects on neutrophil function in vitro. Both light and very light meconium inhibit the oxidative burst. Moderate meconium inhibits phagocytosis.

Chorioamnionitis↗

PubMed1989

The outcome of pregnancies complicated by preterm rupture of the membranes with and without cerclage.

Thirty-two patients with cerclage were compared to 76 patients without cerclage. All pregnancies were complicated with preterm (less than 36 weeks) rupture of the membranes (PTROM). The management following removal of the cerclage was the same for the two groups and consisted of conservative treatment unless chorioamnionitis ensued. It was found that under similar conditions and treatment there was no significant difference between the outcomes of PTROM-complicated gestations with and without a cerclage. The low added risk of cerclage to PTROM should not deter its use when indicated.

Adult↗

PubMed1990

Prolongation of the latent period in patients with premature rupture of the membranes by avoiding digital examination.

Fifty three women with PROM between 26 and 34 weeks of gestation were examined. Twenty five women (group A) underwent one digital examination for cervical assessment while in 28 women (group B) the cervix was evaluated by speculum. No pelvic examinations were performed throughout the latent period. The latent period increased from 3.1 days in group A to 9.5 days in group B (P less than 0.005). Chorioamnionitis developed in 24% in group A and in 18% in group B (N.S.).

Adolescent↗

PubMed1989

Duration of the latency period in preterm premature rupture of the membranes. Maternal and neonatal consequences of expectant management.

111 pregnancies complicated with premature rupture of the membranes (PROM) at a gestational age between 20 and 34 weeks, were observed prospectively with expectant management. Median duration of the latency period was 7 (0-109) days. The duration of the latency period was inversely related to the gestational age at PROM. Intra-uterine death ensued in 9.9% of the pregnancies. Clinical chorioamnionitis ensued in 12.6% of the pregnancies. Eight (7.6%) neonates developed sepsis. None of the babies died as a consequence of sepsis alone. Of the 43 (41.0%) neonates who developed idiopathic respiratory distress syndrome (IRDS), 8 (7.6%) babies died. The perinatal mortality rate was 18.6%. The study seems to justify the expectant management of PROM pregnancies of less than 34 weeks of gestation.

Adult↗

PubMed1995

Obstetrical prognosis for carbon dioxide laser conisation of the uterine cervix.

Carbon dioxide laser conisation is a very reliable surgical technique for cervical intraepithelial dysplasia. As cervical morphology and function are better preserved than with other techniques, obstetrical morbidity should be lower in the often young and pauciparous women who undergo this procedure. In our study comparing the course of 71 pregnancies (55 children) in 54 operated women with that of 82 pregnancies (59 children) in these same women before conisation, the rates for complications at the beginning of pregnancy were similar (respectively, 14.1% and 13.4%, early spontaneous abortions; 2.8% and 2.4%, extrauterine pregnancies; and no late spontaneous abortions). The increased risks of premature delivery (13.2% vs. 8.5%), chorioamnionitis (1.9% vs. 0%), premature rupture of membranes (1.9% vs. 0%) and prematurity (11.3% vs. 1.7%) were not statistically significant. Only the percentage of natural term births was significantly reduced (73.6% vs. 90%; P = 0.025), but this difference was no longer apparent after correction for the prevalence of associated obstetrical pathologies and prematurity and/or cesarean factors which was significantly greater for the 53 pregnancies that developed after carbon dioxide laser conisation.

Abortion, Spontaneous↗

PubMed1995

Comparison of 12- and 72-hour expectant management of premature rupture of membranes in term pregnancies.

OBJECTIVE: To compare 12-hour and 72-hour expectant management of premature rupture of membranes (PROM) in singleton term pregnancies. METHODS: In a prospective, nonrandomized study, 566 low-risk women with singleton term pregnancies presenting with PROM were assigned to either 12-hour or 72-hour expectant management. Patients who had not entered labor at the end of the assigned period were induced with oxytocin. The pregnancy outcome of both methods was compared with regard to infectious complications and method of delivery. RESULTS: There was no statistical difference in the rate of chorioamnionitis between the 12-hour and 72-hour expectant management groups (11.7 versus 12.7%; relative risk [RR] 0.9, 95% confidence interval [CI] 0.6-1.5; P = .83). Cesareans were performed to a similar degree in both groups (4.7 versus 6.7%; RR 0.7, 95% CI 0.3-1.4; P = .39). Fifty-five percent of the 12-hour group underwent oxytocin induction, compared with 17.5% of those in the 72-hour group (RR 5.8, 95% CI 3.9-8.5; P < .001). Women undergoing induction after 72-hour expectant management had an increased risk of cesarean delivery compared with those after a 12-hour wait (RR 5.9, 95% CI 2.3-15.1; P < .001). Overall, women in the 12-hour group had shorter admission-to-discharge times than the 72-hour group (5 versus 6 days, 95% CI of the difference 0.6-1.3; P < .01). CONCLUSION: Regimens of 12-hour and 72-hour expectant management of PROM are comparable regarding infectious complications and pregnancy outcome. However, the longer wait prolongs the interval to delivery and increases hospitalization costs.

Adolescent↗

PubMed1995

Ability of normal vaginal flora to produce detectable phosphatidylglycerol in amniotic fluid in vitro.

OBJECTIVE: To determine if bacteria are capable of producing phosphatidylglycerol in amniotic fluid (AF) and the number of colony forming units (CFU) of bacteria necessary to produce this result. METHODS: Eleven species of bacteria and one species of yeast, common to the female genital tract and implicated in chorioamnionitis, were selected. Amniotic fluid was collected from 21 women and inoculated with 10(8) CFU/mL of each isolate. Aliquots of AF were tested at 0, 4, 12, and 24 hours for colony counts and the presence of phosphatidylglycerol by thin-layer chromatography. RESULTS: The mean gestational age (+/- standard deviation) of the 21 study patients was 33 weeks and 1 day (+/- 4 weeks). Among the 12 species studied, Escherichia coli produced phosphatidylglycerol, at a concentration of 1.75 x 10(8) CFU/mL, beginning 12 hours after incubation. CONCLUSION: Escherichia coli is capable of producing phosphatidylglycerol in AF in vitro and is present in the vagina in 24% of normal pregnant patients. Our findings question the validity of using vaginal pool AF specimens for phosphatidylglycerol determination. Therefore, we recommend that patients presenting with preterm premature rupture of membranes be evaluated by amniocentesis to determine fetal lung maturity with phosphatidylglycerol and the lecithin-sphingomyelin ratio.

Amniotic Fluid↗

PubMed1990

Placental leukotriene B4 release in early pregnancy and in term and preterm labour.

The production of leukotriene B4 (LTB4) by the human placenta in vitro was measured by radioimmunoassay. In early pregnancy (7-12 weeks gestation) LTB4 production rate (pmol/mg dry weight/2 h) was 3.7 (2.6-4.7) (median and range; n = 9) and at term it was 0.7 (0.4-2.3; n = 10) in placental tissue obtained at elective caesarean section, and 2.7 (1.3-3.6; n = 10) in samples following labour of spontaneous onset and vaginal delivery. In spontaneous preterm labour (26-36 weeks gestation) with normal placental histology LTB4 production was 0.7 (0.3-1.7; n = 14), but it was significantly higher in preterm placentas with inflammatory infiltration: 3.1 (0.8-4.8; n = 6). These data show that the production of LTB4 by human placenta is high in early pregnancy, but remains low during the third trimester, with a significant increase in spontaneous labour at term. LTB4 output is low in uncomplicated preterm labour but markedly increased in chorioamnionitis-associated preterm labour.

Adolescent↗

PubMed1986

Peptococcaceae bacteremia.

Bacteremia with Peptococcaceae is an uncommon clinical manifestation of infection with this family of microorganisms. A 20-month review of 12 patients with bacteremic infections due to anaerobic gram-positive cocci revealed that obstetrical patients during the peripartum period constitute the group at greatest risk for the development of such infections. Eight of the 12 patients were young women hospitalized on the obstetrical service. Seven patients had postpartum endometritis and one patient had chorioamnionitis. The remaining four patients include a single patient each with pylephlebitis and microabscesses of the liver, ascending cholangitis, thoracic empyema, and necrotizing soft-tissue infection. Bacteriologic identification of the microorganisms revealed the following: Peptostreptococcus micros (5 patients), Peptostreptococcus asaccharolyticus (5 patients), Peptostreptococcus magnus (1 patient), and Peptococcus species (1 patient). Eleven of the 12 patients received appropriate antibiotic therapy. All patients did well and there were no major sequelae.

Adolescent↗

PubMed1991

A product of activated human granulocytes stimulates prostaglandin E2 synthesis in human amnion cells.

Cell-free supernatant from formylmethionyl-leucyl-phenylalanine (fMLP)-activated granulocytes causes a time- and concentration-dependent stimulation of prostaglandin E2 (PGE2) production in amnion cells. PGE2 concentration in the culture medium after 36 h treatment with granulocyte supernatant (from 40 x 10(6) granulocytes/ml of amnion cell medium), 1.49 +/- 0.71 pg/ng DNA (n = 13), was significantly higher (p = 0.0015) than in control cells (0.33 +/- 0.23 pg/ng DNA, n = 13). Indomethacin abolished this stimulation. Granulocyte supernatant and human epidermal growth factor (hEGF) had an additive effect on amnion cell PGE2 production. Catalase, superoxide dismutase (SOD), protease inhibitors or the platelet-activating factor (PAF) antagonist L-659,989 had no effect. Actinomycin D, cycloheximide and mepacrine reduced the PGE2 production. The phospholipase A2 activity present in granulocyte supernatants was resistant to heating, whereas heating decreased their PGE2-stimulating activity by 92%. Exogenous phospholipase A2 had no effect on PGE2 synthesis. The granulocyte product could be precipitated with ammonium sulphate. On gel filtration of supernatant, two peaks of PGE2-synthesis stimulating activity were obtained (molecular weights 12,000 and 60,000). This data serve to explain the association of chorioamnionitis with preterm labor: activated granulocytes release a protein(s) that induces prostaglandin production in amnion cells, and thus promote labor.

Amnion↗

PubMed1993

The severity of fetal membrane infection and pregnancy complications.

The purpose of this report is to examine the association of histologic chorioamnionitis with microorganisms isolated from the fetal membranes and to evaluate whether microorganisms with or without inflammation are associated with labor characteristics and with pregnancy complications. Inflammation was more common among membranes that yielded pathogenic bacteria (47%, P = 0.002) or Urea-plasma urealyticum (34%, P = 0.03) than among membranes that yielded no growth or nonpathogenic bacteria (20%). Prolonged membrane rupture (P = 0.0001), infant birth weight less than 2500 g (P = 0.02), and intraamniotic infection (P = 0.001) occurred more frequently among those women whose membranes yielded pathogenic bacteria than among those whose membranes yielded no growth or nonpathogenic bacteria. Our findings suggest that placental membranes in which pathogenic bacteria are accompanied by inflammation are associated with the highest risk of pregnancy complications.

Adolescent↗

PubMed2004

How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes?

OBJECTIVE: The purpose of this study was to examine maternal and neonatal outcomes in relation to lengthening intervals of the second stage of labor. STUDY DESIGN: This is a retrospective cohort study of 15,759 nulliparous, term, cephalic, singleton births at the University of California, San Francisco, between 1976 and 2001. The second stage of labor was divided into 1-hour intervals. Maternal and neonatal outcomes were compared with the use of chi-squared and Student t tests, and a probability value of < or =.05 was used to indicate statistical significance. Potential confounders were controlled for with multivariate logistic regression. RESULTS: Increasing rates of cesarean delivery, operative vaginal delivery, and perineal trauma were associated with the second stage beyond the first hour. In multivariate analysis, the >4-hour interval group had higher rates of cesarean delivery (odds ratio, 5.65; P < .001), operative vaginal deliveries (odds ratio, 2.83; P < .001), 3rd- or 4th-degree perineal lacerations (odds ratio, 1.33; P = .009), and chorioamnionitis (odds ratio, 1.79; P < .001). There were no differences in neonatal acid-base status associated with length of second stage. However, there were fewer neonates with a 5-minute Apgar score of <7 (odds ratio, 0.45; P = .01). CONCLUSION: Although the length of the second stage of labor is not associated with poor neonatal outcome, a prolonged second stage is associated with increased maternal morbidity and operative delivery rates.

Analysis of Variance↗