Search

Changing drug safety ratings and conflicting information can make maintaining the mental health of the mother and the well-being of the fetus and infant complex. Here, a pharmacologic framework that [...]

The rate of successful trial of labor after previous cesarean delivery for dystocia is assessed in a large cohort based on the relative birth weights of the two pregnancies. It is likely that increased fetal size relative to previous birth weight plays a significant role in the outcome of a subsequent trial of labor for patients with previous cesarean delivery for dystocia, reducing chances of vaginal delivery.

The success rates of vaginal birth after cesarean (VBAC) delivery, uterine rupture and major maternal/perinatal outcomes are compared between women, with previous cesarean deliveries undergoing trial of labor (TOL) with preterm and term pregnancies, and also maternal and neonatal morbidities in women with preterm pregnancies undergoing a TOL versus repeat cesarean delivery without labor (RCD). The likelihood of VBAC success after TOL in preterm pregnancies is comparable to term gestations, with a lower risk of uterine rupture, and perinatal outcomes are similar with preterm TOL and RCD.

Could the fear of adverse fetal outcomes from asthma drugs be keeping you from managing pregnant patients with asthma as aggressively as nonpregnant patients? You'll be less tempted to hold [...]

The success rates and risks in women with a twin pregnancy who attempt a trial of labor after cesarean delivery are identified. A trial of labor with twins after previous cesarean delivery does not appear to increase maternal morbidity.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2004.06.049 Byline: Alex C. Vidaeff (a), Susan M. Ramin (a), Larry C. Gilstrap (a), Joseph L. Alcorn (b) Abstract: The purpose of this study was to investigate dexamethasone redosing as function of time and dose. Author Affiliation: (a) Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences (b) and the Department of Pediatrics, University of Texas Medical School at Houston, Houston, Tex Article History: Received 23 February 2004; Revised 25 May 2004; Accepted 11 June 2004 Article Note: (footnote) Presented at the Twenty-Fourth Annual Meeting of the Society for Maternal-Fetal Medicine, February 2-7, 2004, New Orleans, La.

Dexamethasone redosing as a function of time and dose was investigated. Results suggest a residual effect of initial exposure that potentiates redosing allowing significant dose reductions.

A study comparing the effect of a single 48-hour exposure to betamethasone or dexamethasone in the cell line and in human type II pneumocytes is presented. The result reveals that dexamethasone and betamethasone achieved similar dose response patterns of surfactant protein-B expression in vitro.

Objective: Postpartum depressive disorders lead to maternal disability and disturbed mother-infant relationships, but information regarding the rates of major depressive disorder in minority women is noticeably lacking. The goal of this study was to determine whether the risk factors for and rate of postpartum major depressive disorder in a predominantly African American and Hispanic clinic population would be similar to those reported for Caucasian women. Method: Investigators systematically screened all women scheduled for their first postpartum visit on selected days at four publicly funded inner-city community maternal health clinics in Dallas County (N=802). A multistage screening process included the Edinburgh Postnatal Depression Scale, the Inventory of Depressive Symptomatology, and the Structured Clinical Interview for DSM-IV for a maximum of three assessments during the initial 3-5-week postpartum period. Results: The estimated rate of major depressive disorder during the postpartum period among women in this setting was between 6.5% and 8.5%. Only 50% of the depressed women reported onset following birth. Bottle-feeding and not living with one's spouse or significant other were associated with depression at the first evaluation; persistent depressive symptoms were linked with the presence of other young children at home. Greater severity of depressive symptoms at first contact predicted major depressive disorder several weeks later. Conclusions: Rates of postpartum depression among Latina and African American postpartum women are similar to epidemiologic rates for Caucasian postpartum and nonpostpartum women. As previously shown for Caucasian women, major depressive disorder in many Latina and African American postpartum women begins before delivery, revealing the need to screen pregnant women for depression. (Am J Psychiatry 2001; 158:1856-1863)

Epidural analgesia is more effective than intravenous analgesia in relieving labor pain in pregnant women with hypertension but it has more side effects. It prolongs the second stage of labor and increases the risk of a forceps delivery and an infection called chorioamnionitis.

Most pregnant women with pneumonia can be treated with erythromycin and about one-fourth can be treated as outpatients. This was the conclusion of a study of 133 pregnant women with community-acquired pneumonia.

A protein called cardiac troponin I may be the best indicator of a heart attack in pregnant women. Diagnosing heart attack in pregnant women is a challenge, because many of the proteins that are increased during a heart attack are also increased during pregnancy. This was confirmed in a study of 51 healthy pregnant women in whom blood levels of several proteins were measured before, during and after delivery. Levels of myoglobin, creatine kinase and creatine kinase MB increased two-fold within 30 minutes after delivery. However, levels of cardiac troponin I did not.

Byline: Stephan A. Shivvers, Frank H. Wians, Joseph H. Keffer, Susan M. Ramin Keywords: Pregnant women; myocardial injury; troponin I Abstract: Objective: Diagnosis of myocardial infarction in pregnant women on the basis of changes in biochemical markers is complicated by the release of some of these markers from noncardiac tissue sources. We compared troponin I levels with those of other markers in normal pregnant women. Study Design: In 51 healthy women at term in labor, cardiac troponin I, myoglobin, creatine kinase, and creatine kinase MB levels were determined at admission, during the second stage of labor, and within 30 minutes, 12 hours, and 24 hours after delivery. Results: Mean admission levels for all markers were below the upper limit of normal. Mean concentrations of myoglobin, creatine kinase, and creatine kinase MB mass were increased nearly twofold within 30 minutes after delivery. The highest level of troponin I (0.134 ng/mL) at all time points was below the cutoff value (0.15 ng/mL) for discriminating myocardial infarction. Conclusions: Because only troponin I levels remained undetectable during and after delivery, it is potentially the most useful biochemical marker for monitoring pregnant women for myocardial injury. (Am J Obstet Gynecol 1999;180:122-7.) Author Affiliation: Dallas, Texas From the Department of Obstetrics and Gynecology.sup.a and the Department of Pathology,.sup.b University of Texas Southwestern Medical Center Article History: Received 16 April 1998; Revised 30 June 1998; Accepted 14 July 1998 Article Note: (footnote) [star] Reprint requests: Stephan A. Shivvers, MD, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75235-9032., [star][star] 0002-9378/99 $8.00 + 0 6/1/93219

Epidural analgesia may prolong labor in childbirth. Researchers compared 199 women treated with epidural analgesia or intravenous meperidine for pain control during delivery. Women treated with the spinal analgesia technique were in active labor an average of 8 hours, compared to 6 hours in women given intravenous pain medication. Oxytocin was used to induce uterine contractions more frequently in women given epidural analgesia.

Byline: James M. Alexander, Michael J. Lucas, Susan M. Ramin, Donald D. McIntire, Kenneth J. Leveno Keywords: Epidural; labor; anesthesia Abstract: Objective: Our purpose was to measure effects of epidural analgesia on labor compared with boluses of meperidine in a cohort of women with similar clinical circumstances. Study Design: One hundred ninety-nine nulliparous women who were delivered spontaneously at term and who received oxytocin for labor augmentation before the initiation of analgesia were identified for analysis. All these women were managed in a low-risk labor unit according to a standardized protocol. This management protocol encouraged early amniotomy and the use of oxytocin when ineffective labor was diagnosed. Results: The demographic characteristics of the two study groups were similar with respect to age, height, weight, and maternal age. The two groups had the same cervical dilatation on admission (3.3 cm) and at the time of analgesia administration (4.1 vs 4.2 cm), indicating similar progress of labor before oxytocin administration. The length of the active phase of labor was longer in the epidural group (7.9 vs 6.3 hours, p = 0.005), as was the second stage (60 vs 48 minutes, p = 0.03). The mean and maximal rates of oxytocin infusion were similar between the two study groups; however, the amount of oxytocin required for each centimeter of cervical change was more in the epidural group (22 vs 16 mU per cm of cervical change, p = 0.009). Neonatal outcomes were unaffected by the type of labor analgesia. Conclusion: Epidural analgesia decreases uterine performance during oxytocin-stimulated labor, resulting in an increase in the length of the first and second stages of labor. (Am J Obstet Gynecol 1998;178:516-20.) Author Affiliation: Dallas, Texas Article History: Received 22 May 1997; Revised 18 September 1997; Accepted 30 September 1997 Article Note: (footnote) [star] From the Departments of Obstetrics and Gynecologya and Academic Computing,b University of Texas Southwestern Medical Center., [star][star] Reprint requests: James M. Alexander, MD, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75235-9032., a 6/1/86552

Uterine manipulation to accomplish a vaginal breech delivery of a second twin may decrease the need for a cesarean section and pose no higher risk of maternal infection or poor infant outcome. Of 718 twin births, patients with cesarean delivery had a 17.7% rate of infection. Vaginal delivery with, and without, uterine manipulation resulted in significantly lower rates of 4.6% and 6.1%, respectively. Infant outcome was comparable between groups. Breech extraction possibly avoided cesarean section in 20% of these cases, without increases in maternal or infant complications.

Byline: James M. Alexander, Larry C. Gilstrap, Susan M. Cox, Susan M. Ramin Keywords: Twins; infection; breech extraction Abstract: Objective: Our purpose was to determine whether manipulation of the second twin increases the risk of postpartum infection. Study Design: Medical records of all twin deliveries between January 1991 and December 1994 were reviewed. The route of delivery (vaginal vs cesarean section) was examined. The vaginal group was further divided into those delivered in the vertex/vertex position (i.e., no uterine manipulation) versus those delivered vertex/breech extraction (i.e., manipulation). The I.sup.2 and Student t test were used where appropriate. Results: A total of 718 twins were identified, and maternal age, parity, gestational age at delivery (36 weeks), and birth weight (2278 gm) were similar among groups. The metritis rate was higher in the cesarean group (74/447 or 18%) than in the vaginal group (17/299 or 5.7%, p < 0.001). In comparing the vaginal group delivered without uterine manipulation with the vaginal group delivered with manipulation (i.e., breech extraction), there was no difference in the incidence of metritis (10/147 or 6.8% vs 7/152 or 4.6%, not significant). The length of time between delivery of twin A and twin B did not affect the metritis rate. Neonatal outcomes including sepsis, neonatal death, and length of hospitalization were similar among groups (not significant). Conclusion: Uterine manipulation of the second twin does not increase the risk of postpartum metritis or neonatal sepsis. In addition, the time interval between delivery of twins A and B has no effect on the rate of metritis. Although the rate of endometritis has been reported to be higher with twins delivered by cesarean section compared to singletons, the 18% rate of endometritis in twins delivered by cesarean section in this study is slightly lower than in our general population of cesarean deliveries (22%). Author Affiliation: Dallas, Texas Article Note: (footnote) [star] From the Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center., [star][star] Reprint requests: James M. Alexander, MD, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75235-9032., a 0002-9378/97 $5.00 + 0 6/6/84357

Byline: Paul J. Wendel, Susan M. Ramin, Cathy Barnett-Hamm, Thomas F. Rowe, F.Gary Cunningham Keywords: Asthma; aminophylline; inhaled corticosteroids Abstract: OBJECTIVE: Our purpose was to study the effect of inhaled corticosteroids on asthma exacerbations in pregnancy. STUDY DESIGN: We prospectively studied 84 pregnant women with 105 asthma exacerbations. Women were hospitalized if the forced expiratory volume in 1 second was Author Affiliation: Dallas, Texas Article History: Received 26 October 1995; Revised 26 January 1995; Accepted 30 January 1996 Article Note: (footnote) [star] From the Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center., [star][star] Reprint requests: Paul J. Wendel, MD, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, 4301 West Markham St., Slot #518, Little Rock, AR 72205-7199., a 0002-9378/96 $5.00 + 0 6/1/72466

Treating pregnant women having severe asthma attacks with intravenous aminophylline does not appear to improve their outcome. In addition to treating with inhaled beta2-adrenergic receptor agonist, 65 pregnant women requiring hospital admission for an asthma attack were randomly assigned to intravenous aminophylline during their hospital stay and then randomly assigned to inhaled corticosteroids at hospital discharge. Women given aminophylline did not respond faster nor did they have shorter hospital stays. However, women assigned to inhaled corticosteroids had fewer readmissions for subsequent attacks.

Prompt diagnosis and hospitalization appear to improve the prognosis of women with acute pancreatitis in pregnancy. Pancreatitis is an inflammation of the pancreas. Of 43 pregnant women with pancreatitis admitted to a Texas hospital over a 10-year period, all responded well to antimicrobial therapy, intravenous hydration, and bowel rest. Of 39 of these women who gave birth in the hospital, 32 delivered full-term, healthy infants. Two of the babies were stillborn and one who was born without a functional brain died after one day. The most common cause of pancreatitis in pregnancy appears to be biliary tract disease which advances with gestational age.

The presence of meconium in the amniotic fluid during labor does not appear to be associated with a lack of oxygen called asphyxia. Meconium is a baby's first stool. Umbilical-cord blood was assayed for lactate, hypoxanthine, and erythropoietin, and concentrations were compared between 28 healthy women in labor with meconium-stained amniotic fluid and 28 similar women with clear amniotic fluid. Fetuses with meconium-stained fluid were older than fetuses that did not pass meconium. This supports the theory that meconium passage relates to maturation of the digestive tract. No fetus showed any signs of fetal distress in labor, and Apgar scores and blood pH, a measure of oxygenation, were similar. Lactate levels and hypoxanthine levels, which are indicators of recent asphyxia, were similar. However, erythropoietin levels were higher in cases of meconium staining. Erythropoietin level appears to correlate with chronic stress or stress in the more distant past.

Angiotensin II may be more effective than ephedrine at preventing the fall in maternal blood pressure that commonly follows administration of spinal anesthesia without compromising uterine blood flow. A group of 30 women undergoing elective repeat cesarean section at term were randomly assigned to a control group, I.V. administration of ephedrine, or I.V. administration of angiotensin II prior to receiving spinal anesthesia. After anesthetic administration, half the control women experienced a fall in blood pressure that required a corrective injection of ephedrine. None of the ephedrine or angiotensin group became hypotensive. However, the incidence of low blood pH, a sign of oxygen deprivation, in the newborn was 40% in the ephedrine group versus none in the angiotensin group or among controls. Angiotensin II levels in that group increased fourfold in the mother's bloodstream, but were unchanged in the baby, indicating that angiotensin II does not cross the placenta.

An ultrasound scan diagnosed the extrusion of the amniotic sac through a uterine tear. A woman who had had curettage for an incomplete miscarriage two years previously presented 33 weeks gestation with decreased fetal movements and intermittent abdominal pain. A routine scan performed 11 weeks earlier had found everything to be normal. Now, however, sonography revealed a tear in the top of the uterus through which protruded a fluid filled sac. There was virtually no amniotic fluid surrounding the fetus. Surgery revealed that the amniotic sac had ballooned through the rent. A healthy baby was delivered, and the rent was closed. Tubal ligation was also performed. An event such as this is exceedingly rare. Uterine perforation occurs less than 1% of the time during curettage. Uterine rents rarely occur in the absence of a uterine scar, and most have no consequences.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2009.06.066 Byline: Marium G. Holland (a), Jerrie S. Refuerzo (a), Susan M. Ramin (a), George R. Saade (b), Sean C. Blackwell (a) Keywords: elective delivery; late preterm birth; practice patterns; prematurity; preterm birth Abstract: Our objective was to describe indications for late preterm birth (LPTB) and estimate the frequency of potentially avoidable LPTB deliveries. Author Affiliation: (a) Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Texas Medical School at Houston, Houston, TX (b) Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, TX Article History: Received 27 February 2009; Revised 31 May 2009; Accepted 30 June 2009 Article Note: (footnote) Reprints not available from the authors., Cite this article as: Holland MG, Refuerzo JS, Ramin SM, et al. Late preterm birth: how often is it avoidable? Am J Obstet Gynecol 2009;201:404.e1-4.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2008.07.014 Byline: Linda Fonseca, Hilaire C. Wood, Michael J. Lucas, Susan M. Ramin, Deepali Phatak, Larry C. Gilstrap, Edward R. Yeomans Keywords: cervical ripening; induction; misoprostol; oxytocin Abstract: The purpose of this study was to compare the vaginal delivery rate in women who undergo labor induction with preinduction misoprostol or oxytocin alone. Author Affiliation: Department of Obstetrics, Gynecology, and Reproductive Sciences, The University of Texas Medical School at Houston, Houston, TX Article History: Received 1 March 2008; Revised 12 May 2008; Accepted 7 July 2008 Article Note: (footnote) Cite this article as: Fonseca L, Wood HC, Lucas MJ, et al. Randomized trial of preinduction cervical ripening: misoprostol vs oxytocin. Am J Obstet Gynecol 2008;199:305.e1-305.e5. , (Dr Fonseca is currently in the Department of Obstetrics, Gynecology, and Reproductive Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL.), Reprints not available from the authors.

Dr. Miles is Maternal-Fetal Medicine Clinical Fellow; Dr. Pschirrer is Maternal-Fetal Medicine Clinical Fellow; Dr. Gilstrap is Professor and Chairman; and Dr. Ramin is Associate Professor and Director, Division of [...]