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To evaluate the predictability of shoulder dystocia using preconceptive and prenatal risk factors.Data from 1,622 term patients with prenatal care prior to 20 weeks who delivered single, vertex fetuses during a consecutive 12-month period were analyzed. Two groups were chosen. The first group was patients whose fetuses experienced shoulder dystocia during delivery (cases). The second group (controls) consisted of the remaining patients, whose fetuses had not experienced shoulder dystocia. The two groups were compared with regard to demographics and pregnancy characteristics.Factors not significantly different between the two groups included were obesity, multiparity, history of diabetes, short maternal stature, postdatism and advanced maternal age. The incidence of macrosomia was significantly higher (P.001) in cases (35.4%) than in controls (4.8%). Other factors associated with shoulder dystocia were previous shoulder dystocia, concurrent diabetes, prior delivery of a fetus4,000 g and excessive weight gain during pregnancy. Many factors previously associated with shoulder dystocia were found to be nonsignificant in our study.Macrosomia appears to be the single important factor associated with shoulder dystocia which, even in the presence of significant risk factors, remains largely unpredictable.

The objective of this retrospective study was to test the hypothesis that vacuum extraction of neonates with a birth weightor = 2000 gm is associated with an increased risk of periventricular-intraventricular hemorrhage (PV-IVH).One hundred sixty-eight neonates weighingor = 2000 gm were entered into this case control study. Fifty-six neonates delivered by silicone-rubber vacuum comprised the study group. For every infant born by vacuum-assisted delivery, two spontaneously delivered neonates served as controls (n = 112) and were matched for best obstetric gestational age (within 1 week), delivery date within 1 year, and birth weightor = 2000 gm. Maternal and neonatal medical records were reviewed for demographic variables, antenatal complications, indication for vacuum-assisted delivery, neonatal birth weight, Apgar scores, umbilical cord blood gas values, and neonatal morbidity including the incidence of PV-IVH. All perinatal outcome variables were compared between the vacuum-assisted and spontaneously delivered groups.Both groups were similar with regard to maternal age, parity, antepartum complications, gestational age at delivery, neonatal birth weight, and gender. Both groups were also similar with regard to the incidence of 1-minute Apgar score5, small for gestational age, cephalhematoma, birth trauma, respiratory distress syndrome, hyperbilirubinemia, and sepsis. There was a significant increased incidence of 5-minute Apgar scores7 in the vacuum-assisted group (p = 0.04). No significant difference was observed in the incidence of PV-IVH grades 1 through 4 (21.4% vacuum group vs 16.1% control group, odds ratio 1.42, 0.58 to 3.45).Indicated use of the silicone-rubber vacuum to assist vaginal delivery of neonates weighingor = 2000 gm does not appear to be associated with an increased risk of PV-IVH or other neonatal complications.

Ascaris lumbroicoides is the most prevalent human parasite worldwide. Although usually asymptomatic, ascaris is responsible for a variety of severe complications such as intestinal obstruction, cholangitis, or hepatitis, which are caused by worm migration. This article is the second known case report of pancreatitis caused by biliary ascaris during pregnancy. We also review the pathophysiology of this disease and review the various treatment modalities available for pregnant patients. We believe that because of the growing influx of immigrants from endemic areas into the United States, the clinician needs a basic understanding of the etiology, diagnosis, and treatment of biliary ascarasis.

To examine the outcome of pregnancies in high-risk patients whose last antepartum fetal assessment was a negative contraction stress test (CST) or a negative modified biophysical profile.Twenty-nine hundred ninety-four women who received modified biophysical profiles were compared with 2450 who had CSTs during the preceding 3 years. Pregnancy outcomes were evaluated in patients whose last test was negative.Seventeen hundred fifty-three patients had negative modified biophysical profiles as the last test before delivery, and 1337 had negative CSTs as the last test before delivery. Adverse perinatal outcomes included perinatal death or death before nursery discharge, cesarean delivery for fetal distress within the first 2 hours of labor, 5-minute Apgar score less than 7, neonatal seizures, or grade III or grade IV central nervous system hemorrhage. Adverse outcomes occurred in 90 patients (5.1%) whose last test before delivery was a negative modified biophysical profile and in 93 patients (7.0%) whose last test was a negative CST (P = .04, odds ratio 1.38, 95% confidence interval 1.01-1.88). Overall, there were 11 perinatal deaths, nine of which resulted from lethal congenital abnormalities.In this population, the frequency of adverse perinatal outcome following a negative modified biophysical profile was no greater than that following a negative CST. Further, the incidence of potentially preventable perinatal death following a negative modified biophysical profile or CST was less than one per 1000 tested high-risk pregnancies.

Our purpose was to evaluate perinatal outcomes in high-risk pregnancies monitored with a modified biophysical profile.All non-insulin-dependent patients referred for antepartum fetal surveillance received a modified biophysical profile biweekly. A modified biophysical profile is a combination of a nonstress test and an amniotic fluid index. Patients with a singleton gestation and intact membranes were entered into a protocol of randomized backup testing for an abnormal modified biophysical profile. Those patients having a nonreactive fetal heart rate, significant variable decelerations, late decelerations, or an amniotic fluid indexor = 5.0 cm received either a contraction stress test or a biophysical profile immediately. Once randomized, a patient received the same backup test, when indicated, with subsequent testing.A total of 2774 patients had 17,429 tests with an uncorrected perinatal mortality rate of 2.9 per 1000. The overall incidence of an adverse perinatal outcome (i.e., perinatal death or nursery death before infant hospital discharge, cesarean delivery for fetal distress within the first 2 hours of labor, 5-minute Apgar score7, neonatal seizures or grade III or IV central nervous system hemorrhage) was 7.0%. When compared with patients having persistently normal modified biophysical profile, patients requiring a backup test had a significantly greater incidence of adverse perinatal outcome (9.3% vs 4.9%, p0.001, odds ratio 2.0, 95% confidence interval 1.5 to 2.7) and small-for-gestational-age infants (5.2% vs 2.4%, p0.001, odds ratio 2.2, 95% confidence interval 1.5 to 3.5). No differences in outcomes between patients randomized to a contraction stress test versus a biophysical profile could be identified either overall or in limiting the analysis to outcome after a negative last test. However, patients having contraction stress test as a backup test had a significantly higher rate of intervention for an abnormal test result than did those having a biophysical profile backup test (23.7% vs 16.6%, p0.002, odds ratio 1.6, 95% confidence interval 1.2 to 2.1).The modified biophysical profile is an excellent means of fetal surveillance and identifies a group of patients at increased risk for adverse perinatal outcome and small-for-gestational-age infants. There does not appear to be a significant benefit with the contraction stress test compared with the biophysical profile as a backup test. Further, the contraction stress test is associated with a higher rate of intervention for an abnormal test than is the biophysical profile.

To compare the clinical outcome in patients with preterm premature rupture of membranes (PROM) who had a sterile speculum examination with those having a digital vaginal examination.We studied 271 singleton pregnancies complicated by preterm PROM from the Memorial Medical Center of Long Beach Perinatal Outreach program that met the criteria for expectant treatment from January 1986 to April 1990. Patients were not included in the study if they had multiple gestations, cerclage, advanced labor, or any indication for delivery on admission (eg, mature lung profile, chorioamnionitis). All subjects were maternal transports to our tertiary care facility and were managed similarly by our perinatal group. The women were questioned as to whether a digital vaginal examination had been performed before transport. Latency period and other obstetric characteristics were then compared. The latency period, defined as days from rupture of membranes until active intervention was initiated or labor began spontaneously, was also stratified by gestational age.One hundred twenty-seven subjects had a digital vaginal examination and 144 had a sterile speculum examination. A significantly (P less than .0001) shorter mean latency period (2.1 +/- 4.0 versus 11.3 +/- 13.4 days) was found in those who had a digital vaginal examination. In addition, a shorter latency period was noted for each gestational age. No difference in uterine activity or cervical dilatation and effacement was noted between the groups on admission.Digital vaginal examinations performed on patients whose pregnancies are complicated by preterm PROM appear to shorten significantly the latency period.

The outcome for pregnancies in women with renal pathology has improved markedly as a result of many new technological changes. The kidney plays a critical role in both normal and complicated pregnancy. Only by understanding these various adaptations can one correctly manage patients whose pregnancies are complicated by some degree of renal impairment and achieve a safe and successful outcome for both mother and baby.