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Background: To compare the obstetric outcome of teenage pregnancies with that of older women., Methods: Retrospective chart review of singleton births > or =24 weeks' gestational age at the American University of Beirut from 1994 to 2003. Adolescents (<20 years) were compared to subsequently delivered women aged 25-30 years (controls), n=486 each., Results: Only 131 (27.0%) adolescents were <18 years. More adolescents were nulliparous (79.8 versus 17.9%; p<0.0001). Preterm delivery <37 but not <34 weeks occurred more frequently in cases (11.1 versus 5.8%, p=0.004). Pre-eclampsia was more commonly encountered (2.9 versus 0.6%; p=0.012) and mean predelivery haematocrit was lower in cases (30.6+/-3.3 versus 33.8+/-4.3%, p<0.001), but the incidence of gestational diabetes, placenta previa, abruptio placentae, breech presentation, or meconium-stained amniotic fluid were similar. Caesarean delivery was performed less frequently in cases (9.2 versus 14.0%; p=0.028), but primary caesarean and operative vaginal delivery rates were similar though vacuum was used more frequently in multiparous controls (0.2 versus 2.7%, p=0.011). Nulliparous cases had shorter first and second stages of labour (384+/-304 versus 524+/-339 min, p<0.0001 and 47+/-36 versus 63+/-50 min, p=0.002), respectively. Mean birth weight was higher in controls (3177+/-567 versus 3284+/-511 g, p<0.001), but intrauterine growth restriction, birth weight <2500 g, low Apgar scores, intrauterine fetal death, and stillbirths were similar in both groups., Conclusions: Adolescents are more likely to deliver preterm than older women, and are more likely to suffer from anaemia and pre-eclampsia. Nulliparous adolescents have a quicker progress of labour while multiparous adolescents require vacuum less frequently compared to their older counterparts. In most other respects, they have comparable maternal and perinatal morbidity.

Objective: To study the recurrence risk of shoulder dystocia in women who have previously experienced at least once shoulder dystocia., Design: A retrospective study of vaginal deliveries complicated by shoulder dystocia. Setting. American University of Beirut Medical Center - Lebanon., Sample: Vaginal deliveries complicated by shoulder dystocia over a 15-year period who had subsequent vaginal delivery. Methods. Charts of index and subsequent deliveries beyond 24 weeks' gestation were reviewed for demographics and intrapartum events. Women were divided into those with recurrent shoulder dystocia (group I) and those with uncomplicated subsequent delivery (group II) and compared., Main Outcome Measures: Recurrent shoulder dystocia and characteristics of women with recurrence., Results: The incidence of shoulder dystocia was 0.9% of all vaginal deliveries. Of 193 shoulder dystocia cases, 48 women had a subsequent delivery. After excluding cesarean deliveries (n=4), 44 women were analyzed. Eleven had recurrent shoulder dystocia (25.0%). Mean birthweight was larger (4,019+/-430 vs. 3,599+/-398 g, p=0.005) with a higher rate of macrosomia > or =4,000 g (63.6 vs. 15.2%, p=0.004) and the birthweight in the subsequent pregnancy was larger than the index pregnancy in a significantly larger proportion of women in group I compared with group II (72.7% vs. 33.3%, p=0.035). Otherwise, maternal age, gestational age at delivery, parity, duration of labor, gender, history of macrosomia, and interval between pregnancies were similar., Conclusions: The risk of recurrence of shoulder dystocia is around 25%. When counseling women about recurrence risk, the absence of macrosomia and a smaller birthweight than the previous pregnancy could be reassuring.

Objective: To assess the effect of the Lebanese civil war on sperm parameters., Design: Retrospective review of patient records., Setting: Males providing semen samples at a university laboratory. Semen samples collected 1985-1989 (during the war) were compared with those obtained 1991-1995 (postwar)., Patient(s): Males with or without a history of infertility providing semen samples at a university central laboratory., Intervention(s): None., Main Outcome Measure(s): Standard clinical semen analysis., Result(s): The sperm concentration was significantly lower during the war compared with the postwar period. However, the percentage of abnormal sperm morphology increased in the postwar period. War had no significant effect on volume and motility. Postwar, the percent azospermic and those <10 million remained the same, but there was a shift in the count from the borderline count (11-20 million) to normal (>20 million)., Conclusion(s): There was a significant decline in sperm concentration during the Lebanese civil war. Increased stress level during the war is believed to be one of the main factors leading to this finding.

Objective: To compare patient satisfaction with two routes of misoprostol for term labour induction., Design: Prospective randomised trial., Setting: Tertiary care hospital., Population: A total of 170 women admitted at > or = 37 weeks of gestation for induction of labour., Methods: Women were randomised to receive 50 micrograms of either sublingual or vaginal misoprostol., Main Outcome Measures: Patient satisfaction with the route of administration., Results: Despite a similar proportion reporting the labour induction as more painful than expected in both groups, a significantly lower proportion mentioned that the pelvic examinations were very painful in the sublingual group (19.7 versus 36.1%, relative risk [RR] 0.5, 95% CI 0.3-0.9). Request for analgesia was similar in both groups. More women in the sublingual group thought that the labour experience was better than expected (RR 2.0, 95% CI 1.2-3.3), had a positive attitude towards induction in subsequent pregnancies (RR 1.6, 95% CI 1.1-2.3) and preferred the same route in subsequent pregnancies (RR 3.1, 95% CI 2.2-4.5). Mean number of misoprostol doses, oxytocin augmentation, tachysystole and hyperstimulation, induction to vaginal delivery interval, vaginal delivery after a single dose, vaginal birth within 12 and 24 hours, and caesarean delivery rates were similar in both groups., Conclusion: Sublingual misoprostol (50 micrograms) is associated with a significantly higher patient satisfaction rate compared with a similar dose of vaginal misoprostol. Sublingual administration offers additional choice to women, in particular those wishing to avoid vaginal administration.

Symptomatic hypocalcemia has been reported infrequently in association with magnesium sulfate (MgSO (4)) tocolytic therapy. We report a 38-year-old woman who presented in preterm labor at 24 3/7 weeks. Twenty hours after starting MgSO (4), she developed chest pain. Studies revealed therapeutic serum Mg level, total serum calcium (Ca) = 5.5 mg/dL, 24-hour urine Ca = 763.9 mg, and low serum uric acid and phosphate levels. All studies corrected day 1 postpartum; urine Ca level corrected on day 2. Even short courses of MgSO (4) can result in severe hypocalcemia, raising the question of whether Ca levels should be routinely monitored.

Background: To review the outcome of subsequent pregnancies in conservatively managed cases of uterine rupture., Methods: Charts of patients with full thickness uterine rupture in the past 25 years were reviewed and information on subsequent pregnancies was extracted from maternal and neonatal charts., Results: Thirty-seven patients with uterine rupture were identified; the uterus was scarred in 62.2%. Ruptures were repaired in 26 (70.3%). Twelve patients subsequently conceived (24 pregnancies), with recurrence in 8/24 (33.3%) pregnancies or 5/12 (41.7%) patients. Patients with recurrence had a shorter median interval from previous rupture (2 versus 5 years), a higher incidence of previous longitudinal ruptures (60.0% versus 0.0%), and the median gestational age at the preceding rupture was lower without reaching statistical significance (34 versus 38 weeks; p = 0.209)., Conclusions: Longitudinal ruptures and short intervals between rupture and subsequent pregnancy predispose to recurrence of uterine rupture.

Calcium channel blockers are becoming more popular as first-line tocolytic agents. Serious side effects have rarely been reported and involved mainly intravenous use of nicardipine. We report the first case of acute pulmonary edema following tocolytic oral nifedipine. Possible contributing factors are mentioned.

We report a 39-year-old primigravida, a case of systemic lupus erythematosus (SLE) and secondary anti-phospholipid syndrome (APS) with a smooth antenatal course who delivered by caesarean for non-reassuring foetal heart rate. On day 2 postoperatively, she developed a sudden severe colicky upper abdominal pain with tachypnoea, dyspnoea, and tachycardia, and blood pressure (BP) reaching 150/95 mmHg. Computed tomography of the abdomen revealed lesions consistent with liver infarction. She developed haemolytic anaemia, elevated liver enzymes, and low platelets (HELLP syndrome); heparin and methylprednisolone were started. On day 3, BP normalized, respiratory symptoms improved but abdominal symptoms persisted. Methylprednisolone was increased to 80 mg/day on day 8 when she had significant clinical response and was discharged on day 16. This case emphasizes that a morbid clinical course including liver infarction should be anticipated in patients with SLE and APS complicated with HELLP syndrome.

Little is known about the outcome of pregnancy in women with beta-thalassemia intermedia (TI). Over 10 years, maternal and neonatal outcomes of women with TI followed at a single thalassemia center were reviewed. Nine spontaneous pregnancies in five women with TI were studied. Six pregnancies resulted in live newborns; two were complicated by first-trimester abortions and one by an unexplained intrauterine fetal death at 36 weeks' gestation. Two patients had splenectomy before pregnancy: one required cesarean delivery and splenectomy at 31(2/7) weeks' gestation for worsening hemolytic anemia and thrombocytopenia and another had splenectomy 8 weeks postpartum for symptomatic hypersplenism. Two patients had received transfusions before pregnancy, and two required them for the first time during pregnancy and developed antibodies, which contributed to worsening of their anemia and repeated transfusions. The mean number of transfusions received during pregnancy was 8.0 +/- 5.2 units. The mean lowest hemoglobin level in pregnancy was 5.2 +/- 2.0 g/dl. Cesarean delivery was performed in 42.9% of cases. Mean gestational age at delivery was 36.7+/- 3.1 weeks with intrauterine growth restriction (IUGR) complicating 57.1% of cases. In conclusion, IUGR complicates more than half of pregnancies with TI. Transfusions are needed in most cases, even in non-transfusion-dependent patients. Postpartum splenectomy might be necessary in some patients.

Background: Magnesium sulfate continues to be widely used as a tocolytic agent despite a paucity of evidence supporting its use. Many practitioners use prolonged courses of magnesium sulfate, sometimes for months. This study was conducted to determine maternal and neonatal outcome of patients exposed to prolonged tocolytic magnesium sulfate., Methods: A retrospective review of maternal and neonatal charts (1995-2003) of pregnancies that received tocolytic magnesium sulfate. Cases who received magnesium sulfate >48 h (n=78) were compared to controls who received it < or =48 h (n=77) for maternal side effects and neonatal outcome., Results: Cases were more likely to be nulliparous (55.1% versus 37.7%, p=0.044), multiple gestations (33.3% versus 10.4%, p=0.001), and of lower gestational age (29.0+/-3.9 versus 30.5+/-3.8 weeks, p=0.017) compared to controls. The median magnesium sulfate infused was 154 (78-5,500) versus 54 (8-86) g (p<0.001) and the highest maternal magnesium level was 6.5+/-1.7 versus 5.6+/-1.9 mg/dl (p=0.002) in cases and controls, respectively. Cases were more likely to have > or =1 adverse side effect (30.8% versus 15.6%, p=0.045). The median neonatal magnesium level was significantly higher in cases (3.3 (1.4-7.2) versus 2.6 (1.1-5.2) mg/dl, p=0.016); however, neonatal mortality and other neonatal morbidity rates were similar in both groups. Abnormal bone mineralization was encountered in 3 neonates (cases)., Conclusions: Maternal morbidity rate is higher with prolonged intake of tocolytic magnesium sulfate compared to < or =48-h regimen. Despite similar neonatal morbidity and mortality rates, bone demineralization in the neonates may be encountered.

We present a 35-year-old previously healthy primigravida who presented at 26(4/7) weeks of gestation with pancytopenia and hepatosplenomegaly. She received 10 transfusions and delivered at 34(4/7) weeks of gestation by cesarean section. Two months later following splenectomy, she was diagnosed with malaria. Physicians should have a high index of suspicion for malaria in the context of splenomegaly and pancytopenia in pregnancy even in the absence of fever.

We present 2 unusual cases of prolapsed pedunculated submucous myomas. In 1 patient, the prolapsed part measured 12 cm, with a 64-cm intrauterine part. The second patient had prolapsed pedunculated submucous myoma, which subsequently retracted into the uterus. Gynecologists should be aware of unusual presentations of pedunculated submucous myoma to plan surgery.

Background: Fowler syndrome is characterized by hydranencephaly, brain stem and basal ganglion calcifications, a glomeruloid vasculopathy of the brain vessels, and a fetal akinesia deformation sequence with muscular hypoplasia. The natural progression of the ultrasonographic features of Fowler syndrome has never been described., Methods: Case report and review of the literature., Results: A primiparous woman with a negative ultrasound at 11 weeks of pregnancy was noted at 15 weeks to have fetal nuchal thickening, generalized skin edema, prominent lateral ventricles, akinesia with arthrogryposis, and pterygia. At 18 weeks, a cystic hygroma with facial edema, hypertelorism, and hydrocephaly were noted; the limb deformity was still evident. Within 1 week, the cystic hygroma regressed partially, but the hydrocephaly deteriorated., Conclusion: The multiple ultrasonographic features of Fowler syndrome may not occur simultaneously and their severity may vary with gestational age., (Copyright 2005 John Wiley & Sons, Ltd.)

Objective: To assess the impact of the Women's Health Initiative (WHI) study on gynecologists' attitudes regarding hormone therapy (HT)., Methods: Questionnaires were mailed to a random sample of Lebanese gynecologists (n=178). The questionnaires solicited practice patterns of HT for postmenopausal women and information provided while counseling before and after the WHI study. Descriptive statistical methods were used to evaluate the responses., Results: Questionnaires were returned by 140 physicians (78.7%), 93.6% of whom were aware of the WHI study. More than 90% of respondents routinely offered HT prior to the study. Of the 85.6% who used a combination of oral estrogen and progesterone (E/P), 40.0% used conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA). Around 67% of gynecologists reported a change in their therapeutic approach after the study. The main changes were: not offering CEE+MPA (27.3%), prescribing CEE+MPA to a select group of patients (37.5%), using other forms of HT (56.8%), or abandoning any form of HT (6.8%). Other practice modifications included a shift to the use of tibolone (18.2%) or alternative therapies (29.5%). Whereas 76.2% of physicians counseled their patients about a decreased risk of cardiovascular events with HT prior to WHI study, only 34.1% continued to do so after the study (p<0.001). The percentage of gynecologists that inform their patients of an increased risk of breast cancer on HT rose from 45.2 to 73.2% (p=0.018). Almost 51% of gynecologists allow their patients to participate in decision making regarding the type of HT, 42.4% would choose for their patients after counseling, while 6.8% of physicians do not counsel their patients in order not to confuse them., Conclusion: In a representative sample of Lebanese gynecologists, there was a significant change in physicians' attitudes towards HT following the publication of the WHI study.

Objective: The purpose of this study was to identify risk factors and complications of placenta previa-accreta (PA)., Study Design: Patients with placenta previa (n = 347) delivered over 20 years were reviewed, divided into PA (cases, n = 22) and no accreta (controls, n = 325), and compared., Results: Cases were older with a higher incidence of smoking and previous cesarean delivery (CS). Grandmultiparity, recurrent abortions, anterior/central placentae, and low socioeconomic status were similar. PA incidence increased with the number of previous CS: 1.9%, 15.6%, 23.5%, 29.4%, 33.3%, and 50.0% after 0, 1, 2, 3, 4, and 5 previous CS, respectively. Hypertensive disorders (odds ratio [OR] 13.9, 95%CI 2.1-91.2], P = .006), smoking (OR 3.4, 95%CI 1.1-10.2, P = .031) and previous CS (OR 7.9, 95%CI 1.7-37.4, P = .009) were selected by the stepwise logistic regression analysis as predictors of PA. Cases had a longer hospital stay, a higher estimated blood loss, and need for transfusion. Cesarean hysterectomy and hypogastric artery ligation were only performed in PA cases. The 2 groups had a similar delivery gestational age and neonatal outcome., Conclusion: Hypertensive disorders, smoking, and previous cesarean are risk factors for accreta in placenta previa patients. Placenta previa-accreta is associated with higher maternal morbidity, but similar neonatal outcome compared with patients with an isolated placenta previa.

Objective: To compare small-for-gestational-age (SGA) twins to appropriate-for-gestational-age (AGA) twins regarding preterm delivery (PTD)., Study Design: Retrospective review of maternal and neonatal records of live, nonanomalous twins > or = 25 weeks' gestation delivered in 1984-2000 in a tertiary care center. Pregnancies (N = 679) were divided into AGA/ AGA (n = 347), SGA-AGA (n = 191) and SGA/SGA (n = 141) groups using singleton growth curves. The PTD rate was compared and logistic regression analysis was done to study factors that influenced PTD at < or = 34 weeks. p < 0.05 was considered significant., Results: The PTD rate at < or = 34 weeks was AGA/AGA (38.6%), SGA-AGA (14.7%) and SGA/SGA (1.4%) (p < 0.001). On multiple logistic regression analysis, discordance significantly increased PTD (OR = 5.05, 2.47-10.31, p = 0.001), while smallness for gestational age significantly decreased PTD (OR = 0.095, 0.05-0.17, p < 0.001). The PTD rate increased directly with the increase in the relative overall weight of the twins., Conclusion: The PTD rate is higher in AGA twins as compared to SGA twins. The PTD rate is directly related to the overall weight of the twins.

Objective: To compare the neonatal outcome of vaginally delivered (VD) to that of abdominally delivered (CS) vertex-nonvertex (Vx/NVx) twins., Methods: Vx/NVx live nonanomalous twin gestations >or=25 weeks delivered from 1984 to 2000 were divided into two groups: VD (N=138), and CS (N=79). The outcome of the second twin was compared., Results: The vaginal delivery rate for the Vx/NVx twins was 63.6%. The median Apgar scores at 1 and 5 min, respectively, were significantly lower in VD [7 (0-9) and 9 (1-10)] compared to CS [8 (2-10) and 9 (2-10)]. The neonatal mortality was also higher in VD (109/1000 vs. 38/1000, p=0.040). Differences in the 1-min Apgar scores persisted when infants <1500 g were excluded. All other neonatal outcome variables studied including respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, trauma, seizures, and length of nursery stay were similar. On logistic regression analysis, vaginal delivery of Vx/NVx twins marginally increased low 5-min Apgar scores and neonatal deaths., Conclusion: Vaginal delivery in vertex-nonvertex twins was achieved in 63.6% of cases at the expense of a higher incidence of low 1- and 5-min Apgar scores and neonatal death.

Objective: This study was undertaken to evaluate the risks and pregnancy outcome in women with prosthetic heart valves on different anticoagulent regimens., Study Design: A retrospective chart review of 82 pregnancies in 33 women with mechanical valve prostheses at a tertiary referral center from 1987 to 2002. The main outcome measures were major maternal complications and perinatal outcome., Results: The valve replaced was mitral (60.6%), aortic (18.2%), and both (21.2%). Fifty-four pregnancies (65.9%) resulted in live births, 9 (11.0%) had stillbirths (all on warfarin), and 12 (14.6%) had spontaneous and 7 (8.5%) therapeutic abortions (all on warfarin). The rate of spontaneous abortion was highest in women on warfarin throughout pregnancy (P < .01). The live birth rate was higher in women on heparin compared with those on warfarin (P < .01), and in those on heparin/warfarin compared with warfarin alone (P < .01). There were no maternal deaths; however, 3 patients had mitral valve thrombosis (2 on heparin and 1 on warfarin) necessitating surgery in 1 patient and medical thrombolysis in 2 patients. Hemorrhagic complications occurred in 5 patients, 4 of whom required transfusion., Conclusion: No single anticoagulant regimen confers complete protection from thromboembolic phenomena in pregnancy. Despite a high maternal morbidity rate, the perinatal outcome is acceptable when pregnancy progresses beyond the first trimester.

The aim of our study was to compare the neonatal outcome of vaginally delivered breech-presenting twins (VD) to those delivered by cesarean (CS). Maternal and neonatal charts of all live, non-anomalous twins delivered at > or =25 weeks of gestation, in a single tertiary care center, over an 11-year period were reviewed. Of 517 twins delivered, 130 breech-presenting twins were analyzed. Thirty-five (26.9%) were delivered vaginally and 95 (73.1%) by cesarean. More patients presented in labor with advanced cervical dilation in the VD compared to the CS group. There was no difference in the incidence of respiratory distress syndrome, intraventricular hemorrhage, need for mechanical ventilation, length of nursery stay or neonatal mortality rate when twin A was compared in the two groups. However, one breech-presenting twin in the VD group had a traumatic delivery at 32 weeks of gestation that caused a spine fracture followed by immediate neonatal death. Although there seems to be no compromise in the immediate neonatal outcome of breech-presenting twins delivered vaginally compared to those delivered by cesarean, the case of head entrapment that led to intrapartum death is quite alarming. Based on our study, we cannot advocate normal vaginal delivery when twin A is non-vertex: cesarean seems to be a safer route of delivery.

Introduction: Osteitis pubis is a poorly understood and uncommon disorder rarely associated with spontaneous delivery., Case Report: We present a case consistent with osteitis pubis that followed a normal vaginal delivery and where symptoms developed earlier than ever previously reported., Discussion: The potential benefit of low molecular heparin is discussed.

Background: The purpose of this study was to compare delivery mode and neonatal outcome in breech pregnancies diagnosed antepartum (Dx group) with those diagnosed on admission for delivery or intrapartum (No-Dx group)., Methods: During an 11-year period, breech pregnancies >/=34 weeks' gestation with a live nonanomalous fetus were reviewed. The Dx group was matched for gestational age, parity, and maternal age to the No-Dx group (n = 256) and compared using the chi2-test, the Mc-Nemar test, and the Wilcoxon rank test. A p-value of < 0.05 was considered significant., Results: Breech type and birthweights were similar in the two groups. In the No-Dx group, 19.5% did not receive prenatal care. More patients in the No-Dx group were admitted with cervical dilation > 4 cm (39.4% vs. 27.0%, p = 0.004), whereas 17.1% of patients in the Dx group were admitted for elective cesarean delivery at term. There was a higher cesarean delivery rate in the Dx group (64.1% vs. 50.8%, p = 0.003), specifically for arrest disorders (15.2% vs. 6.9%, p = 0.008). The neonatal outcome in the two groups was similar regarding Apgar scores, intensive care nursery admission, need for mechanical ventilation, neonatal death, and length of nursery stay., Conclusions: Antepartum diagnosis of breech presentation decreases the threshold for cesarean delivery. Failure to diagnose breech antepartum does not compromise neonatal outcome.

Objective: The purpose of this study was to compare maternal and neonatal complications in spontaneous versus in vitro fertilization twins., Study Design: Twin gestations that were delivered from 1995 to 2000 were reviewed. Cases consisted of 56 in vitro fertilization twins, each of which was matched to two control mothers by age and parity. They were compared regarding various maternal and neonatal complications., Results: In vitro fertilization twins were more likely to have preterm labor compared with control twins, with no difference in the incidences of pregnancy-induced hypertension, gestational diabetes mellitus, placenta previa, or preterm premature rupture of membranes between the two groups. The cesarean delivery rate was significantly higher in cases of twins who were conceived by in vitro fertilization (76.8% vs 58.0%, P=.026), despite a similar rate of elective cesarean delivery and the incidence of nonvertex twin A in both groups. The preterm delivery rate was significantly higher (67.9% vs 41.1%, P=.002) and the gestational age was significantly lower (35+/-3 weeks vs 36+/-3 weeks, P=.043) in cases compared with control subjects. Both twins were, on the average, 230 g lighter in the in vitro fertilization group compared with the control group. However, intrauterine growth restriction was more frequent in the control group (36.6% vs 25%, P=.044). There was a significantly higher incidence of admission to the neonatal intensive care unit, respiratory distress syndrome, a need for mechanical ventilation, and pneumothorax in cases compared with control subjects., Conclusion: When compared with spontaneous twins, in vitro fertilization twins are more likely to be delivered by cesarean delivery and to have a higher incidence of preterm birth and prematurity-related respiratory complications with a longer nursery stay.

Objective: To study the perinatal outcome of vaginally delivered twins when twin B is more than 250 g larger than twin A., Study Design: Maternal and neonatal charts of live-born, nonanomalous twins, >25 weeks' gestation and vaginally delivered over a period of 17 years were reviewed. The results of this review were distributed among two groups: (1). those with twin B more than 250 g larger than twin A (DeltaBW>250) and (2). those where the difference was <250 g (DeltaBW<250). For vaginally delivered twin gestations, the perinatal outcome of twin B in the group DeltaBW>250 was compared to that of its co-twin, and to that of twin B in the group DeltaBW<250., Results: Of the 679 twin gestations reviewed, 138 (20.6%) were in the group DeltaBW>250, of whom 73 (52.9%) delivered vaginally despite malpresentation in 39.7%. The vaginally delivered twin pregnancies in the groups DeltaBW>250 (n=73) and DeltaBW<250 (n=303) had similar demographics, parity, presentation, gestational age at delivery, and duration of the first stage of labor. Discordant twins were more frequent in the group DeltaBW>250 (26.0 versus 9.5%, p=0.001). Twin B in the group DeltaBW<250 was smaller, with higher incidence of growth restriction, low 5 min Apgar score, and hyperbilirubinemia compared to twin B in the group DeltaBW>250. There was no difference in the incidence of intraventricular hemorrhage, seizures, sepsis, neonatal death, and median nursery stay. Except for a lower median Apgar score at 1 min in twin B and a longer median nursery stay in twin A, twins A and B in the group DeltaBW>250 were similar regarding all other neonatal outcome variables., Conclusions: When twin B is more than 250 g larger than A, and both are delivered vaginally, the perinatal outcome is similar to its co-twin as well as to that of twin B of all other vaginally delivered twins. That twin B is larger than A is not itself a contraindication to attempted vaginal delivery.

Background: Transient osteoporosis of the hip (TOH) is a rare clinical disorder of unknown etiology characterized by hip pain and functional disability that resolve spontaneously in 6-24 months., Objectives: To report 2 patients with TOH during pregnancy who had rapid resolution of their illness with the use of calcitonin. To review the literature on TOH with special emphasis on its treatment., Methods: A MEDLINE search of studies published from 1966 to 2002 was performed to review treatment options for TOH and their effect on the natural history of the disease., Results: Our 2 patients developed hip pain during pregnancy with classical changes of TOH on MRI. Both patients received calcitonin, 1 during pregnancy and 1 postpartum with resolution of their symptoms within 6 to 9 weeks. Previous reports in the literature of treatment of TOH showed that antiresorptive agents (bisphosphonates and calcitonin) had shortened the duration of the illness compared with the natural history of the disease., Conclusions: TOH is an under-recognized entity associated with pain and disability. The use of antiresorptive agents may be of help in reducing the duration of the disease., Relevance: To increase the recognition of TOH and to consider therapeutic interventions to shorten the duration of the disease., (Copyright 2003 Elsevier Inc. All rights reserved.)

Thrombolytic therapy has gained popularity as an alternative to surgery in the treatment of prosthetic heart valve thrombosis. We report on the sequential use of streptokinase followed by recombinant tissue type plasminogen activator (rt-PA) for the treatment of a thrombosed prosthetic mitral valve in a pregnant woman at 26 weeks of gestation. Although thrombolysis was unsuccessful, the patient carried till 34 weeks of gestation and delivered by cesarean section a live newborn with an uneventful postpartum course. Based on our case and on what has been previously described in the literature, thrombolytic therapy should be considered as an option in the management of hemodynamically unstable pregnant patients with prosthetic valve thrombosis. When a single agent proves insufficient, combination therapy should be considered as it might provide hemodynamic stability and improvement in cardiac function that would allow patients at a high surgical risk to carry their pregnancy to viability.

The aim of the study was to compare a variety of neonatal outcome variables of growth concordant twin gestations (CT) to that of growth discordant twins (DT). Maternal and neonatal charts of live, non-anomalous twins > 25 weeks' gestation from 1984-2000 with no evidence of twin-twin transfusion syndrome were reviewed for several variables. DT occurred in (N = 81) 11.9% of all twin pregnancies. In 61.7% of DT, twin B was the smaller of the twins. There was no difference in maternal age, admission indications, or antepartum complications between both groups. DT had a significantly higher incidence of growth restriction compared to CT (88.9% vs 43.5%, p < 0.001). More mothers of DT required oxytocin (37.0% vs 26.3%, p = 0.024); however, cesarean delivery rate and indications were similar in both groups. A similar percentage of infants had AS < 4 at 1 min and AS < 7 at 5 min in both groups. There was no difference between the 2 groups in neonatal complications including: trauma, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, pneumonia, seizures, or neonatal mortality. However, DT had a significantly higher incidence of hyperbilirubinemia, need for mechanical ventilation and a longer nursery stay. The neonatal outcome of growth discordant twins is worse than that of concordant twins even in pregnancies uncomplicated by twin-twin transfusion syndrome or congenital anomalies.

Objective: To compare the perinatal outcome of the presenting twin to its co-twin., Study Design: All live nonanomalous twin gestations delivered at >25 weeks' gestation between 1984 and 1994 (N=461) were identified. Twin A was compared to twin B regarding the following variables: presentation, Apgar score (AS) <4 at 1 minute, AS <7 at 5 minutes, birth weight, gender, traumatic delivery, meconium-stained amniotic fluid, cord prolapse, need for mechanical ventilation, intraventricular hemorrhage, respiratory distress syndrome, sepsis, seizures, perinatal mortality, and length of nursery stay., Results: Except for differences in presentation, the perinatal outcome was similar in both twins regarding variables studied. This continued to hold true after subdividing according to mode of delivery, when infants with birth weight < or = 1500 g were considered separately, and when vaginally delivered cephalic twin A was compared to the noncephalic co-twin. However, differences in some outcome variables became evident when pregnancies with only one affected member were analyzed separately., Conclusions: When all twin pairs are considered, the outcome of the second-born twin is similar to that of the first-born regardless of the mode of delivery, presentation, or birth weight < or = 1500 g. If only those twin pairs with one affected and one unaffected twin are considered, it becomes apparent that the presenting twin is at increased risk for infection-related morbidities whereas the co-twin is at risk for other complications.

Uterine rupture is a serious and often tragic complication that is life threatening to both mother and child. It occurs at a frequency of around 1% in patients with a previously scarred uterus. Rupture of an unscarred uterus is an unexpected and devastating complication of pregnancy. With the increased use of misoprostol as a labor-inducing agent, cases of rupture of an unscarred uterus following its use have been published in the literature. We report a case of uterine rupture in a multigravid woman with an intrauterine fetal death at 29 weeks' gestation whose labor was induced with misoprostol. A review of all cases of uterine rupture with misoprostol induction is also included. Excessive doses of misoprostol should be used with extreme caution in multiparous women and in patients with a previously scarred uterus even in the context of intrauterine fetal death or termination of pregnancy.

Background: Failure of ovulation has occasionally been reported following the administration of conventionally recommended doses of exogenous human chorionic gonadotropins., Case: A 25-year-old nulliparous woman with polycystic ovary syndrome underwent ovulation induction for primary infertility. Following successful ovarian stimulation, she failed to ovulate during two consecutive cycles in response to human chorionic gonadotropin doses of 5,000 and 10,000 IU. When challenged with a higher than conventional dose (15,000 IU) on the third cycle, she ovulated and conceived., Conclusion: Conventional doses of exogenous human chorionic gonadotropins occasionally fail to complete the ovulatory process in some women. Women with polycystic ovary syndrome appear to be particularly susceptible. Routine documentation of ovulation and individualization of the dose of exogenous human chorionic gonadotropins could therefore prove to be useful in some of these women in order to achieve the best treatment outcome.

Objective: To evaluate the usefulness of maternal plasma zinc-coproporphyrin (ZCP) level as a marker for intrauterine passage of meconium., Methods: A pilot study consisting of 10 pregnancies with meconium-stained amniotic fluid and 10 pregnancies with clear amniotic fluid was used. The corresponding plasma and amniotic fluid levels of ZCP were measured using spectrofluorometry. ZCP levels in plasma and amniotic fluid were compared between the two groups and the relation between plasma and amniotic fluid ZCP levels in the clear and meconium-stained groups was assessed using Spearman rank-order correlation., Results: Mean amniotic fluid ZCP was significantly higher in the meconium-stained amniotic fluid as compared to the clear amniotic fluid group. Although mean plasma ZCP levels were higher in the meconium-stained amniotic fluid group, this difference was not statistically significant. There was no significant correlation between plasma ZCP levels and amniotic fluid ZCP, but we could categorize patients according to plasma ZCP levels into four categories with different risks for having meconium-stained amniotic fluid., Conclusions: Plasma ZCP might be a promising test for prediction of intrauterine passage of meconium in high-risk patients if confirmed by larger studies. The implications of this prediction on management remain unknown.

Pyloric atresia occurs in one in a million births and usually occurs sporadically. We report a family with nine affected members and review the literature for all reported familial cases. The article stresses the possibility of recurrence of pyloric atresia in the progeny of consanguinous parents, with an emphasis on prenatal diagnosis and counseling, diagnosis of the entity in neonates, associated conditions, and prognosis in sporadic and familial cases. A high index of suspicion in affected families contributes to the early diagnosis and treatment with a great impact on outcome.

Objective: To identify potential predictors of meconium aspiration syndrome (MAS) in pregnancies complicated by moderate or thick meconium-stained amniotic fluid (AF)., Methods: In the period 1990-1993, 937 vertex singleton pregnancies with moderate or thick meconium-stained AF were delivered; of these, 39 neonates developed MAS and 898 did not. The two groups were compared retrospectively according to maternal findings, pregnancy outcome, and neonatal complications, using univariate analysis (P < .05 considered significant) and stepwise multiple logistic regression analysis to identify independent significant factors for prediction of MAS and to calculate odds ratios (OR) and 95% confidence intervals., Results: The two groups had a similar mean gestational age at delivery and birth weight. They also had similar incidences of post-dates pregnancies, small and large for gestational age infants, and amnioinfusion use. Univariate analysis identified significant differences between the two groups in 13 variables, two of which were excluded from logistic analysis because of inadequate data. Logistic regression analysis identified only six variables with independent, statistically significant effects on MAS: admission for induction with nonreassuring fetal heart tracing (OR 6.9), need for endotracheal intubation and suctioning below the vocal cords (OR 4.9), 1-minute Apgar score of 4 or less (OR 3.1), present cesarean delivery (OR 3.0), and previous cesarean delivery (OR 2.5). Cigarette smoking was associated with a lower risk for MAS (OR 0.07). The presence of at least one of the five risk factors had a sensitivity of 92%, a specificity of 56%, a positive predictive value of 8%, and a negative predictive value of 99% for MAS., Conclusion: Considering the high negative predictive value of the test, infants without any risk factors will not develop MAS and thus can be safely allowed to room with their mothers. Furthermore, this model helps to identify infants who may benefit from 24-hour observation and in counseling women about the neonatal risk for developing MAS.

Eclampsia is a life-threatening emergency that continues to be a major cause of serious maternal morbidity and is still the leading cause of maternal mortality worldwide. Complicated and mismanaged cases are responsible for many maternal deaths. Perinatal morbidity and mortality is also high if eclampsia occurs in the antepartum period. This article reviews eclampsia management with special emphasis on puerperal eclampsia. The complications associated with eclampsia are also discussed.