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Background Acute appendicitis is the most common surgical emergency in pregnancy. The purpose of this study is to investigate the clinical presentation, management and outcome in patients who underwent appendectomy during pregnancy. Material and methods The case records of 56 women who underwent appendectomy during pregnancy between January 1985 and December 1997 were reviewed and analyzed. Results The incidence of appendicitis in pregnancy was one in 766 births. The preoperative diagnosis was correct in 75% of the cases. Uterine contractions and a history of diffuse or periumbilical pain migrating to the right lower abdominal quadrant were significantly more frequent among women with appendicitis compared to those patients where the appendectomy revealed a normal appendices. Abdominal pain, nausea, vomiting, leukocyte count, CRP and body temperature were not helpful in establishing the correct diagnosis. There was no maternal morbidity related to the appendectomy. Pregnancy complications were found to be considerable: 4/12 (33%) who underwent appendectomy for appendicitis during the first trimester aborted spontaneously. Second trimester appendectomy for appendicitis was followed by premature delivery in 4/28 (14%). However, no pregnancy complications were observed following third trimester appendectomy for appendicitis. We found no increase in pregnancy complications in cases with perforated appendicitis. Conclusion Appendicitis in pregnancy should be suspected when a pregnant woman complains of new abdominal pain. No laboratory finding was found to be diagnostic for acute appendicitis during pregnancy. Considerable fetal loss was found after appendectomy during pregnancy in the first and second trimester. No increase in pregnancy complications in cases with perforated appendicitis was observed. The combination of symptoms and clinical judgement is still vital in deciding which patient needs surgical treatment. Based on the results in the present study we recommend prophylactic antibiotic treatment in all laparotomies during pregnancy when appendicitis is suspected.

Objective To evaluate the predictive values of fetal fibronectin, bacterial vaginosis, endotoxin and cervical length for preterm birth (< 35 and < 37 weeks) and neonatal morbidity in twin pregnancies. Participants One–hundred and twenty–one women with twin pregnancies recruited into a prospective longitudinal study at three antenatal clinics in the southwest of Sweden. Methods Cervical or vaginal fluid was sampled and determined for fetal fibronectin ( 0.05 μg/mL was used as cutoff), endotoxin ( 100 pg/mL) and bacterial vaginosis (presence of clue cells) at two week intervals from 24 to 34 weeks of gestation. The cervical length was measured with transvaginal sonography at the same time intervals. Main outcome measures Occurrence of preterm birth (< 35 and < 37 weeks of gestation) and neonatal morbidity. Results All positive fetal fibronectin samples obtained at screening between 24 and 34 weeks predicted birth < 35 weeks (RR 18.0; 95% CI2.2–145.9). A positive fetal fibronectin at 28 weeks of gestation predicted delivery < 35 weeks (RR 6.3; 95% CI 2.6–15.1) with a sensitivity, specificity, positive and negative predictive value of 50.0, 92.0, 62.5 and 87.3%, respectively. An independent association between fetal fibronectin at 28 weeks and preterm birth (< 35 weeks) was verified with logistic regression (P= 0.03). A positive fetal fibronectin at 28 weeks of gestation predicted neonatal morbidity (RR 5.1; 95% CI 2.4–11.0) and a longer period of care at the neonatal intensive care unit. The predictive power of cervical sonography was generally low but cervical length (cutoff 33 mm) measured at 28 weeks of gestation was significantly associated with birth < 37 weeks (RR 2.2; 95% CI 1.1–4.2). The presence of endotoxin correlated to bacterial vaginosis, but these tests were not significantly related to preterm birth or neonatal morbidity. Conclusions Fetal fibronectin predicted preterm birth and neonatal morbidity in twin pregnancies. The predictive value of cervical length determinations was low. Endotoxin and bacterial vaginosis had no predictive power for preterm delivery in this study.

This nationwide study examined the annual changes in cesarean section rates in relation to perinatal mortality, the condition of the newborn at birth, and different indications for the procedure in Sweden. Since 1973 all obstetric units have sent copies of medical birth registration forms for newborns to the National Board of Health and Welfare. Information about the cesarean section rate, indications for the surgery, Apgar scores, and perinatal mortality between 1973 and 1990 was obtained from this data base. The cesarean section rate increased from 5 percent in 1973 to 12.3 percent in 1983, and thereafter declined steadily to 10.84 percent in 1990. Perinatal mortality was halved from 14.2 to 6.3 per 1000 live births, and the number of newborns with low Apgar scores (< 4 at 1 min and/or < 7 at 5 min) decreased from 20 to 14 per 1000 live births. We conclude that it is possible to lower the cesarean section rate on a nationwide basis without increasing risks to newborn infants.

A prospective study was undertaken to evaluate the risk of uterine rupture or dehiscence after cesarean section. During the 10 years of the study, 24,644 patients were delivered of infants. Of these women, 2036 (8.3%) had previously undergone cesarean section. A trial of labor was allowed in 1008 of these patients, and 92.2% were delivered vaginally. The incidence of uterine rupture in this trial of labor group was 0.6%, compared with 0.4% in the total group. Cesarean section scar rupture caused no serious complications in either the mothers or the offspring in the trial of labor group. Uterine rupture in this group was not associated with use of oxytocin or epidural analgesia. Patients with lower-segment scar rupture had no history of puerperal pyrexia. The incidence of uterine dehiscence was 4%. In summary, the risk of uterine rupture in patients who have previously undergone cesarean section but are allowed a trial of labor is low and not associated with serious complications. Vaginal delivery is therefore considered the safest route of delivery in these patients. (Am J Obstet Gynecol 1989;160:569-73.)

The benefits of X-ray pelvimetry and electronic monitoring of fetal heart rate and intra-uterine pressure were studied prospectively in order to predict the likelihood of a successful vaginal birth after previous cesarean section (CS). In 1982, a total of 369 parturients (7% of all deliveries) who had previously undergone CS were studied. Trial of labor (TL) was allowed in 160 cases (43.4%) and planned repeat CS was performed in 209 patients (56.6%). Patients in the TL group were compared with a matched control group. One hundred and fifty patients (94%) in the TL group gave birth by the vaginal route. There were no differences in the duration of the first and second stage of labor, duration of ruptured membranes (ROM), maternal blood loss or the incidence of CS and vacuum extraction between the TL group and the control group. Rates of low Apgar score (less than 7) at 1 and 5 min were the same in both groups. Intensive fetal monitoring during the course of labor, together with X-ray pelvimetry in selected cases, markedly reduced the incidence of acute repeat CS with no change in the overall rate of successful vaginal delivery compared with our previous results.

During a 3-year period, 1,319 women delivered of their infants by cesarean section were prospectively studied to determine the type and rate of postcesarean complications and to identify risk factors which predispose to postoperative morbidity. The overall complication rate was 14.5% and the most common complication was infection (13.3%), in particular, endometritis (6.6%), urinary tract infection (3.1%), and wound infection (1.6%). A lower complication rate was seen in elective operations (4.7%) compared with emergency operations (24.2%). Four significant factors that predispose to postoperative morbidity were identified: duration of ruptured membranes prior to operation (p less than 0.001), duration of labor prior to operation (p less than 0.001), anemia (p less than 0.01), and obesity (p less than 0.01). Patients with a combination of risk factors had an increased complication rate, in some cases as high as 91%. The clinical relevance of these findings in trying to decide possible ways to reduce the complication rate by changing the delivery routines is discussed.

During the years 1973-79, 704732 births took place in Sweden and 63 075 cesarean sections (CS) were performed. Within the study period there were 20 maternal deaths associated with delivery or puerperium. Thirteen of these patients were delivered by CS and 7 by the vaginal route. The hospital records of the 13 deaths associated with CS were closely analysed and it was found that 5 of the patients were critically ill before the beginning of surgery, and the CS per se was not responsible for these deaths. The 8 remaining maternal deaths gave a corrected (cesarean-attributed) maternal mortality rate of 12.7/100 000 cesarean deliveries. For vaginal deliveries the mortality rate was 1.1/100 000 deliveries. Thus, the risk of maternal death from CS in Sweden was twelve times as high as that from vaginal parturition. All maternal deaths except one, associated with CS, occurred after emergency operation. No deaths were ascribable to anesthesia complications. The most common causes of death after CS were pulmonary embolism, amniotic fluid embolism, coagulopathy and peritonitis. Time trends in the causes of maternal death in Sweden are discussed.

Placenta percreta is a very uncommon but serious complication of pregnancy. A case of spontaneous rupture of the uterus in the third trimester of pregnancy, due to placenta percreta, is described. The etiology of placenta percreta and therapeutic aspects of this obstetric complication are discussed.

A prospective study was conducted to determine the risk of placenta previa and unexplained antepartum hemorrhage after a previous cesarean section (CS). Of a total of 24,644 patients, 81 (0.33%) had a placenta previa which demanded abdominal delivery. The risk of placenta previa was 0.25% with an unscarred uterus and 1.22% in patients with one or more previous CS (the difference was statistically significant p less than 0.001). The corresponding figures for unexplained antepartum hemorrhage were 0.40% and 3.81%, respectively (p less than 0.001). Patients presenting with a placenta previa and a scarred uterus had a 16% risk of undergoing cesarean hysterectomy because of placenta accreta and severe hemorrhage compared to 3.6% in patients with placenta previa and an unscarred uterus. In conclusion, cesarean deliveries predispose to placenta previa, placenta accreta and antepartum hemorrhage during subsequent pregnancies. This relationship has to be considered in the cost-benefit equation for decision of route of delivery.

Over a 3-year period all infants (n = 7401) born at the Department of Obstetrics and Gynecology, Central Hospital, Boras Sweden, were studied for signs of respiratory disease. For all infants who developed signs of respiratory disorders the mode of delivery and the type of anesthesia used in cesarean section (CS) were analysed. The incidence of respiratory disorders in the whole material was 3.0% (n = 220) and the mortality rate for these disorders was 0.24%. There was a significantly higher incidence (p less than 0.001) of respiratory disorders in infants weighing greater than or equal to 2500 g born by CS vis-a-vis infants born by the vaginal route. The group born by elective CS under maternal general anesthesia had a higher (p less than 0.05) rate of respiratory disorders than those born by elective CS under maternal epidural anesthesia. It is concluded that the risk of respiratory disorders in infants delivered by CS is related to the mode of delivery per se. Consequently, a reduction in the proportion of such interventions ought to reduce the overall number of infants developing respiratory disease, as indicated in the present study.

The neuroprotective effect of kynurenic acid, an unspecific antagonist of excitatory amino acid receptors, was evaluated in a model of hypoxic-ischemia in neonatal rats. One-week-old rats were subjected to ligation of the left carotid artery and exposure to 7.7% O2/92.3% N2 for 2 h. Kynurenic acid (300 mg/kg) was administered i.p. immediately after the period of hypoxic-ischemia in one group (n = 32) and compared with saline-treated (n = 27). After 2 weeks the rats were sacrificed and the brain damage evaluated by comparing the weight of the lesioned and unlesioned hemispheres. In rats receiving kynurenic acid the reduction in weight of the lesioned hemisphere was 25.4 +/- 3.3% as compared to 37.8 +/- 3.6% in saline-treated controls (P less than 0.001). The results suggest that excitatory amino acids are involved in the development of postischemic damage in the immature brain.

The incidence of surgical complications associated with cesarean section (CS) was studied prospectively in 1319 patients undergoing CS during the years 1978, 1979 and 1980 (18% of all deliveries). The overall complication rate was 11.6% (9.5% patients with minor complications and 2.1% with major complications). The complication rate for emergency operations was 18.9% and for elective CS, 4.2%--a highly significant difference. (p less than 0.001). Six risk factors were associated with the occurrence of surgical complications in emergency cases: Station of the presenting part of the fetus in relation to the spinal plane (p less than 0.001), labor prior to surgery (p less than 0.001), low gestational age (less than 32 weeks) (p less than 0.001), rupture of fetal membranes (with labor) prior to surgery (p less than 0.01), previous CS (p less than 0.01), and skill of the operator (p less than 0.05). However, no such risk factors were found in the elective group. The clinical relevance of these findings is summarized in two conclusions. Firstly, the proportion of emergency operations needs to be reduced, either in favor of elective procedures, or by allowing more patients to give birth by the vaginal route. Secondly, emergency CS requires great skill on the part of the surgeon, and should therefore not be entrusted to young, inexperienced obstetricians.

The course of pregnancies subsequent to cesarean section (CS) was studied. During the years 1970-72, 543 women were delivered by CS at Borås Central Hospital. A questionnaire was sent to all 543 during the autumn of 1976 and the spring of 1977. The questions concerned further conceptions and the outcome of all subsequent pregnancies after CS. Of the 440 (81%) women who answered the questionnaire, 244 (55.5%) became pregnant, the total number of subsequent pregnancies being 306. The incidence of spontaneous abortion, extra-uterine pregnancy and legal abortion was not significantly higher than the corresponding rate for the total material for our department during the same period. Among the 215 women who completed a new pregnancy, an elective CS was performed in 81 cases (38%). Trial of labor occurred in 143 patients, 91 of whom (68%) gave birth per vaginam , while 43 (32%) were delivered by acute CS. In nearly half of the acute CS cases the indication was a narrow pelvis not detected until labor had started. This indicates that roentgenologic pelvimetry should be considered in certain cases, when planning delivery after a previous CS.