The purpose of this analysis was to study the relationship between an increasing cesarean delivery rate and term neonatal seizures and peripartum deaths. This was a retrospective analysis of annually collated institut...The purpose of this analysis was to study the relationship between an increasing cesarean delivery rate and term neonatal seizures and peripartum deaths. This was a retrospective analysis of annually collated institutional data on cesarean delivery and perinatal outcome. Of 77,350 women who delivered at 37 weeks’ gestation or more through 12 years (1989 to 2000), the cesarean rate increased from 6.9% to 15.1% ; perinatal mortality at term, average 3.1/1000, was unchanged. The cesarean rate for nulliparas doubled from 8.3% to 17.5% . The overall neonatal term seizure rate (overall 1.3/1000; and for nulliparas 2.5/1000) did not change. The overall peripartum death rate (0.8/1000) was unchanged, although the rate for nulliparas (1.5/1000) showed a significant decline. Overall seizure rate in nulliparas was 5- fold higher than in multiparas; presumed intra- partum asphyxia was associated with 84% of both seizures and neonatal deaths in nulliparas. Among 2547 prelabor cesarean deliveries, there were no peripartum deaths and one neonatal seizure, an incidence comparable with that in multiparas who labored. Despite a greater than 2- fold rise in cesarean section rate, the seizure rate and overall peripartum death rate at term did not alter significantly. Neonatal seizures occurred 5 times more often following first deliveries.展开更多
OBJECTIVE: To estimate the risk of survival of unaffected cofetuses of anomalous triplets. METHODS: Retrospective cohort study of triplets delivered in the United States from 1995 through 1998. Four triplet clusters w...OBJECTIVE: To estimate the risk of survival of unaffected cofetuses of anomalous triplets. METHODS: Retrospective cohort study of triplets delivered in the United States from 1995 through 1998. Four triplet clusters were identified: cluster A (all members anomaly- free); cluster B (1 anomalous member); cluster C (2 anomalous members), and cluster D (all 3 members anomalous). We compared the risk for stillbirth and infant mortality among nonanomalous fetuses in clusters A, B, and C after adjusting for intracluster correlations. RESULTS: A total of 7,560 triplet clusters (98.9% ) were analyzed after excluding cluster D (1.1% ). The total still- birth rate was 20.9 (cluster A), 61.0 (cluster B), and 81.1 (cluster C) per 1,000 (P for trend <.001), and infant mortality rate was 56.4 (cluster A), 108.8 (cluster B), and 196.1 (cluster C) per 1,000 (P for trend <.001). Using cluster A as the referent category, the risk for stillbirth among anomaly- free clustermates climbed with increase in the number of siblings with anomalies in a dose- response pattern (adjusted odds ratio, 95% confidence interval 1.5, 0.7- 3.1, for cluster B; and 5.2, 1.4- 18.8, for cluster C; P for trend = .03). For infant mortality, the only rise in risk was in cluster C (3.3, 1.6- 6.7), whereas cluster B showed comparable risk with the referent category (0.8, 0.5- 1.4; P for trend >.05). CON- CLUSION: The presence of anomalous fetuses compromises the survival of normal cotriplets. These findings could prove useful for counseling affected parents and highlight the need for follow- up of normal coinfants of anomalous fetuses.展开更多
Aim: To study the health and development of children in a developing and low- income country. Methods: The health and development of children in Lahore in nor thern Pakistan have been studied since 1981 in a collabora...Aim: To study the health and development of children in a developing and low- income country. Methods: The health and development of children in Lahore in nor thern Pakistan have been studied since 1981 in a collaborative project between P akistani and Swedish university institutions and the Swedish Agency for Research Cooperation with Developing Countries (SAREC). The study described in this pape r comprised four different areas in Lahore with different degrees of urbanizatio n and different social conditions. All pregnancies in the four areas were regist ered during the period March 1984 to July 1986 and were followed up from the 5th month of pregnancy. All 1476 children born after 1 September 1984 were followed up from birth to 12 y of age. Results: The perinatal mortality in the whole mat erial was 5.4%. It was highest in the periurban slum (7.5%) and lowest in the upper-middle class cohort (3.3%). Overall infant mortality was 10%. It was hi ghest (14%) in the periurban slum and lowest (2%) in the upper-middle class g roup. Overall incidence of serious birth defects was 5%. It was highest in the periurban slum community (7%) and lowest in the upper-middle class cohort (3% ). The overall cumulative incidence of severe mental retardation per 100 live bi rths was 1.1. It was highest (2.2) in the periurban slum and lowest (0.4) in the upper-middle class group. The overall prevalence of mild mental retardation am ong 6-10-y-old children was 6.2 per 100. It was highest in the periurban slum (10.5) and lowest (1.3 per 100) in the upper-middle class group. Poverty, maln utrition, birth trauma and consanguinity were common causes of infant mortality and mental retardation in Lahore, Pakistan. Conclusion: Preventive measures with provision of obstetric and health services, services for genetic information an d risk evaluation, vaccination programmes and identification of children with re tarded development for specific stimulation and habilitation measures, e.g. orga nized play activities, are important in developing and low-income countries.展开更多
Objective: The study was aimed to define obstetric factors associated with shoulder dystocia. Methods: A population-based study comparing all singleton, vertex, term deliveries with shoulder dystocia with deliveries w...Objective: The study was aimed to define obstetric factors associated with shoulder dystocia. Methods: A population-based study comparing all singleton, vertex, term deliveries with shoulder dystocia with deliveries without shoulder dystocia was performed. Statistical analysis was done using multiple logistic regression analysis. Results: Shoulder dystocia complicated 0.2%(n=245) of all deliveries included in the study(n=107965). Independent risk factors for shoulder dystocia in a multivariable analysis were birth-weight ≥4000 g(OR=24.3; 95%CI 18.5-31.8), vacuum delivery(OR=5.7, 95%CI 3.4-9.5), diabetes mellitus(OR=1.7, 95%CI 1.2-2.5) and lack of prenatal care(OR=1.5, 95%CI 1.1-2.3). A significant linear association was found between birth-weight and shoulder dystocia, using the Mantel-Haenszel procedure. Pregnancies complicated with shoulder dystocia had higher rates of third-degree perineal tears as compared to the comparison group (0.8%versus 0.1%; P < 0.001). Similarly, perinatal mortality was higher among newborns delivered after shoulder dystocia as compared to the comparison group(3.7%versus 0.5%; OR=7.4, 95%CI 3.5-14.9, P< 0.001). In addition, these newborns had higher rates of Apgar scores lower than 7 at 1 and 5 min as compared to newborns delivered without shoulder dystocia(29.7%versus 3.0%; OR=13.8, 95%CI 10.3-18.4, P< 0.001 and 2.1%versus 0.3%; OR=7.2, 95%CI 2.8-18.1, P< 0.001, respectively). Combining risk factors such as large for gestational age, diabetes mellitus and vacuum delivery increased the risk for shoulder dystocia to 6.8%(OR=32.6, 95%CI 10.1-105.8, P< 0.001). Conclusions: Independent factors associated with shoulder dystocia were birth-weight ≥4000 g, vacuum delivery, diabetes mellitus and lack of prenatal care.展开更多
Objective: To evaluate the performance of abdominal palpation as a screening test for intrauterine growth retardation (IUGR) in a low risk population, under standard practice conditions. Study design: Population based...Objective: To evaluate the performance of abdominal palpation as a screening test for intrauterine growth retardation (IUGR) in a low risk population, under standard practice conditions. Study design: Population based observational study of 6318 consecutive low risk singleton pregnancies. The Dutch obstetric system distinguishes low from high risk pregnancies. In the low risk group abdominal palpation as a screening test is performed by midwives. If a complication, like IUGR, during prenatal care is assessed, the women is referred to a consulted obstetrician. Ultrasound is performed by the consulted obstetrician. In case of sustained suspicion the women is selected as high risk. Outcome parameters: severe small for gestational age (SGA) birthweight below 2.3rd centile, all SGA birthweight below 10th centile, operative delivery, neonatal morbidity and perinatal mortality. Screening value of abdominal palpation, abdominal palpation combined with ultrasound, and the performance of high risk selection was assessed by conventional performance measures. Results: Abdominal palpation as a screening test for IUGR is of limited value: the observed sensitivities were 28%for severe SGA and 21%for SGA p≤10, respectively. After ultrasound in case of sustained suspicion, the sensitivity in detection of severe SGA was 25%and positive predictive value (PPV) 16%. In detection of SGA p≤10 sensitivity was 15%and PPV 55%, which means 45%were false positives. The sensitivity of the Dutch obstetric system in selection of high risk pregnancies in detection of severe SGA was 53%, in detection of SGA p≤10 was 37%. Perinatal mortality was 0.9%(57/6318) and 32%of these cases were SGA. Six cases of fetal death were unrecognised during prenatal care (0.09%) and seem preventable. The prevalence of a 5 min Apgar Score≤7 was significantly higher in the SGA infants if SGA was defined as p≤10. Conclusions: The diagnostic performance of abdominal palpation as a screening test for IUGR detection in a low risk population is disappointing. However, various stratagems such as routine ultrasound do not improve detection rate or perinatal morbidity and mortality.展开更多
Objective: To evaluate the pregnancy outcome in patients with abnormal uterine artery Doppler flow velocity waveforms (FVWs) at 19-21 weeks, which were subsequently normal by 24-26 weeks, and to study the effect of ...Objective: To evaluate the pregnancy outcome in patients with abnormal uterine artery Doppler flow velocity waveforms (FVWs) at 19-21 weeks, which were subsequently normal by 24-26 weeks, and to study the effect of lowdose aspirin on these waveforms. Design: The study group consisted of 49 patients who had abnormal uterine artery flow velocity waveforms (FVWs) at 19-21 weeks. These women were initially commenced on 100 mg slowrelease aspirin at 20 weeks, which was discontinued at the followup visit, after confirming normal uterine artery Doppler FVW. The control group consisted of 730 patients with normal uterine artery Doppler waveforms at 19-21 weeks. The main outcome measures were: small for gestational age (SGA) < 10th centile, preeclampsia, placental abruption, and perinatal mortality rate (PMR). Results: When compared with the control group, the study group had an increased risk of placental abruption (2%versus 0.27%, P=0.05) 95%Confidence Intervals CI=0.01-0.13), low birth weight (3087 versus 3383 gm, P=0.0003), SGA <10th centile (32.7%versus 11.9%, P≤0.0001, CI=0.14-0.5), and PMR (2/49 versus 1/730, P < 0.0001, CI=0.003-0.37). Conclusions: These findings suggest that delayed normalisation of the uterine artery Doppler waveform is not a benign phenomenon. This subgroup of patients is at increased risk of pregnancy complications, in particular SGA and placental abruption. These patients could benefit from serial ultrasound scans in the third trimester to evaluate fetal growth and wellbeing. Aspirin does not appear to play a major part in modifying uterine artery blood flow.展开更多
文摘The purpose of this analysis was to study the relationship between an increasing cesarean delivery rate and term neonatal seizures and peripartum deaths. This was a retrospective analysis of annually collated institutional data on cesarean delivery and perinatal outcome. Of 77,350 women who delivered at 37 weeks’ gestation or more through 12 years (1989 to 2000), the cesarean rate increased from 6.9% to 15.1% ; perinatal mortality at term, average 3.1/1000, was unchanged. The cesarean rate for nulliparas doubled from 8.3% to 17.5% . The overall neonatal term seizure rate (overall 1.3/1000; and for nulliparas 2.5/1000) did not change. The overall peripartum death rate (0.8/1000) was unchanged, although the rate for nulliparas (1.5/1000) showed a significant decline. Overall seizure rate in nulliparas was 5- fold higher than in multiparas; presumed intra- partum asphyxia was associated with 84% of both seizures and neonatal deaths in nulliparas. Among 2547 prelabor cesarean deliveries, there were no peripartum deaths and one neonatal seizure, an incidence comparable with that in multiparas who labored. Despite a greater than 2- fold rise in cesarean section rate, the seizure rate and overall peripartum death rate at term did not alter significantly. Neonatal seizures occurred 5 times more often following first deliveries.
文摘OBJECTIVE: To estimate the risk of survival of unaffected cofetuses of anomalous triplets. METHODS: Retrospective cohort study of triplets delivered in the United States from 1995 through 1998. Four triplet clusters were identified: cluster A (all members anomaly- free); cluster B (1 anomalous member); cluster C (2 anomalous members), and cluster D (all 3 members anomalous). We compared the risk for stillbirth and infant mortality among nonanomalous fetuses in clusters A, B, and C after adjusting for intracluster correlations. RESULTS: A total of 7,560 triplet clusters (98.9% ) were analyzed after excluding cluster D (1.1% ). The total still- birth rate was 20.9 (cluster A), 61.0 (cluster B), and 81.1 (cluster C) per 1,000 (P for trend <.001), and infant mortality rate was 56.4 (cluster A), 108.8 (cluster B), and 196.1 (cluster C) per 1,000 (P for trend <.001). Using cluster A as the referent category, the risk for stillbirth among anomaly- free clustermates climbed with increase in the number of siblings with anomalies in a dose- response pattern (adjusted odds ratio, 95% confidence interval 1.5, 0.7- 3.1, for cluster B; and 5.2, 1.4- 18.8, for cluster C; P for trend = .03). For infant mortality, the only rise in risk was in cluster C (3.3, 1.6- 6.7), whereas cluster B showed comparable risk with the referent category (0.8, 0.5- 1.4; P for trend >.05). CON- CLUSION: The presence of anomalous fetuses compromises the survival of normal cotriplets. These findings could prove useful for counseling affected parents and highlight the need for follow- up of normal coinfants of anomalous fetuses.
文摘Aim: To study the health and development of children in a developing and low- income country. Methods: The health and development of children in Lahore in nor thern Pakistan have been studied since 1981 in a collaborative project between P akistani and Swedish university institutions and the Swedish Agency for Research Cooperation with Developing Countries (SAREC). The study described in this pape r comprised four different areas in Lahore with different degrees of urbanizatio n and different social conditions. All pregnancies in the four areas were regist ered during the period March 1984 to July 1986 and were followed up from the 5th month of pregnancy. All 1476 children born after 1 September 1984 were followed up from birth to 12 y of age. Results: The perinatal mortality in the whole mat erial was 5.4%. It was highest in the periurban slum (7.5%) and lowest in the upper-middle class cohort (3.3%). Overall infant mortality was 10%. It was hi ghest (14%) in the periurban slum and lowest (2%) in the upper-middle class g roup. Overall incidence of serious birth defects was 5%. It was highest in the periurban slum community (7%) and lowest in the upper-middle class cohort (3% ). The overall cumulative incidence of severe mental retardation per 100 live bi rths was 1.1. It was highest (2.2) in the periurban slum and lowest (0.4) in the upper-middle class group. The overall prevalence of mild mental retardation am ong 6-10-y-old children was 6.2 per 100. It was highest in the periurban slum (10.5) and lowest (1.3 per 100) in the upper-middle class group. Poverty, maln utrition, birth trauma and consanguinity were common causes of infant mortality and mental retardation in Lahore, Pakistan. Conclusion: Preventive measures with provision of obstetric and health services, services for genetic information an d risk evaluation, vaccination programmes and identification of children with re tarded development for specific stimulation and habilitation measures, e.g. orga nized play activities, are important in developing and low-income countries.
文摘Objective: The study was aimed to define obstetric factors associated with shoulder dystocia. Methods: A population-based study comparing all singleton, vertex, term deliveries with shoulder dystocia with deliveries without shoulder dystocia was performed. Statistical analysis was done using multiple logistic regression analysis. Results: Shoulder dystocia complicated 0.2%(n=245) of all deliveries included in the study(n=107965). Independent risk factors for shoulder dystocia in a multivariable analysis were birth-weight ≥4000 g(OR=24.3; 95%CI 18.5-31.8), vacuum delivery(OR=5.7, 95%CI 3.4-9.5), diabetes mellitus(OR=1.7, 95%CI 1.2-2.5) and lack of prenatal care(OR=1.5, 95%CI 1.1-2.3). A significant linear association was found between birth-weight and shoulder dystocia, using the Mantel-Haenszel procedure. Pregnancies complicated with shoulder dystocia had higher rates of third-degree perineal tears as compared to the comparison group (0.8%versus 0.1%; P < 0.001). Similarly, perinatal mortality was higher among newborns delivered after shoulder dystocia as compared to the comparison group(3.7%versus 0.5%; OR=7.4, 95%CI 3.5-14.9, P< 0.001). In addition, these newborns had higher rates of Apgar scores lower than 7 at 1 and 5 min as compared to newborns delivered without shoulder dystocia(29.7%versus 3.0%; OR=13.8, 95%CI 10.3-18.4, P< 0.001 and 2.1%versus 0.3%; OR=7.2, 95%CI 2.8-18.1, P< 0.001, respectively). Combining risk factors such as large for gestational age, diabetes mellitus and vacuum delivery increased the risk for shoulder dystocia to 6.8%(OR=32.6, 95%CI 10.1-105.8, P< 0.001). Conclusions: Independent factors associated with shoulder dystocia were birth-weight ≥4000 g, vacuum delivery, diabetes mellitus and lack of prenatal care.
文摘Objective: To evaluate the performance of abdominal palpation as a screening test for intrauterine growth retardation (IUGR) in a low risk population, under standard practice conditions. Study design: Population based observational study of 6318 consecutive low risk singleton pregnancies. The Dutch obstetric system distinguishes low from high risk pregnancies. In the low risk group abdominal palpation as a screening test is performed by midwives. If a complication, like IUGR, during prenatal care is assessed, the women is referred to a consulted obstetrician. Ultrasound is performed by the consulted obstetrician. In case of sustained suspicion the women is selected as high risk. Outcome parameters: severe small for gestational age (SGA) birthweight below 2.3rd centile, all SGA birthweight below 10th centile, operative delivery, neonatal morbidity and perinatal mortality. Screening value of abdominal palpation, abdominal palpation combined with ultrasound, and the performance of high risk selection was assessed by conventional performance measures. Results: Abdominal palpation as a screening test for IUGR is of limited value: the observed sensitivities were 28%for severe SGA and 21%for SGA p≤10, respectively. After ultrasound in case of sustained suspicion, the sensitivity in detection of severe SGA was 25%and positive predictive value (PPV) 16%. In detection of SGA p≤10 sensitivity was 15%and PPV 55%, which means 45%were false positives. The sensitivity of the Dutch obstetric system in selection of high risk pregnancies in detection of severe SGA was 53%, in detection of SGA p≤10 was 37%. Perinatal mortality was 0.9%(57/6318) and 32%of these cases were SGA. Six cases of fetal death were unrecognised during prenatal care (0.09%) and seem preventable. The prevalence of a 5 min Apgar Score≤7 was significantly higher in the SGA infants if SGA was defined as p≤10. Conclusions: The diagnostic performance of abdominal palpation as a screening test for IUGR detection in a low risk population is disappointing. However, various stratagems such as routine ultrasound do not improve detection rate or perinatal morbidity and mortality.
文摘Objective: To evaluate the pregnancy outcome in patients with abnormal uterine artery Doppler flow velocity waveforms (FVWs) at 19-21 weeks, which were subsequently normal by 24-26 weeks, and to study the effect of lowdose aspirin on these waveforms. Design: The study group consisted of 49 patients who had abnormal uterine artery flow velocity waveforms (FVWs) at 19-21 weeks. These women were initially commenced on 100 mg slowrelease aspirin at 20 weeks, which was discontinued at the followup visit, after confirming normal uterine artery Doppler FVW. The control group consisted of 730 patients with normal uterine artery Doppler waveforms at 19-21 weeks. The main outcome measures were: small for gestational age (SGA) < 10th centile, preeclampsia, placental abruption, and perinatal mortality rate (PMR). Results: When compared with the control group, the study group had an increased risk of placental abruption (2%versus 0.27%, P=0.05) 95%Confidence Intervals CI=0.01-0.13), low birth weight (3087 versus 3383 gm, P=0.0003), SGA <10th centile (32.7%versus 11.9%, P≤0.0001, CI=0.14-0.5), and PMR (2/49 versus 1/730, P < 0.0001, CI=0.003-0.37). Conclusions: These findings suggest that delayed normalisation of the uterine artery Doppler waveform is not a benign phenomenon. This subgroup of patients is at increased risk of pregnancy complications, in particular SGA and placental abruption. These patients could benefit from serial ultrasound scans in the third trimester to evaluate fetal growth and wellbeing. Aspirin does not appear to play a major part in modifying uterine artery blood flow.
