Faculty Bibliography

OBJECTIVE: Our purpose was to examine the risk of uterine rupture during induction or augmentation of labor in gravid women with 1 prior cesarean delivery. STUDY DESIGN: The medical records of all gravid women with history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. The current analysis was limited to women at term with 1 prior cesarean delivery and no other deliveries. The rate of uterine rupture in gravid women within that group undergoing induction was compared with that in spontaneously laboring women. The association of oxytocin induction, oxytocin augmentation, and use of prostaglandin E(2) gel with uterine rupture was determined. Logistic regression analysis was used to examine these associations, with control for confounding factors. RESULTS: Of 2774 women in the analysis, 2214 had spontaneous onset of labor and 560 women had labor induced with oxytocin or prostaglandin E(2) gel. The overall rate of rupture among all patients with induction of labor was 2.3%, in comparison with 0.7% among women with spontaneous labor (P =.001). Among 1072 patients receiving oxytocin augmentation, the rate of uterine rupture was 1.0%, in comparison with 0.4% in nonaugmented, spontaneously laboring patients (P =.1). In a logistic regression model with control for birth weight, use of epidural, duration of labor, maternal age, year of delivery, and years since last birth, induction with oxytocin was associated with a 4.6-fold increased risk of uterine rupture compared with no oxytocin use (95% confidence interval, 1.5-14.1). In that model, augmentation with oxytocin was associated with an odds ratio of 2.3 (95% confidence interval, 0.8-7.0), and use of prostaglandin E(2) gel was associated with an odds ratio of 3.2 (95% confidence interval, 0.9-10.9). These differences were not statistically significant. CONCLUSION: Induction of labor with oxytocin is associated with an increased rate of uterine rupture in gravid women with 1 prior uterine scar in comparison with the rate in spontaneously laboring women. Although the rate of uterine rupture was not statistically increased during oxytocin augmentation, use of oxytocin in such cases should proceed with caution.

OBJECTIVE: We sought to determine whether there is a difference in the rate of symptomatic uterine rupture after a trial of labor in women who have had 1 versus 2 prior cesarean deliveries. STUDY DESIGN: The medical records of all women with a history of either 1 or 2 prior cesarean deliveries who elected to undergo a trial of labor during a 12-year period (July 1984-June 1996) at the Brigham and Women's Hospital were reviewed. Rates of uterine rupture were compared for these 2 groups. Potential confounding variables were controlled by using logistic regression analyses. RESULTS: Women with 1 prior cesarean delivery (n = 3757) had a rate of uterine rupture of 0.8%, whereas women with 2 prior cesarean deliveries (n = 134) had a rate of uterine rupture of 3.7% (P =.001). In a logistic regression analysis that was controlled for maternal age, use of epidural analgesia, oxytocin induction, oxytocin augmentation, the use of prostaglandin E(2) gel, birth weight, gestational age, type of prior hysterotomy, year of trial of labor, and prior vaginal delivery, the odds ratio for uterine rupture in those patients with 2 prior cesarean deliveries was 4.8 (95% confidence interval, 1.8-13. 2) CONCLUSIONS: Women with a history of 2 prior cesarean deliveries have an almost 5-fold greater risk of uterine rupture than those with only 1 prior cesarean delivery.

OBJECTIVE: To assess the risk of trisomy 18 and trisomy 21 associated with isolated choroid plexus cysts diagnosed by ultrasound in the second trimester. METHODS OF STUDY SELECTION: We reviewed the unabridged PREMEDLINE and MEDLINE databases for articles written in the English language regarding second-trimester fetal isolated choroid plexus cysts and trisomies 18 and 21, published in the period 1987-1997. Selection criteria included only second-trimester, prospective studies in which the rate of fetal isolated choroid plexus cysts could be calculated, the number of fetuses with trisomy 18 and 21 was reported clearly, and pregnant women of all ages were included, rather than only those at high risk for aneuploidy due to advanced maternal age. TABULATION AND RESULTS: Thirteen prospective studies, comprising 246,545 second-trimester scans, were selected. Among 1346 fetuses with isolated choroid plexus cysts, seven had trisomy 18, and five had trisomy 21. For each study, a 2 x 2 table was constructed and the likelihood ratio of a positive test was computed. The likelihood ratios for trisomies 18 and 21 were found to be homogeneous (P = .08 for trisomy 18, and P = .16 for trisomy 21). The summary likelihood ratio and 95% confidence interval (CI) for each chromosomal abnormality were calculated using the Mantel-Haenszel fixed effects model of meta-analysis. The summary likelihood ratio for trisomy 18 was 13.8 (CI 7.72, 25.14, P < .001) and for trisomy 21 was 1.87 (CI 0.78, 4.46, P = .16). CONCLUSION: The likelihood of trisomy 18 was 13.8 times greater than the a priori risk in fetuses with isolated choroid plexus cysts diagnosed in the second trimester. However, the likelihood of trisomy 21 was not significantly greater than the a priori risk with isolated choroid plexus cysts. The data supported offering pregnant women karyotyping to rule out trisomy 18 when maternal age at delivery is 36 years or older, or when the risk for trisomy 18 detected by serum multiple-marker screen is more than one in 3000.

BACKGROUND: Placenta previa percreta with invasion of the broad ligament and uterine cervix is an extremely rare condition and carries high maternal and fetal morbidity and mortality. CASE: A 39-year-old, multiparous woman with two previous cesarean sections presented in active labor at term with placenta previa percreta involving the left broad ligament and cervix. The patient was managed by antepartum diagnosis of placenta previa accreta, supracervical hysterectomy, and blood transfusion. CONCLUSION: This case was managed consistent with the literature, and favorable maternal and fetal outcomes were achieved.

OBJECTIVE: To construct a management guide for preterm pregnancies complicated by severely abnormal umbilical artery Doppler velocimetry. METHODS: A retrospective chart review was conducted on all cases of absent or reversed end-diastolic flow umbilical artery Doppler velocimetry identified through an ultrasound data base. Maternal and perinatal outcome variables were retrospectively reviewed and analyzed using both parametric and nonparametric statistical techniques. Seventy-one cases were identified over a 5-year period. After excluding multiple gestations, anomalous fetuses, and two cases that were terminated before 24 weeks' gestation, 56 singleton gestations remained for analysis. RESULTS: Among the 56 subjects, there were 45 survivors and 11 deaths (five fetal and six neonatal deaths). Nonsurvivors had a significantly lower gestational age at diagnosis and delivery. Nonsurviving live-born neonates had lower Apgar scores and were significantly smaller; however, there were no differences in proportion or severity of fetal growth restriction in survivors and nonsurvivors. There were no differences in last biophysical profile before delivery or interval from diagnosis of reversed end-diastolic flow to delivery. Predictors of nonsurvival were the presence of reversed end-diastolic flow and oligohydramnios. Perinatal mortality for reversed end-diastolic flow was 333/1000 and 94/1000 for absent end-diastolic flow. Risk for perinatal death was highly gestational age dependent. For delivery at less than 26 weeks, survival was one of four; at 26-27.9 weeks, survival was seven of 12; and at 28 weeks or greater, survival was 37 of 40. CONCLUSION: Whereas severely abnormal umbilical artery blood flow poses significant risk for pregnancy, perinatal mortality is dominated by gestational age at diagnosis and delivery. This may reflect the severity of the disease or the low survival of very immature gestations. Interventions on behalf of the fetus at very early gestational ages should be undertaken with caution.

OBJECTIVES: By means of hospital-based data over 9 years we sought to evaluate the clinical indications and incidence of emergency peripartum hysterectomy by demographic characteristics and reproductive history. STUDY DESIGN: From the obstetric records of all deliveries at Brigham and Women's Hospital between Oct. 1, 1983, and July 31, 1991, we identified all women undergoing emergency peripartum hysterectomy, calculated crude and adjusted incidence rates, conducted statistical tests of linear trends and heterogeneity, and observed the clinical indications preceding the onset of this procedure. RESULTS: There were 117 cases of peripartum gravid hysterectomy identified during this period, for an overall annual incidence of 1.55 per 1000 deliveries. The rate increased with increasing parity and was significantly influenced by placenta previa and a history of cesarean section. The incidence by parity increased from one in 143 deliveries in nulliparous women with placenta previa to one in four deliveries in multiparous women with four or more deliveries with placenta previa. Likewise, the incidence increased from one in 143 deliveries in women with one prior live birth and a prior cesarean section to one in 14 deliveries in multiparous women with four or more deliveries with a history of a prior cesarean section. Both these trends were highly significant (p < 0.001). Abnormal adherent placentation was the most common cause preceding gravid hysterectomy (64%, p < 0.001), with uterine atony accounting for 21%. Although no maternal deaths occurred, maternal morbidity remained high, including postoperative infection in 58 (50%), intraoperative urologic injury in 10 patients (9%), and need for transfusion in 102 patients (87%). CONCLUSIONS: The data identify abnormal adherent placentation as the primary cause for gravid hysterectomy. The data also illustrate how the incidence of emergency peripartum hysterectomy increases significantly with increasing parity, especially when influenced by a current placenta previa or a prior cesarean section. Maternal morbidity remained high although no maternal deaths occurred

OBJECTIVE: To study fetuses who had the sonographic diagnosis of hemivertebrae made in utero (excluding open neural tube defects) and to determine the incidence of associated anomalies, karyotypes, and neonatal outcome. METHODS: Twenty-seven fetuses with sonographically detected vertebral abnormalities (excluding neural tube defects) and postnatal follow-up were included in the study. Associated structural defects and karyotypic anomalies were tabulated. The outcome for fetuses with isolated vertebral abnormalities on prenatal sonogram was compared with that of fetuses with associated anomalies. RESULTS: Eleven of 27 fetuses had hemivertebrae as the only sonographic anomaly. Nine of the 11 were live-born with a good outcome; one patient elected pregnancy termination, and one fetus died of sepsis after premature rupture of the membranes. Sixteen fetuses had other anomalies including cardiac, intestinal, renal, intracranial, and limb anomalies. Seven of these 16 had Potter syndrome, two of whom also had sacral agenesis. Only five of those with additional anomalies survived; five died and six pregnancies were electively terminated. Because four of the six aborted fetuses had Potter syndrome (renal dysgenesis), a lethal malformation, a total of at least nine of the 16 fetuses with other anomalies would not have survived. All seven fetuses with severe oligohydramnios had lethal anomalies. Eighteen fetuses underwent karyotyping (including all those with isolated vertebral anomalies), and all had normal karyotypes. CONCLUSION: Our study suggests that sonographically diagnosed, isolated fetal vertebral anomalies carry a good prognosis and the likelihood of a normal karyotype. The presence of associated anomalies reduces the survival to 50%, and when accompanied by significant oligohydramnios, the mortality is 100%.