Aims: The purpose of this study was to examine factors
relevant to mode of delivery in term pregnancies complicated
by gestational and pre-gestational diabetes.
Methods: A retrospective chart review of term (≥ 37
weeks) singleton pregnancies complicated by Class A2
through Class R pregnancies which delivered from
1991–1997 was performed. Exclusion criteria were
prior cesarean delivery, non-vertex presentation, fetal
structural defects, or any contraindications to vaginal
delivery. Maternal and fetal factors relevant to mode of
delivery were examined and compared. Stepwise logistic
regression analysis was performed to examine
factors predictive of delivery mode.
Results: A total of 148 patients met study criteria. Induction
rates were 60.9% for gestational and 79.8% for
pre-gestational diabetics. The overall cesarean delivery
rate by Diabetes Class for A2, B, C, D–F pregnancies
was 20.3 %, 40 %, 37 %, and 57.1% respectively. In
Class A2 pregnancies no factor was associated with cesarean
delivery and only nulliparity (p 5 0.03) was associated
in Class B–F pregnancies.
Conclusions: These results suggest that physician
factors may play an important role in the risk for cesarean
delivery in our diabetic population.
Objective: A sonographically short cervix is a powerful predictor of spontaneous preterm delivery. However, the etiology and optimal management of a patient with a short cervix in the mid-trimester of pregnancy remain uncertain. Microbial invasion of the amniotic cavity (MIAC) and intra-amniotic inflammation are frequently present in patients with spontaneous preterm labor or acute cervical insufficiency. This study was conducted to determine the rate of MIAC and intra-amniotic inflammation in patients with a cervical length <25 mm in the mid-trimester.
Study design: A retrospective cohort study was conducted of patients referred to our high risk clinic because of a sonographic short cervix or a history of a previous preterm birth. Amniocenteses were performed for the evaluation of MIAC and for karyotype analysis in patients with a short cervix. Fluid was cultured for aerobic and anaerobic bacteria, as well as genital mycoplasmas. Patients with MIAC were treated with antibiotics selected by their physician.
Results: Of 152 patients with a short cervix at 14–24 weeks, 57 had amniotic fluid analysis. The prevalence of MIAC was 9% (5/57). Among these patients, the rate of preterm delivery (<32 weeks) was 40% (2/5). Microorganisms isolated from amniotic fluid included Ureaplasma urealyticum (n=4) and Fusobacterium nucleatum (n=1). Patients with a positive culture for Ureaplasma urealyticum received intravenous Azithromycin. Three patients with Ureaplasma urealyticum had a sterile amniotic fluid culture after treatment, and subsequently delivered at term. The patient with Fusobacterium nucleatum developed clinical chorioamnionitis and was induced.
Conclusion: (1) Sub-clinical MIAC was detected in 9% of patients with a sonographically short cervix (<25 mm); and (2) maternal parenteral treatment with antibiotics can eradicate MIAC caused by Ureaplasma urealyticum. This was associated with delivery at term in the three patients whose successful treatment was documented by microbiologic studies.
To determine the frequency of sepsis and other adverse neonatal outcomes in women with a clinical diagnosis of chorioamnionitis.
We performed a secondary analysis of a multi-center placebo-controlled trial of vitamins C/E to prevent preeclampsia in low risk nulliparous women. Clinical chorioamnionitis was defined as either the “clinical diagnosis” of chorioamnionitis or antibiotic administration during labor because of an elevated temperature or uterine tenderness in the absence of another cause. Early-onset neonatal sepsis was categorized as “suspected” or “confirmed” based on a clinical diagnosis with negative or positive blood, urine or cerebral spinal fluid cultures, respectively, within 72 h of birth. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by logistic regression.
Data from 9391 mother-infant pairs were analyzed. The frequency of chorioamnionitis was 10.3%. Overall, 6.6% of the neonates were diagnosed with confirmed (0.2%) or suspected (6.4%) early-onset sepsis. Only 0.7% of infants born in the setting of chorioamnionitis had culture-proven early-onset sepsis versus 0.1% if chorioamnionitis was not present. Clinical chorioamnionitis was associated with both suspected [OR 4.01 (3.16–5.08)] and confirmed [OR 4.93 (1.65–14.74)] early-onset neonatal sepsis, a need for resuscitation within the first 30 min after birth [OR 2.10 (1.70–2.61)], respiratory distress [OR 3.14 (2.16–4.56)], 1 min Apgar score of ≤3 [OR 2.69 (2.01–3.60)] and 4–7 [OR 1.71 (1.43–2.04)] and 5 min Apgar score of 4–7 [OR 1.67 (1.17–2.37)] (vs. 8–10).
Clinical chorioamnionitis is common and is associated with neonatal morbidities. However, the vast majority of exposed infants (99.3%) do not have confirmed early-onset sepsis.