We evaluated acute neonatal morbidities in the delivery room associated with primary cesarean performed prior to labor and in the first or second stages of labor. A retrospective cohort study was conducted on subjects undergoing term, primary cesareans at the Women's Pavilion, Miller Children's Hospital in Long Beach, California from 2000 to 2007. Acute neonatal morbidities were tabulated as a function of time during labor when cesarean was performed. Composite neonatal morbidity was defined as the presence of at least one of the following: low 5-minute Apgar score, need for intubation, and/or admission to neonatal intensive care unit. One thousand forty-five subjects delivered by cesarean without labor, 3098 in first stage, and 951 in second stage. Five-minute Apgar score < 7 was more common in cesareans performed during second stage than during first stage or without labor [3/1045 (0.3%) versus 28/3098 (0.9%) versus 12/951 (1.3%), P = 0.039]. Composite neonatal morbidity was not significantly different among the stages. Acute neonatal morbidities were not affected by the presence or absence of labor. Potential long-term sequelae require further study.

Objective: To compare latency period, infectious morbidity, neonatal morbidity and neonatal mortality in twin versus singleton pregnancies complicated by preterm premature rupture of membranes (PPROM) remote from term. Methods: A retrospective, matched cohort study comparing 41 twin and 82 singleton pregnancies complicated by PPROM between 24-0/7 and 31-6/7 weeks' gestation. The data were obtained by reviewing maternal and neonatal charts. Results: The median latency periods were 3.6 days (interquartile range 1.5-13.9 days) for twins and 6.2 days (interquartile range 2.9-11.8 days) for singletons (p = 0.86). Twins were less likely to be complicated by clinical chorioamnionitis when compared with singletons (4/41 [9.8%] vs. 19/82 [23.2%], relative risk [RR] 0.42, 95% confidence interval [CI] 0.18-0.96). Histological evidence of chorioamnionitis was also lower in twins compared with singletons (14/39 [35.9%] vs. 46/68 [67.7%], RR 0.56, 95% CI 0.34-0.92). These differences persisted after adjusting for race, insurance status, latency period and route of delivery. Neonatal morbidity and mortality rates were similar between the two groups. Conclusions: There was not a statistically significant difference in the latency periods for twin and singleton pregnancies complicated by PPROM. Clinical chorioamnionitis and histological evidence of infection were significantly less common in twins compared with singletons.

We compared the effectiveness of antenatal betamethasone for the prevention of neonatal morbidity and mortality in preterm twin and singleton gestations. We conducted a case-control study of women with twin versus singleton gestations who received betamethasone for risk of prematurity in a university-affiliated, community-based, tertiary care center between 1997 and 2005. Cases were identified from clinical care and pharmacy databases, then matched for neonatal gender and gestational age (GA) at delivery. Sixty cases and 60 controls of deliveries occurring between 24 and 34 weeks' gestation were identified. The mean GA was 30.4 +/- 2.7 weeks. There were no differences between the groups in maternal demographics (with the exception of maternal age), birth weight, head circumference, Apgar scores, need for mechanical ventilation, days on ventilator, intraventricular hemorrhage grade 3 or 4, necrotizing enterocolitis suspected sepsis, total days in neonatal intensive care unit, or neonatal deaths. No differences in major morbidities or mortality were found in singletons versus twins. Concerns that the added maternal plasma volume in multiple gestations could lessen the neonatal benefits of antenatal betamethasone were not substantiated. This study may be affected by beta-error due to small sample size and sampling bias as a result of a retrospective study.

OBJECTIVE The purpose of this study was to assess the correlation and agreement between transvagi-nal and transabdominal cervical length measurement after bladder emptying as well as the feasibility of transabdominal sonography in cervical length screening. METHODS This was a prospective cohort study involving 287 participants (14-34 weeks' gestation) from January to December 2003. After voiding, transabdominal and transvaginal cervical length measurements were obtained. The optimal trans-abdominal technique was established during an unblinded series of transabdominal and transvaginal cervical length measurements (n = 96). The same measurements were obtained in 191 participants under a blinded 2-sonographer protocol. The transabdominal cervical length cutoff to ensure 100% sensitivity in detecting a short cervix (<or=2.5 cm) was determined. RESULTS There was no difference between mean transabdominal and transvaginal cervical lengths +/- SD (3.57 +/- 0.74 versus 3.61 +/- 0.74 cm; P =.20). The Pearson correlation coefficient was 0.824. The 95% tolerance interval for any paired observation (transabdominal minus transvaginal) was -0.92 to 0.84 cm. All transvaginal cervical lengths of 2.5 cm or less were associated with paired transabdominal cervical lengths of 3 cm or less. CONCLUSIONS With an optimal sonographic technique, postvoid transabdominal cervical measurement shows a close correlation and agreement with transvaginal assessment and is useful for cervical length screening.

OBJECTIVE The purpose of this study was to examine complications of labor induction compared to spontaneous labor in multiparas. STUDY DESIGN This was a retrospective cohort study of multiparous women with live, singleton pregnancies at term, who had no contraindications to labor or labor induction. Cesarean delivery was the primary outcome. RESULTS Of the study subjects, 7208 experienced spontaneous labor, 2190 underwent labor induction with oxytocin, and 239 underwent labor induction requiring cervical ripening agents. Oxytocin-induced multiparas were 37% more likely to require cesarean compared to those with spontaneous labor (OR, 1.37; 95% CI, 1.10-1.71) and nearly 3 times more likely to undergo cesarean when cervical ripening agents were used (OR, 2.82; 95% CI, 1.84-4.53). Women requiring cervical ripening were also 10 times more likely to spend more than 12 hours in labor than those with spontaneous labor. CONCLUSION Multiparas undergoing labor induction are at increased risk for obstetric complications compared to spontaneous labor.

OBJECTIVE This study was undertaken to assess whether racial differences in the risk of cesarean delivery result from differing practices of their caregivers or the hospitals at which they deliver. STUDY DESIGN A retrospective cohort study was performed using the Perinatal Database of the Memorial Health Care System. Logistic regression was used to estimate the risk of primary cesarean delivery among patients eligible for labor. The contribution of hospital and physician level cluster correlation was evaluated using fixed and random effects regression models. RESULTS Compared with white patients, black and Hispanic patients were 75% and 22% more likely to undergo primary cesarean delivery. Further adjustment for hospital and physician level cluster correlation resulted in persistently increased risks of primary cesarean delivery in black (54%) and Hispanic patients (12%). CONCLUSION Hospital site of delivery and individual physician practices do not fully explain racial differences in the risk of primary cesarean delivery.

Objective: To elucidate the regulation of the nitric oxide (NO) and carbon monoxide (CO) pathways in preeclampsia and to evaluate the ratio of asymmetric dimethylarginine (ADMA) to symmetric dimethylarginine (SDMA) as a marker for preeclampsia. Methods: Maternal plasma and placental samples were obtained from 20 participants with preeclampsia and 23 controls. Enzyme-linked immunosorbent assay was used to measure plasma NO, ADMA, and SDMA as well as placental NO and hemeoxygnase 1 (HO-1). Western blot was used to measure placental dimethylarginine dimethylaminotransferases (DDAH-I and DDAH-II). Results: Placental DDAH-I, placental DDAH-II, placental NO, and placental HO-1 were significantly decreased in participants with preeclampsia. While ADMA and SDMA levels were decreased in preeclampsia, the ADMA-SDMA ratio was not significantly different. Conclusions: Decreased DDAH and HO with preeclampsia suggest that they are important points in the regulatory pathways of NO and CO production that are altered in preeclampsia. The ADMA-SDMA ratio is not a useful test for preeclampsia.

Introduction: Labor induction is now reported to occur in up to 30 - 40% of obstetrical patients. There are a number of pharmacological options available to facilitate labor induction, including oxytocin and analogues of prostaglandins E1 and E2, which have particular utility when labor induction necessitates cervical ripening, as when labor induction occurs in the context of an unfavorable cervix. Areas covered: This paper reviews acceptable pharmacological options for labor induction, especially when cervical ripening is required. These options include oxytocin and a number of prostaglandin formulations using dinoprostone and misoprostol. It also covers several analyses of published clinical trials (Phase-III) describing evidence of effectiveness. Expert opinion: Oxytocin is best used when labor needs to be induced in the context of a favorable cervix. When the cervix is not favorable, cervical ripening using prostaglandins should precede labor induction. Either dinoprostone or misoprostol are superior to oxytocin alone for cervical ripening. However, judicious, careful considerations need to be made at the outset of labor induction so as to balance maternal and fetal risks, and these should be guided by institutional policies that reflect the evidence-base.

Abstract OBJECTIVE: To assess cerclage benefit in women with short cervix also receiving 17-alpha-hydroxyprogesterone caproate (17P) to prevent recurrent preterm birth (PTB). METHODS: Secondary analysis of a multicenter trial of ultrasound-indicated cerclage for shortened cervical length (CL). Women with prior spontaneous PTB at 16-33 6/7 weeks, singleton gestation and CL<25mm between 16-22 6/7 weeks were counseled on use of 17P and randomized to cerclage or no cerclage. Outcomes of women who received 17P were analyzed by randomization group. Primary outcome was PTB<35 weeks. RESULTS: 99 women received 17P: 47 cerclage; 52 no cerclage. Rates of PTB<35 weeks were similar, 30% for cerclage and 38% for no cerclage (aOR 0.64 (0.27- 1.52)). In women with CL<15mm, PTB<35 weeks was reduced for the cerclage group (17% versus 75%, p=0.02). However, this difference was nullified after controlling for total progesterone doses received (p=0.40). CONCLUSIONS: Cerclage was shown not to offer additional benefit for the prevention of recurrent PTB in women with short CL<25mm receiving 17P, but the sample size is insufficient for a definite conclusion given the 36% non-significant decrease in the odds of PTB<35 weeks. Cerclage may further offer substantial benefit to women with very short CL<15mm and further study is needed.

Abstract OBJECTIVE: An association between Helicobacter pylori (H pylori) and thrombocytopenia has been demonstrated in the literature in a non-pregnant population. The purpose of this study was to determine whether or not there is a similar association in the third trimester of pregnancy in a Hispanic population. METHODS: This is a secondary analysis of 82 pregnant Hispanic women with and without hyperemesis gravidarum who underwent serologic evaluation for H. pylori IgG. Results of complete blood counts obtained in the third trimester were analyzed for thrombocytopenia. RESULTS: Of the 82 subjects who had H. pylori testing, 54 subjects had both serum H. pylori IgG results and third trimester platelet levels. The prevalence of thrombocytopenia was 11.1%(6/54). Thirty-six subjects were seropositive for H. pylori IgG and 18 subjects were seronegative. Of the 36 subjects who were H. pylori seropositive, 4 (11.1%) developed thrombocytopenia compared to 3 of 18 (16.7%) H. pylori seronegative subjects (P=0.67). There was no difference between the groups in their mean platelet values (205 K/cu mm vs. 212 K/cu mm, P=0.69). CONCLUSIONS: In this limited study, we found no association between H. pylori and thrombocytopenia in the pregnant Hispanic population.

OBJECTIVE:: To compare neonatal outcomes by method of delivery in preterm (34 weeks of gestation or prior), small-for-gestational-age (SGA) newborns in a large diverse cohort. METHODS:: Birth data for 1995-2003 from New York City were linked to hospital discharge data. Data were limited to singleton, liveborn, vertex neonates delivered between 25 and 34 weeks of gestation. Births complicated by known congenital anomalies and birth weight less than 500 g were excluded. Small for gestational age was used as a surrogate for intrauterine growth restriction. Associations between method of delivery and neonatal morbidities were estimated using logistic regression. RESULTS:: Two thousand eight hundred eighty-five SGA neonates meeting study criteria were identified; 42.1% were delivered vaginally, and 57.9% were delivered by cesarean. There was no significant difference in intraventricular hemorrhage, subdural hemorrhage, seizure, or sepsis between the cesarean delivery and vaginal delivery groups. Cesarean delivery compared with vaginal delivery was associated with increased odds of respiratory distress syndrome. The increased odds persisted after controlling for maternal age, parity, ethnicity, education, primary payer, prepregnancy weight, gestational age at delivery, diabetes, and hypertension. CONCLUSION:: Cesarean delivery was not associated with improved neonatal outcomes in preterm SGA newborns and was associated with an increased risk of respiratory distress syndrome. LEVEL OF EVIDENCE:: II.

AIMS To compare the short-term maternal and neonatal outcomes of very low birth weight (VLBW) breech singletons by mode of delivery. METHODS All breech fetuses born from 24-0/7 to 26-6/7 weeks' gestation at our institution between 2000 and 2008 were eligible for the study. Abstracted medical record data included maternal demographics, delivery data, and neonatal outcomes. RESULTS There were 26 vaginal and 39 cesarean deliveries. Maternal age did not differ between groups; gestational age was greater in the cesarean group by five days. Short-term neonatal outcomes did not differ between groups. Of the 39 cesarean deliveries, 27 involved classical uterine incisions. Estimated blood loss (732 mL vs. 362 mL) and postpartum infection rate (26% vs. 4%) were greater with cesarean delivery. CONCLUSION Neonatal outcome is not improved in VLBW infants born by cesarean section. Given the morbidity of classical cesarean sections, vaginal delivery of the breech VLBW infant may be safely considered.

AIM To evaluate the association of angiotensin-converting enzyme (ACE) gene polymorphism with risk/severity of persistent pulmonary hypertension of the newborn (PPHN) among at risk infants. METHODS Infants ≥ 34 weeks with respiratory distress at birth were recruited. PPHN was diagnosed clinically and by cardiac echocardiogram. Control group consisted of infants with respiratory distress who did not develop PPHN. ACE genotyping (DD, II, DI genotypes) and serum ACE levels were determined. RESULTS A total of 120 infants were included (PPHN = 44; control = 76). Frequency of ACE DD genotype was not different between the two groups of infants (25% versus 33%). Among PPHN infants, severity of illness did not differ between genotypes. Mean (SD) serum ACE levels [15 (9) versus 24 (13) versus 29 (14) U/L] were positively associated with the number of D alleles and inversely associated with infants' gestational age (GA) and level of cardiovascular support. Conclusion: Angiotensin-converting enzyme gene polymorphism did not impact the risk or severity of PPHN among infants ≥ 34 weeks GA.

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We sought to determine if maternal use of selective serotonin reuptake inhibitors (SSRIs) in the second half of pregnancy is associated with persistent pulmonary hypertension of the newborn (PPHN). We performed a case-controlled study (1:6 ratio) of infants delivered at Madigan Army Medical Center with primary PPHN from 2003 through 2009. Study and control patients were compared for the following clinical factors: SSRI use after 20 weeks gestation, mode of delivery, maternal disease, body mass index, tobacco use, fetal gender, maternal age, and parity. We identified 20 cases of primary PPHN out of 11,923 births for an incidence of 0.17%. Mode of delivery was the only factor we found to be associated with PPHN. Specifically, cesarean delivery (CD) prior to the onset of labor increased the risk for PPHN: odds ratio (OR)= 4.9, confidence interval (CI) 1.7 to 14.0. Importantly, use of SSRIs in the second half of pregnancy was identified in 5% of the controls but none of the cases (OR = 0, CI 0 to 3). PPHN is associated with CD prior to the onset of labor but not with SSRI use in the second half of pregnancy. Previous studies linking PPHN to SSRI use relied on after-the-fact patient interviews and incomplete records. Additional studies are needed to verify these results.

The appropriate time and the optimal mode of delivery of twins are still controversial. We assessed the effect of gestational age and the mode of elective delivery of twins on the occurrence of neonatal respiratory morbidity (NRM) and of maternal morbidity. This study included twins born beyond 35 weeks' gestation. NRM was defined as respiratory distress syndrome (RDS) and transient tachypnea of the newborn (TTN). Additionally, maternal complications related to the different modes of delivery were taken into account. Of 711 twin pregnancies (1422 liveborn neonates) included, 74 (5.2%) experienced NRM. Maternal age > 25 years, delivery at an earlier gestational age, and delivery by emergency cesarean section maintained statistical significance with NRM. From the maternal point of view, increased length of hospitalization ( P = 0.045) and the need for postoperative antibiotics ( P = 0.0065) were significantly higher following an emergency cesarean section than after an elective cesarean birth. The risk of NRM in twins born beyond 37 weeks' gestation is rather low. We suggest considering elective cesarean delivery at completion of 37 weeks. This can be performed safely in regard to NRM, the trade-off being reduced maternal morbidity associated with elective cesarean delivery.

Persistent pulmonary hypertension of the newborn (PPHN) is one of the most serious conditions in neonates resulting in a high mortality and morbidity. New alternative therapies for PPHN have been sought to improve survival and reduce morbidity. To report an initial experience of using beraprost sodium (BPS) to treat infants with PPHN and to assess its effect on oxygenation and hemodynamic stability over a 72-hour study period. The clinical data of neonates who received BPS as an adjunctive therapy for PPHN in our hospital between July 2007 and June 2008 were retrospectively reviewed. During the study period, 7 infants with PPHN were successfully treated with BPS. The mean gestational age and birth weight were 39.3 ± 1.5 weeks and 3,365.7 ± 569.8 g, respectively. BPS was initiated at a median age of 42.7 h after birth (range: 2.1-166.5 h) with a baseline mean oxygen index (OI) of 33.9 ± 15.7 and a baseline mean systolic blood pressure (SBP) of 79.4 ± 9.9 mm Hg. The mean difference of OI at 24, 48 and 72 h following the treatment was -15.7 ± 14.8 (p = 0.043),-18.2 ± 12.3 (p = 0.018) and -16.7 ± 17.5 (p = 0.042), respectively. The mean SBP was significantly reduced as early as 6 h after initiation of treatment (-11.1 ± 11.5 mm Hg, p = 0.034) without changes in heart rate. Three cases were complicated with chronic lung disease, and the remaining 4 cases were normal at hospital discharge. No neurodevelopmental and cardiopulmonary disorders were observed in all cases at 1 year of age. BPS may be used as an alternative treatment for infants with PPHN giving a significant improvement in oxygenation.

OBJECTIVE: The purpose of our study was to analyze the frequency of preterm deliveries in Obstetrics & Gynecology Clinic, University Clinical Centre of Kosovo, Prishtina (Republic of Kosovo), as well as to assess the survival advantage of premature newborns according to mode of delivery (cesarean section vs. vaginal). MATERIAL AND METHODS: A cohort of 12,466 deliveries from the year 2002 was studied retrospectively and preterm deliveries were analyzed. Survival advantage until 28 days of life associated with cesarean and vaginal delivery was assessed with regard to birth weights (500-999 g, 1000-1499 g, 1500-1999 g, and 2000-2499 g). RESULTS: There were 1,135 preterm deliveries which resulted in 1,189 preterm infants (including multiples). The overall cesarean delivery rate in this group was 32.2%. Among preterm newborns with birth weight 500-999 g, 68 children were delivered vaginally and 5 by caesarean section (5.7% and 0.4% of all preterm babies respectively). None of the infants survived. The percentage of children from cesarean deliveries in the other groups was higher: for preterm infants with birth weight 1000-1499 g--3.2%, 1500-1999 g--8.8% and 2000-2499 g--19.8%. A survival advantage associated with cesarean section was observed in neonates with birth weight 1000-1499 g (p < 0.01). CONCLUSIONS: On the basis of our study it can be concluded that cesarean delivery is associated with a decreased neonatal mortality risk in preterm neonates but only in those with birth weight of 1000-1499 g.

PURPOSE: To determine whether timing or type of delivery affects the incidence of transient tachypnea of the newborn (TTN) in late preterm and term pregnancies. METHODS: The cases of 85 newborns delivered at Fatih University Hospital and diagnosed with TTN between January 2006 and March 2009 were reviewed. For every newborn with TTN, four infants who were not transferred to the neonatal intensive care unit (n = 340) were randomly selected and adjusted for year of delivery. Findings for delivery type (cesarean [CS]+ labor, elective CS [ECS], vaginal), gestational age at delivery, and other relevant parameters were compared in the TTN and control groups. RESULTS: Forty-five (53%) of the 85 TTN newborns were premature and 73 (86%) were delivered by CS. Multivariate regression analysis identified male gender, CS delivery, lower gestational age, absence of PROM as risk factors for onset of TTN. In the CS + labor and ECS subgroups, the risk of TTN was significantly higher for babies delivered prior to 38 weeks' gestation than for those delivered at 38 weeks or later (OR = 8.13 and 95%CI = 3.58-18.52 vs. OR = 7.14 and 95%CI = 2.81-18.18, respectively; p < 0.001 for both). However, there was no increased risk of TTN in either of these subgroups when babies delivered at 38 weeks' gestation were compared with those delivered at >/=39 weeks (p > 0.05). At all gestational ages investigated in the study, infants delivered vaginally were less likely to develop TTN than those delivered via CS + labor or ECS. CONCLUSIONS: Lower gestational age, CS delivery, and male sex are independent risk factors for TTN. Performing ECS no earlier than 38 weeks' gestation may decrease the risk of TTN. Labor before CS is not sufficient to decrease the frequency of TTN, even after 37 weeks of gestation, whereas vaginal birth appears be protective against TTN.