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Clinical Significance of Precipitous Labor

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Precipitous labor is defined as expulsion of the fetus within less than 3 hours of commencement of regular contractions. We retrospectively examined our cases of precipitous labor to identify the clinical significance and perinatal outcomes following precipitous labor in singleton vertex deliveries. A retrospective population-based study was conducted comparing women with singleton precipitous labor and those with labor of normal duration. We examined the clinical characteristics and outcomes by comparing patients with precipitous labor and those with labor of normal duration in 0 and two-parous singleton pregnant women. Using a multivariate analysis, precipitous labor in nulliparous women was independently associated with teenagers (adjusted OR: 1.71, 95% CI: 0.99 - 2.95, P = 0.049), preterm delivery (adjusted OR: 1.77, 95% CI: 1.16 - 2.70, P < 0.01) and hypertensive disorders (adjusted OR: 1.77, 95% CI: 1.19 - 2.65, P < 0.01), while in two-parous women, it was independently associated with hypertensive disorders (adjusted OR: 2.64, 95% CI: 1.33 - 5.24, P < 0.01). No significant differences were noted between the two groups regarding maternal or neonatal complications on both nulliparous and two-parous women. Although precipitous labor was associated with hypertensive disorders in singleton vertex deliveries, it was not associated with maternal or neonatal outcomes.
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150
Original Article
J Clin Med Res. 2015;7(3):150-153
ress
Elmer
Clinical Signicance of Precipitous Labor
Shunji Suzuki
Abstract
Background: Precipitous labor is dened as expulsion of the fetus
within less than 3 hours of commencement of regular contractions.
We retrospectively examined our cases of precipitous labor to identify
the clinical signicance and perinatal outcomes following precipitous
labor in singleton vertex deliveries.
Methods: A retrospective population-based study was conducted
comparing women with singleton precipitous labor and those with
labor of normal duration. We examined the clinical characteristics
and outcomes by comparing patients with precipitous labor and those
with labor of normal duration in 0 and two-parous singleton pregnant
women.
Results: Using a multivariate analysis, precipitous labor in nullipa-
rous women was independently associated with teenagers (adjusted
OR: 1.71, 95% CI: 0.99 - 2.95, P = 0.049), preterm delivery (adjusted
OR: 1.77, 95% CI: 1.16 - 2.70, P < 0.01) and hypertensive disorders
(adjusted OR: 1.77, 95% CI: 1.19 - 2.65, P < 0.01), while in two-pa-
rous women, it was independently associated with hypertensive disor-
ders (adjusted OR: 2.64, 95% CI: 1.33 - 5.24, P < 0.01). No signicant
differences were noted between the two groups regarding maternal or
neonatal complications on both nulliparous and two-parous women.
Conclusion: Although precipitous labor was associated with hyper-
tensive disorders in singleton vertex deliveries, it was not associated
with maternal or neonatal outcomes.
Keywords: Precipitous labor; Hypertensive disorders; Maternal out-
come
Introduction
Not only can labor be too slow, but it also can be abnormally
rapid [1-4]. Precipitous labor is extremely rapid labor and de-
livery. It is dened as expulsion of the fetus within less than
3 h of commencement of regular contractions [1]. It has been
supposed to result from an abnormally low resistance of the
soft pass of birth canal, from abnormally strong uterine and
abdominal contractions, or rarely from the absence of pain-
ful sensations [1]. The prevailing opinion has been that too
rapid a labor can result in maternal injury and place the fetus
at risk for traumatic or asphyxia insults [1]. For example, the
uterus that contracts with unusual vigor before labor may be
likely to be hypotonic after delivery, with hemorrhage from the
placental implantation as the consequence. Postpartum hemor-
rhage associated with uterine atony following short labor in
multiparous women seems to be experienced often in the clini-
cal setting. In addition, precipitous labor has been observed to
be associated with the higher rate of placental abruption [2, 3].
However, limited information exists on maternal and perina-
tal outcome after precipitous labor, especially in nulliparous
women [2, 3]. For example, in an earlier study with 99 precipi-
tous labors at term by Mahon et al [2], precipitous labor oc-
curred mostly in multiparous women. In their study, there were
only nine nulliparous women (9.1% of all precipitous delivery)
with precipitous delivery.
In this study, therefore, we retrospectively examined our
cases of precipitous labor to identify the clinical signicance
and perinatal outcome following precipitous labor.
Patients and Methods
A retrospective population-based study was conducted com-
paring women with singleton precipitous labor and those with
labor of normal duration. Labor of normal duration is dened
as expulsion of the fetus with 3 - 30 h after commencement
of regular contractions in nulliparous women and 3 - 15 h af-
ter commencement of regular contractions in parous women,
while prolonged labor is dened as expulsion of the fetus more
than 30 h after commencement of regular contractions in nul-
liparous women and more than 15 h after commencement of
regular contractions in parous women [5]. Deliveries in this
study occurred between the years 2009 and 2013 in the Japa-
nese Red Cross Katsushika Maternity Hospital, one of main
Perinatal Centers in Tokyo, Japan. In our hospital, oxytocin
has not been used in the routine for prevention of postpartum
Manuscript accepted for publication December 12, 2014
Department of Obstetrics and Gynecology, Japanese Red Cross Katsushika
Maternity Hospital, Tokyo, Japan. Email: czg83542@mopera.ne.jp
doi: http://dx.doi.org/10.14740/jocmr2058w
Articles © The authors | Journal compilation © J Clin Med Res and Elmer Press Inc™ | www.jocmr.org
151
Suzuki J Clin Med Res. 2015;7(3):150-153
hemorrhage in cases of precipitous labor. Data were collected
from the patients’ charts that consist of information collected
directly after delivery by the midwives who examine the in-
formation routinely before entering it into the database. The
following clinical characteristics and outcomes were analyzed:
parity; maternal age; gestational age; birth weight; maternal
complications such as hypertensive diseases, glucose intoler-
ance; placental abruption; oxytocin use; delivery modes; neo-
natal Apgar score at 1 and 5 min; umbilical artery pH; post-
partum hemorrhage requiring hemotransfusion; perineal tears
(severe perineal laceration: perineal laceration either third- or
fourth-degree laceration); and cervical tears.
In this study, we examined these clinical characteristics
and outcomes by comparing patients with precipitous labor
and those with labor of normal duration in 0 and two-parous
women.
Table 1. Incidences of Precipitous and Prolonged Singleton Labors
Parity Total
Vaginal labor
Cesarean delivery
Precipitate labor Normal Prolonged labor
0 5,555 386 (6.9) 3,776 (68.0) 29 (0.5) 1,364 (24.6)
1 3,880 817 (21.1) 1,844 (47.5) 48 (1.2) 1,171 (30.2)
2 1,308 320 (24.5) 590 (45.1) 8 (0.6) 390 (29.8)
≥ 3 496 83 (16.7) 277 (55.8) 3 (0.6) 133 (26.8)
Total 11,239 1,606 (14.3) 6,487 (57.7) 88 (0.8) 3,058 (27.2)
Table 2. Clinical Characteristics and Outcomes in Nulliparous Women With and Without Precipitate Labor
Precipitate labor Normal group P-value Crude OR 95% CI
Total 386 3776
Maternal age
< 20 years 21 (5.4) 115 (3.0) 0.01 1.85 1.14 - 3.00
20 - 34 years 263 (68.1) 2,670 (70.7) - Reference -
≥ 35 years 101 (26.2) 991 (25.2) 0.78 1.03 0.81 - 1.32
Gestational age at delivery
< 37 weeks 53 (13.7) 159 (4.2) < 0.01 3.47 2.49 - 4.84
37 - 40 weeks 293 (75.9) 3,050 (80.8) - Reference -
41 - 42 weeks 40 (10.3) 563 (14.9) 0.08 0.74 0.53 - 1.04
Hypertensive disorders 36 (9.3) 174 (4.6) < 0.01 2.13 1.46 - 3.10
Glucose intolerance 10 (2.6) 87 (2.3) 0.72 1.13 0.58 - 2.19
Oxtocin use 106 (27.5) 1,353 (35.8) < 0.01 0.68 0.54 - 0.86
Placental abruption 4 (1.0) 58 (1.5) 0.44 0.67 0.24 - 1.86
Vacuum/forceps delivery 56 (14.1) 411 (12.2) 0.05 1.35 1.00 - 1.82
Neonatal birth weight
< 2,500 g 110 (28.5) 349 (9.2) 0.01 3.64 2.84 - 4.67
2,500 - 3,499 g 293 (75.9) 3,039 (80.5) - Reference -
≥ 3,500 g 40 (10.3) 388 (10.3) < 0.01 0.39 0.22 - 0.68
Apgar score at 1 min < 4 0 (0) 14 (0.4) 0.23 - -
Apgar score at 5 min < 7 1 (0.3) 7 (0.2) 0.75 1.40 0.17 - 11.40
Umbilical artery pH < 7 0 (0) 10 (0.3) 0.31 - -
Total blood loss ≥ 1,000 mL 28 (7.3) 319 (8.4) 0.42 0.85 0.57 - 1.27
Hemotransfusion 4 (1.0) 18 (0.5) 0.15 2.19 0.74 - 6.49
Cervical laceration 12 (3.1) 66 (1.3) 0.06 1.8 0.97 - 3.37
Severe perineal laceration 14 (3.6) 141 (3.7) 0.91 0.97 0.55 - 1.70
Values are expressed as number (percentage). OR: odds ratio; CI: condence interval. Severe perineal laceration, perineal laceration either third- or
fourth-degree laceration.
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152
Precipitous Labor J Clin Med Res. 2015;7(3):150-153
Statistical signicance was ascertained using the X
2
test or
Fishers exact test for differences in qualitative variables and
the Student’s t-test for differences in continuous variables. A
multivariate logistic regression model, with backward elimi-
nation, was constructed in order to nd independent factors
associated with precipitous labor. Odds ratios (ORs) and their
95% condence intervals (CIs) were computed. P < 0.05 was
considered statistically signicant.
Results
During the study period, there were 11,239 singleton deliveries
in our hospital as shown in Table 1. Of these, 1,606 (14.3%)
were precipitous deliveries. The incidence of precipitous labor
in the parous women (21.5%) was signicantly higher than
that in the nulliparous women (6.9%, OR: 3.66, 95% CI: 3.24
- 4.13, P < 0.01).
Table 2 shows clinical characteristics and outcomes of the
two groups of nulliparous women with precipitous and normal
labor. The women with precipitate deliveries were more likely
to be younger, at lower gestational age of delivery, without
oxytocin use, lower birth weight of infant, and hypertensive
disorders as compared to those without precipitate deliveries.
Using a multivariate analysis, precipitous labor was indepen-
dently associated with teenagers (adjusted OR: 1.71, 95% CI:
0.99 - 2.95, P = 0.049), preterm delivery (adjusted OR: 1.77,
95% CI: 1.16 - 2.70, P < 0.01) and hypertensive disorders (ad-
justed OR: 1.77, 95% CI: 1.19 - 2.65, P < 0.01). No signicant
differences were noted between the two groups regarding ma-
ternal or neonatal complications as shown in Table 2.
Table 3 shows clinical characteristics and outcomes of the
two groups of two-parous women with precipitous and normal
labor. The women with precipitate deliveries were more likely
to have oxytocin use and hypertensive disorders as compared
to those without precipitate deliveries. Using a multivariate
analysis, precipitous labor was independently associated with
hypertensive disorders (adjusted OR: 2.64, 95% CI: 1.33 -
Table 3. Clinical Characteristics and Outcomes in Two-Parous Women With and Without Precipitate Labor
Precipitate labor Normal group P-value Crude OR 95% CI
Total 320 590
Maternal age
< 20 years 0 (0) 1 (0.2) 0.47 - -
20 - 34 years 169 (52.8) 326 (55.3) - Reference -
≥ 35 years 151 (47.2) 263 (44.6) 0.46 1.11 0.84 - 1.46
Gestational age at delivery
< 37 weeks 21 (6.6) 30 (5.1) 0.28 1.37 0.77 - 2.44
37 - 40 weeks 261 (81.6) 511 (86.6) - Reference -
41 - 42 weeks 38 (11.9) 49 (8.3) 0.07 1.52 0.97 - 2.38
Hypertensive disorders 30 (9.4) 15 (2.7) < 0.01 3.71 1.99 - 6.92
Glucose intolerance 10 (3.1) 15 (2.5) 0.61 1.24 0.55 - 2.79
Oxtocin use 35 (10.9) 35 (5.9) < 0.01 1.95 1.19 - 3.18
Placental abruption 4 (1.3) 4 (0.7) 0.38 1.85 0.46 - 1.47
Vacuum/forceps delivery 9 (2.8) 16 (2.7) 0.97 1.01 0.44 - 2.32
Neonatal birth weight
< 2,500 g 28 (8.8) 42 (7.1) 0.35 1.27 0.77 - 2.10
2,500 - 3,499 g 247 (77.2) 470 (79.7) - Reference -
≥ 3,500 g 45 (14.1) 48 (13.2) 0.65 1.1 0.74 - 1.63
Apgar score at 1 min < 4 0 (0) 1 (0.2) 0.46 - -
Apgar score at 5 min < 7 0 (0) 0 (0) - - -
Umbilical artery pH < 7 0 (0) 0 (0) - - -
Total blood loss ≥ 1,000 mL 17 (5.3) 32 (5.4) 0.94 0.98 0.53 - 1.79
Hemotransfusion 0 (0) 0 (0) - - -
Cervical laceration 3 (0.9) 8 (1.4) 0.58 0.69 0.18 - 2.61
Severe perineal laceration 0 (0) 3 (0.5) 0.2 - -
Values are expressed as number (percentage). OR: odds ratio; CI: condence interval. Severe perineal laceration, perineal laceration either third- or
fourth-degree laceration.
Articles © The authors | Journal compilation © J Clin Med Res and Elmer Press Inc™ | www.jocmr.org
153
Suzuki J Clin Med Res. 2015;7(3):150-153
5.24, P < 0.01). No signicant differences were noted between
the two groups regarding maternal or neonatal complications
as shown in Table 3.
Discussion
The incidence of precipitous labor in this study was about 14%
of all singleton deliveries, which seemed to be higher than
those reported in the United States and other countries: 0.1-
3% [1-3]. In Japan, the onset of labor is usually dened by the
patient’s report of the commencement of regular contractions
of 10-min intervals. The high incidence in this study may be
attributed to the different denitions as well as the diagnosis of
regular contractions by monitoring and not patient’s report in
other countries. In this study, in addition, the incidence of pre-
cipitous labor in the nulliparous women was higher than that
in parous women, as it is known that generally parous patients
have shorter deliveries. This result was supported by some pre-
vious studies [1-3].
In some previous studies [2, 3], one of main perinatal
complications associated with precipitous labor has been re-
ported to be placental abruption, because placental abruption
can cause tachysystole, and thus shorter deliveries. On the
contrary, we did nd the high incidence of placental abrup-
tion in the women with precipitous labor. The reason leading
to the different outcomes is not clear. However, our medical
policy performing cesarean section immediately after the di-
agnosis of placental abruption might have attributed to reduce
the rate of vaginal delivery in cases of placental abruption [6].
In this study, although the incidence of placental abruption was
not associated with precipitous labor, hypertensive disorders
seemed to attribute to the increased odds of precipitous labor.
Recently, the deciency of maternal immune response to the
fetus that may result in preeclampsia or in pregnancy loss has
been discussed as a rejection to the fetus [7, 8]. Therefore, in
hypertensive disorders such as preeclampsia, the pathophysi-
ology of rejection to the fetus may be able to cause effective
uterine contractions for early expulsion of the fetus. Other-
wise, the hypertensive disorders might be a preliminary stage
of the placental abruption.
In this study, teenagers and preterm delivery were asso-
ciated with precipitous labor in nulliparous women. The soft
residence of birth canal in young women may cause rapid de-
livery and prevent the extensive lacerations of the cervix, va-
gina, vulva or perineum. The smallness of infants in preterm
delivery may also prevent these lacerations. In addition, the
Japanese women seemed to wish to take cesarean delivery in
cases of preterm labor that can take a long time as expected,
and these trends might have contributed to the current results.
In an earlier study by Sheiner et al [3], precipitous labor
was associated with some maternal complications including
perineal lacerations, postpartum hemorrhage, retained placen-
ta, hemotransfusion and prolonged hospitalization. These ma-
ternal complications have been previously reported as possible
consequences of precipitous labor due to abnormally strong
uterine contractions combined with non-dilated cervix and
highly resistant birth canal [1, 3]. On the contrary, in this study
precipitous labor seemed to be not associated with adverse ma-
ternal outcomes. The high incidence of teenagers, small infants
and preterm delivery in the precipitous labor of this study may
contribute to the unchanged incidence of maternal complica-
tions due to maternal soft birth canal and/or small fetus passing
through. Otherwise, the current outcomes may be attributed to
the different denitions of the commencement of regular con-
tractions between some studies.
In this study, at last, precipitous labor was not associated
with maternal or neonatal outcomes. The current result sup-
ports the previous observations [1-3].
Conclusion
Based on the current results, although precipitous labor was
associated with hypertensive disorders in singleton vertex de-
liveries, it was not associated with maternal or neonatal out-
comes.
Conicts of Interest
Authors have no disclosures or conicts of interest.
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... Over the study period, the incidence of OHD in this study was 0.22%, which is similar to that reported in other studies (Table 4), and our findings were in line with previous studies of accidental OHDs [1][2][3][4][5][6][7][8]11]. OHDs have been reported to be associated with the risk of prematurity [1][2][3]25]. In our study, prematurity was significantly higher for the OHDs than for the in-hospital births. ...
... Teenage mothers and preterm deliveries were found to pose a risk of OHDs. The soft birth canal in young women and small preterm infants may cause rapid delivery [25]. Multiparous mothers and lack of prenatal care were also related to OHDs in previous reports [1][2][3][4][5]9]. ...
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Background: Precipitate labour is a vaginal delivery which occurs within 3 hours after onset of labour, there is limited data available on risk factors associated with precipitate labour, while some data suggests it is associated with certain complications. Objective: This study was aimed to know the frequency of precipitate labour, risk factors associated with precipitate labour and its related complications in local population. Material and methods: We conducted a prospective study, in which we enrolled eligible pregnant female and they were asked about risk factors on admission to labour and delivery ward, these females were observed for duration of labour and its related complications at Dr Sulaiman Alhabib
... (10) No significant effect of the parity was observed in the current study in contrary to the study done by Shunji and Mahon who found that the incidence of the precipitate labor was higher in parous women. (15,16) Family history is the most common associated risk factor detected in the current study which is yet to be detected. ...
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... (10) No significant effect of the parity was observed in the current study in contrary to the study done by Shunji and Mahon who found that the incidence of the precipitate labor was higher in parous women. (15,16) Family history is the most common associated risk factor detected in the current study which is yet to be detected. ...
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Objective: Although fetal growth restriction (FGR) is associated with an increased risk of cesarean delivery during induced labor, there is little evidence to guide labor management in such cases. This study aimed to investigate whether discontinuation of oxytocin infusion affects the cesarean delivery rate and the risk of maternal and neonatal complications associated with induced labor in pregnancies with suspected FGR. Methods: This was a retrospective cohort study of singleton pregnancies with vertex presentation and indications for labor induction due to FGR after 34.0 weeks of gestation at our institution from January 2010 to December 2017. Two parallel groups were compared: women who received oxytocin continuously until delivery (continuation group) and women whose oxytocin was discontinued at the beginning of the active phase of labor (discontinuation group). Results: There were 74 women in the continuation group and 51 women in the discontinuation group. The incidence of cesarean deliveries was higher (5.4% vs 2.0%) in the continuation group, but this difference was not statistically significant. However, the incidence of uterine tachysystole (23.0% vs 9.8%) was significantly higher in the continuation group than in the discontinuation group. Differences in labor management did not affect the lengths of the active phase and second stage of labor (mean, 136 ± 122 minutes and 34.2 ± 45 minutes, respectively; 122 ± 104 minutes and 48.8±67 minutes in the continuation group and discontinuation group, respectively). The incidence of postpartum hemorrhage and adverse neonatal outcomes were not significantly different between groups. Conclusions: Oxytocin can be safely discontinued after the active phase of labor in women undergoing labor induction for FGR without an increased risk of cesarean delivery or other unfavorable outcomes. Therefore, this strategy may be considered an alternative to continued oxytocin infusion.
... Whereas active labours and births were typically described as being "very very fast" -P30. A precipitate, or abnormally rapid labour is clinically defined as the expulsion of the baby within less than 3 hours of commencement of regular contractions ( Suzuki, 2015 ). For maternity staff this occurrence was seemingly an unexpected "shock" -P16. ...
Article
Objective The Ehlers-Danlos syndromes (EDS) and Hypermobility Spectrum Disorders (HSD) have profound and life-threatening consequences in childbearing as they affect connective tissues throughout the body. Hypermobile EDS (hEDS) and HSD are estimated here for the first time to affect 6 million (4.6%) pregnancies globally per year. The aim of this study was to arrive at a deeper biopsychosocial understanding of childbearing in the context of hEDS/HSD. Methods English speaking women aged over 18 years who had previously given birth and had a confirmed medical diagnosis of hEDS/HSD or equivalent diagnosis under a preceding nosology were included in this study (n=40). Narrative interviews were used to collect qualitative data from this international sample of participants. Thematic narrative analysis was used to understand how participants made sense of their experiences. Findings Participants were aged between 25 and 55. Births (n= 52) between 1981 and 2018 were captured across United Kingdom=29 (73%), United States of America=10 (25%) and Canada=1 (2%). The majority of participants interviewed recounted a worsening of symptoms during pregnancy and postnatal complications. Anaesthesia was often reportedly ineffective, and for many, long latent phases of labour quickly developed into rapidly progressing active labours and births. Maternity staff were observed to be panicked by these unexpected outcomes and were deemed to lack the knowledge and understanding of how to care for women in this context. Poor maternity care resulted in women disengaging from services, trauma, stress, anxiety and an avoidance of future childbearing. Key conclusions and implications for practice Cases of hEDS/HSD should no longer be considered rare in maternity services. Maternity staff must be adequately prepared for this new reality. As a first step, www.hEDSTogether.co.uk has been developed to provide a repository of evidence in relation to this topic, along with a freely downloadable toolkit for use in practice. It is important to listen, acknowledge and respond to women with hEDS/HSD appropriately throughout their childbearing journey. Dismissal can lead to trauma and needless morbidity.
Article
Objective: To study the association between precipitous labor (less than 3 hours) and the onset of transient tachypnea in singleton fetuses in cephalic presentation with term vaginal deliveries. Methods: This cohort study included women delivered from 2013 through 2017 in our French tertiary university hospital maternity unit. Inclusion criteria were vaginal delivery of liveborn singleton fetus in cephalic presentation and at term. We compared women with precipitous labor and those with longer labor. The principal endpoint was the rate of transient tachypnea of the newborn (TTN). We investigated risk factors for TTN besides duration of labor. Results: Comparison of 2644 women with precipitous labor and 7571 with longer labor showed a lower TTN rate in the precipitous labor group (1.6 vs 2.7%; P=0.003). The association was no longer significant after adjustment for the risk factors identified in the univariate analysis (adjusted OR 0.99, 95% CI 0.64-1.54). Risk factors identified for TTN were non-clear amniotic fluid, shoulder dystocia, umbilical cord encirclement, birth weight less than 2500 g, use of cervical ripening and operative vaginal delivery. Conclusion: Precipitous labor, lasting less than 3 hours, is not associated with a higher risk of transient tachypnea in term newborns after vaginal delivery.
Article
Objective: Birth outcomes of women with anorexia nervosa are poorly understood. We hypothesized that hospitalization for anorexia nervosa before or during pregnancy is associated with an elevated risk of adverse maternal and infant birth outcomes. Method: We performed a retrospective cohort study of 2,134,945 pregnancies in Quebec, Canada, from 1989 to 2016. The main exposure measure was anorexia nervosa requiring hospital treatment before or during pregnancy. Outcome measures included stillbirth, preterm birth, low birth weight, small-for-gestational age birth, preeclampsia, gestational diabetes, cesarean delivery, and other pregnancy disorders. We computed risk ratios and 95% confidence intervals (CI) for the association between anorexia nervosa and birth outcomes adjusted for maternal characteristics. Results: Compared with no hospitalization, anorexia nervosa hospitalization was associated with 1.99 times the risk of stillbirth (95% CI 1.20-3.30), 1.32 times the risk of preterm birth (95% CI 1.13-1.55), 1.69 times the risk of low birth weight (95% CI 1.44-1.99), and 1.52 times the risk of small-for-gestational age birth (95% CI 1.35-1.72). The associations with low birth weight and small-for-gestational age birth were more prominent in women hospitalized for anorexia nervosa during pregnancy or within 2 years of delivery. Hospitalization for anorexia nervosa was associated with certain maternal outcomes, including precipitate labor, acute liver failure, and admission to an intensive care unit. Discussion: Hospitalization for anorexia nervosa before or during pregnancy is associated with adverse infant and maternal outcomes. Infants are primarily at risk of stillbirth, preterm birth, low birth weight, and small-for-gestational age birth.
Article
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Successful pregnancy requires strict temporal regulation of maternal immune function to accommodate the growing fetus. Early implantation is facilitated by inflammatory processes that ensure adequate vascular remodeling and placental invasion. To prevent rejection of the fetus, this inflammation must be curtailed; reproductive immunologists are discovering that this process is orchestrated by the fetal unit and, in particular, the extravillous trophoblast. Soluble and particulate factors produced by the trophoblast regulate maternal immune cells within the decidua, as well as in the periphery. The aim of this review is to discuss the action of recently discovered immunomodulatory factors and mechanisms, and the potential effects of dysregulation of such mechanisms on the maternal immune response that may result in pregnancy loss or preeclampsia.
Article
We reviewed the obstetric records of 40 singleton deliveries complicated by placental abruption which developed at patients' homes after 24 weeks' gestation. Of the 40 cases complicated by placental abruption which developed at home, 13 cases (33%) were defined as showing adverse outcomes (5 cases of IUFD and 8 cases of UA pH < 7.0). The rate of patients who complained of abdominal pain without bleeding was higher in the adverse outcome group than in the control group (p = 0.02). The average time interval between the onset and hospital (or clinic) visit in the adverse outcome group was longer than in the control group (p = 0.03). Adverse outcomes due to placental abruption which developed at home were associated with the symptom of pain without bleeding and a long time interval between the onset and hospital (or clinic) visit.
Article
Any delivery in the emergency department is considered a precipitous birth and is an anxiety-producing event. Many deliveries proceed without incident. However, the emergency physician must be prepared for several dreaded scenarios, such as nuchal cord, shoulder dystocia, and breech birth. This article reviews the basics, complications, and management of such deliveries.
Article
To determine the characteristics and consequences of short labor. Ninety-nine term pregnancies with singleton vertex presentation and labor lasting 3 hours or less were compared with controls with longer labor, matched to the index cases by maternal age, parity, and birth weight. Short labor occurred mostly in multiparas. Both the first and second stages of labor were found to be shortened in these cases. There was significantly more placental abruption, uterine tachysystole, and maternal cocaine use among short-labor cases. Major perineal lacerations, postpartum hemorrhage, birth trauma, and low Apgar scores were distributed approximately equally between cases and controls. A preponderance of the bad outcomes in the short labors occurred in the subgroup of those with rates of dilatation and descent that exceeded established 95th percentile limits. Labors of 3 hours or less in duration were strongly associated with placental abruption, but were otherwise not major contributors to maternal and fetal morbidity.
Article
Preeclampsia has been recognized clinically since the time of Hippocrates: however its etiology and pathophysiology remain enigmatic. This pregnancy-specific syndrome typically presents in late pregnancy as hypertension, edema, and proteinuria. Investigations over the past 15 years have revealed that preeclampsia is associated with abnormal placentation, reduced placental perfusion, endothelial cell dysfunction, and systemic vasospasm. Since it occurs more commonly in primigravidae and in women with underlying collagen-vascular diseases, an immunological component has long been suspected. Increased prevalence in high-order and molar pregnancies and those associated with increased placental mass suggests that trophoblastic volume and fetal antigen load are correlated with the syndrome. Epidemiological reports indicate that the prevalence of preeclampsia is decreased in women who received heterologous blood transfusions, practiced oral sex, or when a long period of cohabitation preceded an established pregnancy. Conversely, the use of condoms as a primary mode of contraception is associated with a higher risk of preeclampsia. These studies suggest that prior exposure to foreign or paternal antigens imparts a protection against the likelihood of developing preeclampsia. Clinical evidence of cellular and humoral immune dysfunction is associated with the syndrome. Fibrin and complement deposition and "foam" cells in atherosis lesions resemble the histopathology of renal allograft rejection. Relative T-cell, natural killer cell, and neutrophil activation have been reported in preeclampsia and circulating cytokines and antiphospholipid antibodies are more prevalent in preeclampsia than in normal pregnant women. These abnormalities are consistent with the systemic endothelial cell dysfunction that has been postulated as a pathophysiological feature of preeclampsia. While such associations do not prove causality, they suggest testable hypotheses for continued basic and clinical investigation of this major complication of human pregnancy.
Article
The study was aimed to identify risk factors and to elucidate pregnancy outcome following precipitate labor, i.e. expulsion of the fetus within less than 3 h of commencement of contractions. A comparison of patients with and without precipitate labor, delivered during the years 1988-2002, was conducted. Patients who underwent cesarean deliveries were excluded from the analysis. A multiple logistic regression model, with backward elimination, was performed to investigate independent risk factors for precipitate labor. The number of vaginal deliveries that occurred during the study period was 137,171. Of these, 99 were precipitate. Independent risk factors for precipitate labor, using a backward, stepwise multivariate analysis were: placental abruption (odds ratio (OR) = 30.9, 95% confidence interval (CI) 15.9-60.4, P < 0.001); fertility treatments (OR = 3.9, 95% CI 1.7-9.0, P = 0.002); chronic hypertension (OR = 3.1, 95% CI 1.2-7.8, P = 0.015); intrauterine growth restriction (IUGR) (OR = 2.9, 95% CI 1.2-6.8, P = 0.014); prostaglandin E2 induction (OR = 1.9, 95% CI 1.1-3.5, P = 0.045); birth weight < 2,500 g (OR = 1.8, 95% CI 1.1-3.1, P = 0.020); and nulliparity (OR = 1.7, 95% CI 1.1-2.6, P = 0.014). No significant differences were noted between the groups regarding perinatal complications such as meconium stained amniotic fluid, perinatal mortality and low Apgar scores. However, there were higher rates of maternal complications in the precipitate labor group such as cervical tears and grade 3 perineal tears (18.2% versus 0.3%, P < 0.001; and 2.0% versus 0.1%, P < 0.001, respectively), post-partum hemorrhage (13.1% versus 0.4%, P < 0.001); retained placenta (2.0% versus 0.5%, P = 0.02); the need for revision of uterine cavity and packed-cells transfusions (34.3% versus 4.9%, P < 0.001; and 11.1% versus 1.1%, P < 0.001, respectively) and prolonged hospitalization (27.6% versus 19.2%, P = 0.035) as compared to the controls. Precipitate labor is associated with higher rates of maternal complications.
Management of normal vaginal delivery
  • N Sugino
Sugino N. Management of normal vaginal delivery (in Japanese). Nippon Sanka Fujinka Gakkai Zasshi. 2008;61:N451-N457.