Randomized controlled trial of prolonged second stage: extending the time limit vs usual guidelines.

BACKGROUND: Guidelines for management of the second stage have been proposed since the 1800s and were created largely by expert opinion. Current retrospective data are mixed regarding differences in maternal and neonatal outcomes with a prolonged second stage. There are no randomized controlled trials that have evaluated whether extending the second stage of labor beyond current American College of Obstetricians and Gynecologists recommendations is beneficial. OBJECTIVE: The purpose of this study was to evaluate whether extending the length of labor in nulliparous women with prolonged second stage affects the incidence of cesarean delivery and maternal and neonatal outcomes. STUDY DESIGN: We conducted a randomized controlled trial of nulliparous women with singleton gestations at 36 0/7 to 41 6/7 weeks gestation who reached the American College of Obstetricians and Gynecologists definition of prolonged second stage of labor, which is 3 hours with epidural anesthesia or 2 hours without epidural anesthesia. Women were assigned randomly to extended labor for at least 1 additional hour, or to usual labor, which was defined as expedited delivery via cesarean or operative vaginal delivery. The exclusion criteria were intrauterine fetal death, planned cesarean delivery, ageyears, and suspected major fetal anomaly. Primary outcome was incidence of cesarean delivery. Maternal and neonatal outcomes were compared secondarily. Statistical analysis was done by intention-to-treat. RESULTS: Seventy-eight nulliparous women were assigned randomly. All of the women had epidural anesthesia. Maternal demographics were not significantly different. The incidence of cesarean delivery was 19.5% (n = 8/41 deliveries) in the extended labor group and 43.2% (n = 16/37 deliveries) in the usual labor group (relative risk, 0.45; 95% confidence interval, 0.22-0.93). The number needed-to-treat to prevent 1 cesarean delivery was 4.2. There were no statistically significant differences in maternal or neonatal morbidity outcomes. CONCLUSION: Extending the length of labor in nulliparous women with singleton gestations, epidural anesthesia, and prolonged second stage decreased the incidence of cesarean delivery by slightly more than one-half, compared with usual guidelines. Maternal or neonatal morbidity were not statistically different between the groups; however, our study was underpowered to detect small, but potentially clinical important, differences

Severe Hyperlipidemia Induced Hemorrhagic Pancreatitis during Pregnancy

Background. We report a case of familial hyperlipidemia in pregnancy that resulted in hemorrhagic pancreatitis. Case. A patient at 27-week gestation was admitted for recurrent pancreatitis secondary to severe hyperlipidemia. With conservative care, the patient improved but on the fourth day of admission she experienced a sudden onset of hypotension and was diagnosed with hemorrhagic pancreatitis. Conclusion. Pancreatitis caused by hyperlipidemia is an uncommon event during pregnancy. A familiarity with the severe complications associated with this potentially life-threatening condition is important

Peanut ball for decreasing length of labor: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION: Prolonged length of labor is associated with increased maternal and neonatal complications. Therefore, great attention has been given to interventions aimed at reducing the length of labor. One such intervention is the peanut ball, a large elongated exercise ball placed between a woman's legs during labor. OBJECTIVE: The aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to assess the effect of the use of peanut ball in reducing length of labor. STUDY DESIGN: Data sources: MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library were searched from inception until January 2019. SELECTION CRITERIA: Selection criteria included RCTs of laboring women with singleton gestations in cephalic presentation at term (≥37weeks) who were randomized to either use of peanut ball or control group (no peanut ball). DATA COLLECTION AND ANALYSIS: Four trials with 648 nulliparous and multiparous women in spontaneous or induced labor were identified and included. 330 women were randomized to the intervention (peanut ball between the knees during labor) and 318 women to the control. Summary measures were reported as mean difference (MD) with 95% of confidence interval (CI) using the random effects model of DerSimonian and Laird. The primary outcome was total length of labor. PROSPERO Registration Number: CRD42018082438 RESULTS: Total length of labor was 79min shorter in the peanut ball group, but this was not significant (MD -79.1 min, 95% CI -204.9, 46.7). Peanut ball use showed trends toward higher incidence of spontaneous vaginal deliveries (RR 1.1, 95% CI 1.0, 1.2) and lower incidence of cesarean deliveries (RR 0.8, 95% CI 0.6, 1.0). CONCLUSIONS: Peanut ball use was not associated with a significant decrease in total length of labor. Since there were trends toward reductions in length of labor, an increased incidence in spontaneous vaginal deliveries, and lower incidence of cesarean deliveries, more research is needed

Pessary versus cerclage versus expectant management for cervical dilation with visible membranes in the second trimester.

OBJECTIVE: We evaluated pessary for dilated cervix and exposed membranes for prolonging pregnancy compared to cerclage or expectant management. METHODS: Multicenter retrospective cohort study of women, 15-24 weeks, singleton pregnancies, dilated cervix ≥2 cm and exposed membranes. Women received pessary, cerclage or expectant management. Primary outcome was gestational age (GA) at delivery. Secondary outcomes were time until delivery, preterm premature rupture of membranes (PPROM) and neonatal survival. RESULTS: About 112 women met study criteria; 9 - pessary, 85 - cerclage and 18 - expectant management. Mean GA at delivery was 22.9 ± 4.5 weeks with pessary, 29.2 ± 7.5 weeks with cerclage and 25.6 ± 6.7 weeks with expectant management (p = 0.015). Time until delivery was 16.1 ± 18.9 days in the pessary group, 61.7 ± 48.2 days in the cerclage group and 26.8 ± 33.4 days in the expectant group (p \u3c 0.001). PPROM occurred less frequently and neonatal survival increased in women with cerclage. There was a significant difference in all the perinatal outcomes with cerclage compared with either pessary or expectant management. CONCLUSIONS: Perinatal outcomes with pessary were not superior to expectant management in women with dilated cervix with exposed membranes in the second trimester in this small retrospective cohort

Moyamoya Disease in Pregnancy: Management after Intracranial Bypass Grafting

Moyamoya disease (MD) is a chronic, progressive cerebrovascular disease distinguished by bilateral stenosis or occlusion of the arteries around the circle of Willis with resulting prominent arterial collateral circulation. We describe a pregnant woman in whom this diagnosis was confirmed by cerebral angiogram and treated with bilateral superficial temporal artery-middle cerebral artery (STA-MCA) bypass grafting prior to conception. The patient was managed with strict blood pressure monitoring and low-dose aspirin antepartum, intrapartum, and postpartum. The patient presented in spontaneous labor at term and underwent a spontaneous vaginal delivery without complications

Influence of pelvic osteotomy on birth canal size

Six pelvic osteotomies (Salter, Sutherland, Steel, Tönnis, Chiari, and periacetabular) were performed on the right hemipelvis of adult female pelvic plastic models. Each pelvis underwent conventional X-ray and computed tomographic digital pelvimetry before and after osteotomy. The change in the anteroposterior and transverse dimensions at the inlet, midpelvis, and outlet were calculated. None of the osteotomies significantly decreased the inlet. The Salter and Sutherland osteotomies decreased the midpelvis to borderline low. The Salter, Sutherland, and Steel osteotomies significantly decreased the pelvic outlet. These changes correlated closely with those in living patients. Much of this decrease is nullified when the osteotomy is performed prior to the pubertal growth spurt.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/47232/1/402_2004_Article_BF00451876.pd