Why VBAC in Northern New England is still viable: the Northern New England perinatal quality improvement network.

Under the strong leadership of Maternal-Fetal Medicine specialists and the support of the tertiary care centers serving the region, Northern New England (NNE) initiated a collaborative project to improve the availability and safety of trial of labor after cesarean delivery. The project involved over 250 individuals from over 30 organizations and resulted in a strong regional guideline that has been implemented by institutions across the nation. The availability of trial of labor after cesarean in NNE has increased.

Operative vaginal delivery: a comparison of forceps and vacuum for success rate and risk of rectal sphincter injury.

Objective: We investigated the success rate of operative vaginal delivery and risk of rectal sphincter injury when forceps or vacuum was used.

Study Design: Cases were identified by a retrospective review of delivery logbooks and an obstetric database. Rotations were excluded.

Adjustment for case mix in comparisons of cesarean delivery rates: university versus community hospitals in Vermont.

Objective: Our objective was to determine whether case mix model adjustment would help to explain differences in cesarean delivery rates between community and university hospitals. We also wished to define a patient population in which the cesarean delivery rate would be more reflective of individual practice patterns than of obstetric or medical risk.

Study Design: Established risk factors for cesarean delivery were identified by retrospective chart review at two community hospitals (designated A and B) and a university hospital.

Adenosine diphosphate-induced platelet activation inhibited by magnesium in a dose-dependent manner.

Objective: To examine the hypothesis that magnesium inhibits platelet activation at concentrations equivalent to therapeutic levels.

Methods: Fifteen subjects were enrolled: five healthy, female donors with regular, spontaneous menstrual cycles; five women with uncomplicated third-trimester pregnancies; and five preeclamptic subjects before magnesium therapy. Anticoagulated whole blood was added to tubes containing 0.

Increase in fetal breech presentation in female carriers of Duchenne muscular dystrophy.

Female carriers of Duchenne muscular dystrophy (DMD) may demonstrate elevated serum creatine kinase (CK) and reduction of muscle dystrophin in all muscle types. We hypothesized that decreased dystrophin in uterine or pelvic girdle musculature might affect the obstetrical performance of females heterozygous for a dystrophin mutation. We reviewed the outcome of 34 deliveries resulting in 35 children from 13 women who were mothers of males attending a muscular dystrophy clinic.

Cardiovascular function before, during, and after the first and subsequent pregnancies.

This study was designed to test the hypothesis that the vascular remodeling of pregnancy begins early, persists for at least 1 year after delivery, and is accentuated by a second pregnancy. Serial estimates of heart rate, arterial pressure, left ventricular volumes, cardiac output, and calculated peripheral resistance were obtained before pregnancy, every 8 weeks during pregnancy, and 12, 24, and 52 weeks postpartum in 15 nulliparous and 15 parous women using electrocardiography, automated manometry, and M-mode ultrasound. During pregnancy, body weight increased 14.

Cesarean deliveries at a university hospital: analysis of rates and indications.

The objective of this paper is to evaluate the influence of patient risk status on the incidence of and indications for cesarean delivery. All live births > or = 23 weeks at the University of Vermont in 1995 (n = 2395) were retrospectively analyzed for delivery route, indication for cesarean, gestational age, parity, and practice group (to reflect risk status). The total cesarean rate was 14.

Labor induction with a prenatal diagnosis of fetal macrosomia.

Since our institution has a low cesarean rate (14%), it was our hypothesis that the rate of cesarean delivery in patients who underwent induction for macrosomia would be similar to the cesarean rate in patients with similar birth weights who entered labor spontaneously. A retrospective analysis of cases seen from December 1993 to July 1995 revealed 53 nondiabetic patients who underwent induction for fetal macrosomia. These study patients were matched to the next nondiabetic patient delivering a child of equal or greater birth weight who entered labor spontaneously.

Hysterotomy to effect vaginal delivery with mentum anterior head entrapment.

Background: Entrapment of the aftercoming head after mentum anterior rotation is a life-threatening complication of vaginal breech delivery. Few options exist when rotation and flexion from this position cannot be performed successfully either transabdominally or with vaginal maneuvers.

Case: A term primigravida presented with a singleton breech in advanced labor.

Uterine artery Doppler velocimetry in the detection of adverse obstetric outcomes in women with unexplained elevated maternal serum alpha-fetoprotein levels.

Objective: We hypothesized that in pregnancies complicated by unexplained elevations of maternal serum alpha-fetoprotein, second-trimester uterine artery Doppler findings would detect adverse obstetric outcomes.

Study Design: One hundred three subjects with unexplained elevations of maternal serum alpha-fetoprotein had uterine artery Doppler velocimetry studies performed at the time of targeted ultrasonographic examination (17 to 22 weeks). A resistance index > 95th percentile or the presence of a uterine notch was considered abnormal.

Detection of fetal HLA-DQa sequences in maternal blood: a gender-independent technique of fetal cell identification.

The objective of this study was to detect fetal HLA-DQa gene sequences in maternal blood. HLA-DQa genotypes of 70 pregnant women and their partners were determined for type A1. We specifically sought couples where the father, but not the mother, had genotype A1.

The effect of sustained exercise on follicular phase levels of 17 beta-estradiol in recreational athletes.

Objective: Our purpose was to test the hypothesis that sustained exercise elevates circulating levels of 17 beta-estradiol in an intensity-dependent manner.

Study Design: Blood samples were obtained in the follicular phase of the menstrual cycle from 75 female recreational athletes before and immediately after 20 minutes of aerobics or running at their usual exercise intensity.

Results: The levels of 17 beta-estradiol rose after exercise 97% of the time.

Fetal heart rate response to sustained recreational exercise.

Objective: We aimed to test the hypotheses that fetal heart rate increases during and after sustained exercise and that the magnitude of the increases is related to gestational age and the duration, intensity, and type of exercise.

Study Design: Maternal oxygen uptake and fetal heart rate were monitored in 120 regularly exercising women in association with routine 20-minute workouts between 16 and 39 weeks' gestation.

Results: In 97% of the studies fetal heart rate increased during and after exercise.

Hepatitis B surface antigen screening in a nonindigent population.

The recommendation for universal screening of all pregnant women for hepatitis B surface antigen (HBsAg) is based on data from publicly funded hospitals. We retrospectively reviewed screening results of 2,696 mothers who delivered between May 1989 and April 1990. Our population was 85% privately funded.

Pregnancy loss and thrombosis with protein C deficiency.

Objectives: Protein C inhibits coagulation and promotes fibrinolysis. This study investigates the association between protein C deficiency and pregnancy loss, thrombosis in pregnancy, and thrombosis with oral contraception.

Study Design: Fifteen protein C--deficient patients and 37 controls from a single kindred were studied.

Sera antioxidant activity in uncomplicated and preeclamptic pregnancies.

Uncontrolled lipid peroxidation may play an important role in the pathophysiology of preeclampsia by causing vascular endothelial cell dysfunction. Sera contain antioxidant mechanisms that serve to control lipid peroxidation. We tested the hypothesis that the sera antioxidant protective mechanisms are diminished in women with preeclampsia.

Elevated maternal serum alpha-fetoprotein levels and maternal risk factors. Their association with pregnancy complications.

Maternal serum alpha-fetoprotein (MS-AFP) screening programs identify a population of pregnant women with elevated MS-AFP values. When the levels are unassociated with a fetal anomaly, those women have a high incidence of pregnancy complications. Such patients were compared to a population with normal MS-AFP values to determine the incidence of historical risk factors and to ascertain if their presence affected the rate of pregnancy complications.

Prenatal diagnosis of autosomal recessive polycystic kidney disease: variable outcome within one family.

Autosomal recessive polycystic kidney disease is frequently diagnosed in utero by obstetric ultrasonography. We report a case in which there were varying outcomes of this disorder in three affected fetuses in a family. Recognition of variable expression within one family is important when parents are considering termination of a pregnancy with an affected fetus.

Elevated maternal serum alpha-fetoprotein: association with placental sonolucencies, fetomaternal hemorrhage, vaginal bleeding, and pregnancy outcome in the absence of fetal anomalies.

Elevated maternal serum alpha-fetoprotein (MSAFP) levels have been associated with an increased incidence of both placental sonolucencies and pregnancy complications. We designed a prospective study to test the hypothesis that the presence of these sonolucencies or a positive maternal Kleihauer-Betke stain would be associated with an elevated risk of obstetric complications. We enrolled 95 women with singleton pregnancies, elevated MSAFP, and no evidence of fetal anomalies on second-trimester ultrasound evaluation.

The changing glycemic response to exercise during pregnancy.

This study was designed to test the hypothesis that pregnancy reverses the nonpregnant hyperglycemic response to sustained exercise. Serial data were obtained from 75 exercising women. Before pregnancy, exercise produced an intensity-dependent increase in blood glucose that averaged 1.

When do cardiovascular parameters return to their preconception values?

To determine if the postpartum period is reflective of a woman's cardiovascular status before pregnancy, we performed serial studies of 13 women before conception and at 6 and 12 weeks post partum. All pregnancies were singleton without hypertensive complications. Cardiac output, stroke volume, and end-diastolic volume were calculated with M-mode echocardiography from the left ventricular dimensions with subjects in the left lateral position.

The VO2max of recreational athletes before and after pregnancy.

This study was designed to test the hypothesis that pregnancy has an added training effect (increases "absolute" VO2max) in well-conditioned, recreational athletes. VO2max was measured serially in 20 nonpregnant recreational athletes who maintained their exercise within +/- 10% of initial levels over a 15-month period and 20 similar women who conceived and continued exercise at a reduced level during pregnancy with a return to within 20% of initial levels by 12 wk postpartum. Initially the two groups were similar in terms of age (30 +/- 1 vs 30 +/- 2 yr), weight 57.

Neonatal morphometrics after endurance exercise during pregnancy.

This study was designed to test the hypothesis that continuation of a regular running and/or aerobics program during late pregnancy at or above 50% of preconceptional levels limits fetal growth. Accordingly, detailed neonatal morphometric data were gathered in the offspring of two groups: 77 well-conditioned recreational runners and aerobic dancers who were delivered at term after continuing their exercise regimen at or above 50% of the preconceptional level throughout pregnancy and 55 matched controls. Daily exercise performance was quantitated before conception and throughout pregnancy.