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 277,896 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%. An increase in the incidence of shoulder dystocia has been recorded over the last 20 years, probably just because it has now been regularly registered at maternity wards as an obstetric complication. The risk factors for shoulder dystocia include fetal macrosomia, fetal malformations and tumors, maternal adiposity, excessive weight gain during pregnancy, diabetes mellitus, pathologic pelvis, multiparity, short maternal stature, advanced maternal age, postterm pregnancy, so-called midforceps delivery or vacuum extraction, prolonged delivery stage II, oxytocin labor induction, premature fetal expression according to Kristeller, and previous shoulder dystocia in macrosomatic children. The sequels of shoulder dystocia and obstetric maneuvers for incarcerated shoulder release include clavicular fracture, brachial plexus lesions, sternocleidomastoid muscle distension with or without hematoma, diaphragmatic paralysis, Horner's syndrome, peripartal asphyxia and consequential cerebral lesions (cerebral palsy), and peripartal death. Maternal complications due to shoulder dystocia are postpartal hemorrhage, cervical and vaginal lacerations, frequent infections during the puerperium, symphysiolysis and rupture of the uterus, and secondary cesarean section with related complications due to unsuccessful obstetric procedures or as continuation of Zavanelli's maneuver. McRoberts' maneuver (or Gaskin maneuver) is recommended as the initial procedure for shoulder release in case of shoulder dystocia. If it fails, other obstetric procedures such as Resnik's suprapubic pressure and Woods' grip with posteriorly placed arm release should be used, always with gross lateral episiotomy. The performance of all these obstetric procedures requires skilfull and highly experienced obstetrician and obstetric team as a whole.
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PMID:Fetal shoulder dystocia. 1259 26

Diabetes in pregnancy, whether the woman had diabetes prior to becoming pregnant or developed gestational diabetes, is associated with many complications and risks. In the first trimester, organogenesis can be disrupted by complications due to poor control of the mother's diabetes, leading to fetal malformations or perinatal mortality. Problems with glucose control in the remainder of the pregnancy can also have consequences for the child. These include macrosomia, shoulder dystocia, pre-eclampsia, hypoglycemia and an increased risk for obesity and diabetes in the future. Therefore, aggressive and prompt treatment of the high blood sugar levels, which cause these complications, is necessary. This review looks at the current treatments for pregnancies complicated by diabetes and evaluates the place of new and possible future treatments including diet, exercise, insulin, insulin analogs and oral and inhaled agents.
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PMID:New and future diabetes therapies: are they safe during pregnancy? 1268 46

Reasons for inducing labor at term in pregnancies complicated by diabetes include the avoidance of fetal demise and the prevention of excessive fetal growth and its concomitant conditions, shoulder dystocia and Cesarean delivery. Objectively evaluating the risks and benefits of labor induction is potentially confounded by the status of the cervix at the time of initiation of induction, early determination of an arrest disorder and physician bias toward Cesarean delivery for women who have diabetes. In non-diabetic women, incorporating estimates of fetal weight in deciding the route of delivery has not diminished the incidence of shoulder dystocia, and may have increased the incidence of Cesarean deliveries. Currently available evidence suggests that, while induction of labor for women who have diabetes may not carry much maternal or fetal risk, the benefit of this procedure is unclear.
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PMID:Induction of labor versus conservative management of pregnant diabetic women. 1268 58

Seemingly coincidental occurrence of various pathological conditions may derive from common etiologic denominators. While reviewing 240 malpractice claims involving shoulder dystocia related fetal injuries, we found two antenatal complications in the background conspicuously often. Chronic or pregnancy induced hypertension was identifiable in 80 instances (33%). Pregnancy induced or preexisting diabetes was diagnosed 48 times (20%). Many of these patients were poorly controlled. The blood pressure was usually checked during the antenatal visits. However, about one-half of all patients received no diabetic screening. Therefore, this study may underestimate the actual incidence of diabetes. It has been calculated that the frequency of diabetes in pregnancy and that of hypertension, is about 5% in the United States. Thus, the rates of these complications in this selected group of gravidas was severalfold higher than in the general population. Since hypertension causes retarded fetal growth, it cannot be a direct cause of arrest of the shoulders at delivery. The likely common denominator is maternal diabetes a known predisposing factor both for preeclampsia and shoulder dystocia at birth. In the course of litigations for fetal injuries, demonstration of the predisposing role of seemingly unrelated shortcomings of the medical management may profoundly influence the outcome. This principle is demonstrated by the presentation of an actual malpractice action which resulted in a substantial settlement.
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PMID:Diabetes, hypertension and birth injuries: a complex interrelationship. 1288 40

Gestational diabetes mellitus is a common but controversial disorder. While no large randomized controlled trials show that screening for and treating gestational diabetes affect perinatal outcomes, multiple studies have documented an increase in adverse pregnancy outcomes in patients with the disorder. Data on perinatal mortality, however, are inconsistent. In some prospective studies, treatment of gestational diabetes has resulted in a decrease in shoulder dystocia (a frequently discussed perinatal outcome), but cesarean delivery has not been shown to reduce perinatal morbidity. Patients diagnosed with gestational diabetes should monitor their blood glucose levels, exercise, and undergo nutrition counseling for the purpose of maintaining normoglycemia. The commonly accepted treatment goal is to maintain a fasting capillary blood glucose level of less than 95 to 105 mg per dL (5.3 to 5.8 mmol per L); the ambiguity (i.e., the range) is due to imperfect data. The postprandial treatment goal should be a capillary blood glucose level of less than 140 mg per dL (7.8 mmol per L) at one hour and less than 120 mg per dL (6.7 mmol per L) at two hours. Patients not meeting these goals with dietary changes alone should begin insulin therapy. In patients with well-controlled diabetes, there is no need to pursue delivery before 40 weeks of gestation. In patients who require insulin or have other comorbid conditions, it is appropriate to begin antenatal screening with nonstress tests and an amniotic fluid index at 32 weeks of gestation.
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PMID:Management of gestational diabetes mellitus. 1568 96

The prevalence of obstetric, perinatal and neonatal complications associated with fetal macrosomia at Holberton Hospital in Antigua and Barbuda was assessed by a retrospective, case-control study. All babies of birthweight (BW) greater than 4.5 kg born between July 1991 and January 1997 and all babies with BW greater than 4.0 kg born between July 1991 and January 1995, were included. Control babies, were selected from those born on the same day as the index case. Babies of BW > 4.0 kg and babies of BW > 4.5 kg were 5.7% and 1% of births respectively Records were complete for 157 large babies (40 with BW > 4.5 kg) and 157 control babies < 4.0 kg. Mothers of large babies were significantly older, more parous, more likely to have diabetes mellitus, hypertension, and deliver after 40 weeks gestation. At delivery, mothers of large babies were more likely to bleed. Large babies had lower one minute and five minute Apgar score, were more likely to be meconium stained, have respiratory distress, have birth trauma or dystocia and to be admitted to Special Care Nursery. There was no difference in Caesarean section rate, hospital days, neonatal jaundice or mortality. Babies with BW > 4.5 kg had mortality of 7.5% versus 1.8% for those < 4.5 kg. Fetal macrosomia remains a difficult obstetrical problem associated with significant maternal, perinatal and neonatal consequences. Morbidity and mortality are still significant in developed and developing countries alike.
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PMID:A case control study of the prevalence of perinatal complications associated with fetal macrosomia in Antigua and Barbuda. 1464 6

The present study was aimed to investigate pregnancy outcome among obese women and specifically the correlation between maternal obesity and incidence of caesarean section (CS) while controlling for the potential confounding effects of other variables associated with obesity. A population-based study was performed comparing all pregnancies of obese (maternal pre-pregnancy body mass index (BMI) of 30 kg/m2 or more) and non-obese patients, between the years 1988 and 2002. Patients with hypertensive disorders and diabetes mellitus as well as patients lacking prenatal care were excluded from the analysis. Stratified analyses, using the Mantel-Haenszel technique, and a multiple logistic regression model were performed to control for confounders. During the study period there were 126,080 deliveries meeting the inclusion criteria, of which 1769 (1.4%) occurred in obese patients. Using a multivariable analysis, the following conditions were significantly associated with maternal obesity: failure to progress during the first stage (odds ratio (OR) = 3.1; 95% confidence interval [CI] 2.5, 3.8; P < 0.001), fertility treatments (OR = 2.0; [95% CI 1.6, 2.5]; P < 0.001), previous CS (OR = 1.7; [95% CI 1.5, 1.9]; P < 0.001), malpresentations (OR = 1.4; [95% CI 1.2, 1.6]; P < 0.001), recurrent miscarriages (OR = 1.4; [95% CI 1.2, 1.7]; P < 0.001) and fetal macrosomia (OR = 1.4; [95% CI 1.2, 1.7]; P < 0.001). Higher rates of caesarean deliveries were found among obese parturients (27.8% vs. 10.8%; OR = 3.2; [95% CI 2.9, 3.5]; P < 0.001). When controlling for possible confounders, using the Mantel-Haenszel technique, the association between maternal obesity and CS remained significant. No significant differences were noted between the groups regarding perinatal complications such as perinatal mortality, congenital malformations, shoulder dystocia and low Apgar scores. In conclusion, a significant association was found between obesity and CS even after the exclusion of hypertensive disorders and diabetes mellitus. Importantly, obesity alone was not associated with adverse perinatal outcome. Obstetricians should be encouraged to allow obese patients not suffering from diabetes or hypertensive disorders an adequate trial of labour.
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PMID:Maternal obesity as an independent risk factor for caesarean delivery. 1513 Jan 59

We prenatally diagnosed MELAS syndrome in a fetus whose mother and older brother had the MELAS-specific A3243G mutation. The mutant mtDNA level of the amniotic fluid cells was not significantly different from that of the postnatal peripheral blood and hair follicle samples. The obstetrical course was uncomplicated except for transient exacerbation of the mother's diabetes, which required insulin control. At term, the infant was macrosomic, and the delivery was complicated by shoulder dystocia. MELAS syndrome in itself does not influence either the prenatal course of the mother or the fetal outcome. In contrast to the fulminating clinical course of this mother's first child, MELAS symptoms did not develop in her second child until age four, despite similar high tissue levels of mutant mtDNA. The phenotypic diversity in two offspring with similar higher levels of mutant mtDNA suggests that prenatal genetic diagnosis of cultured amniotic cells may yield results that are poor prognosticators of fetal outcome.
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PMID:Prenatal diagnosis of a fetus harboring an intermediate load of the A3243G mtDNA mutation in a maternal carrier diagnosed with MELAS syndrome. 1516 11

The purpose of this retrospective study is to evaluate the perinatal outcome in cases with birth injuries, suggesting shoulder dystocia. This survey involves 92 cases of live newborns (gestational age between 37 and 42 weeks) with shoulder injuries. Another control group of 120 cases of live mature newborns without any shoulder injuries is studied for comparison. There are no significant differentialities between those two groups, regarding age, parity, weight and height of the parturients. Shoulder dystocia is most frequently found in newborns of 3500-4000 g birthweight. Antepartum, risk factors for shoulder dystocia are: diabetes, obesity of the mother and chronological postterm pregnancy. Intrapartum, the evaluated risk factors prove to be unreliable because the same were found in as many as one half of the non-traumatic vaginal deliveries. In 27% of the cases, shoulder dystocia occurs most probably after the passage of the shoulder through the pelvic inlet. The most frequent type of shoulder injury is fracture of the clavicle (90.2%), followed by paresis of the brachial plexus (7.6%). Severe shoulder dystocia both from obstetrical and neonatological point of view is found in 2-3% of the cases.
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PMID:[Shoulder dystocia--risk factors and fetal outcome]. 1531 34

In a primipara, 28 years of age and with a BMI of 44 kg/m2, a Zavanelli manoeuvre was performed. Due to uterine atony she had to undergo a hysterectomy. A multipara, 39 years of age and with a BMI of 66 kg/m2, experienced that her weight exceeded the limits of the beds and that local anaesthesia was hard to perform; she suffered from a lesion of the lumbosacral plexus caused by a shoulder dystocia. In the end, both mothers and their babies could go home in a moderate condition. Obesity is becoming more prevalent and brings with it an increase in obstetric risks. During pregnancy and delivery, morbidly obese patients should be monitored by a gynaecologist. Special interest should focus on screening for (gestational) diabetes, hypertension and foetal growth. Ultrasound may detect congenital malformations early; however, the sensitivity of ultrasound is lower in morbidly obese patients. When macrosomia is expected, a clear plan should be made regarding the mode of delivery. It is useful to make a treatment protocol for morbidly obese patients.
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PMID:[Morbid obesity: a risk factor for obstetric complications]. 1570 41


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