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This study concerns women followed from the first trimester of pregnancy, in a university clinic in Paris in 1977, 1979 and 1981. The cesarean section rate was separately analysed for primiparas, and multiparas with and without previous cesarean section. The overall rate of cesarean section was 11.4% in 1977, 17.2% in 1979 and 21.1% in 1981. The 9.6% increase observed between 1977 and 1981 is mainly attributable to an increase in primary cesarean section, particularly among primiparas, between 1977 and 1979. This does not seem to have arisen from sample variations. There is a change in obstetrical attitude and more cesarean sections are performed in cases of hypertension, breech presentation or intrauterine growth retardation. The greater number of previously sectioned women explains the increase in the rate between 1979 and 1981. The main fact among primiparas is the 18.8% increase in diagnosis of dynamic dystocia between 1979 and 1981. Three key areas allow us to envisage a reduction in cesarean section rate: obstetrical attitude towards previous cesarean section, breech presentation, and management of labor, whose perturbations lead to diagnosis of dynamic dystocia.
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PMID:Can the number of cesarean sections be reduced without risk? An analysis of rates and indications in a university clinic. 377 Feb 79

From 1st January 1992 to 30 June 1994, 8489 delivered at the Dakar University Hospital. Among them, there were 953 cesarean sections, i.e. 11.2%. Epidemiological analysis revealed that mean parity was 2 for a mean age of 26 years. 22% of the women had a clinically perceptible pelvic problem. The indications for cesarean section were divided into 3 groups: mandatory operations (feto-pelvic disproportion, haemorrhagic placenta praevia, dystocia): 41.4%; prudent operations (long-awaited infant, fetal suffering, breech presentation, cicatricial uterus): 50%; and necessary operations (maternal disease, especially hypertension): 8.6%. There was a high postoperative mortality (1.4%) and major morbidity, especially infection (10%). Neonatal prognosis was also poor with a 14% early neonatal mortality. These findings reflect the major problems facing obstetricians in Senegal and Subsaharian Africa. Improved prognosis necessarily will involve better organization of our health systems allowing easier access to life-saving cesarean section for our rural populations.
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PMID:[Indications and prognosis of cesarean sections at the Dakar University Hospital Center]. 778 93

Senegal's maternal mortality rate of about 850/100,000 is one of the highest in the world. A program of epidemiologic surveillance of obstetrical pathology and surgery was established in 1992 in Senegal's 18 obstetric services. The monitoring program targets extrauterine pregnancy; cesarean delivery; hysterectomy for rupture, infections, or hemorrhage; forceps or vacuum extraction delivery; and embryotomy. The National Office of Maternal-Child Health and Family Planning periodically calculates intervention rates based on standardized reports from the centers. Indications for cesarean were classified into three groups: obligatory, referring to conditions such as fetopelvic disproportion in which the delivery could not otherwise proceed; prudent, for cases such as scarred uteri or breech presentation in which cesarean is not indispensable but may provide a better prognosis for the mother or child; and necessity, in which dynamic dystocia, hypertension, or other usually preventable maternal condition has not been adequately treated and threatens to lead to emergency cesarean to save the mother's life. During 1992, around 3220 women underwent obstetrical surgery. 75% of the interventions were cesareans, 10% were forceps deliveries, 9% were extrauterine pregnancies, 3% were hysterectomies, 1% were embryotomies, and 2% were other. The average maternal age for all interventions and for cesareans was 26 years, 7 months. 18.2% of interventions were in women under 20. 36% were primiparas, 25% had 2-3 children, 16% had 4-5, and 23% had 6 or more. Average parity was 3.5. 67% of forceps or vacuum extraction deliveries were in primiparas, while 64% of hysterectomies for infection or hemorrhage and 40% for rupture were in grand multiparas. The principal study objective was to determine surgical coverage of obstetric pathology for the country and its regions. In 1992, 0.66% of deliveries in Senegal were cesareans, with rates ranging from 1.24% in Dakar to 0.24% in Tambacounda. 50% of the cesareans were for obligatory indications, 28% were for indications of prudence, and 22% were for indications of necessity. The proportion for different categories of indications differed greatly in different regions. The maternal mortality rate for all indications was 4.7%, representing over 150 deaths. 29% of deaths occurred during the intervention and 71% in the postoperative period. The maternal mortality rate was 0.8% for extrauterine pregnancy, 1.9% for forceps deliveries, 4.4% for cesareans, 29.3% for hysterectomies for rupture, and 32.0% for hysterectomies for infection or hemorrhage. The perinatal mortality rate for all indications except extrauterine pregnancy was nearly 30%. A goal of 3% of deliveries by cesarean has been established for Senegal to ensure that all situations defined as obligatory will be treated by cesarean. Steps must be taken to improve the accessibility and quality of obstetrical surgery throughout the country.
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PMID:[Epidemiological surveillance and obstetrical dystocias surgery in Senegal]. 785 Jan 91

Improvements in reproductive function invariably follow renal transplantation. The possibility of conception in women of childbearing age emphasizes the need for compassionate and comprehensive counselling. Couples who want a child should be encouraged to discuss all the implications. Therapeutic abortion is undertaken in 20% of conceptions and the spontaneous abortion rate is about 14%, the same as for the normal population. Of the conceptions that continue beyond the first trimester, 93% end successfully. In most women, renal function is augmented during pregnancy, but permanent impairment occurs in 15% of pregnancies. In others there may be transient deterioration in late pregnancy (with or without proteinuria). There is a 30% chance of developing hypertension, pre-eclampsia or both. Preterm delivery occurs in 45-60%, and intrauterine growth retardation in at least 20% of pregnancies. Despite its pelvic location, the transplanted kidney rarely produces dystocia and is not injured during vaginal delivery. Caesarean section should be reserved for obstetric reasons only. Neonatal complications include respiratory distress syndrome, leucopenia, thrombocytopenia, adrenocortical insufficiency and infection. No predominant or frequent developmental abnormalities have been described and data on infancy and childhood are encouraging. Future clinical and laboratory research needs to focus on improving prepregnancy assessment criteria, better understanding of the mechanisms of gestational renal dysfunction, proteinuria and the rare, but devastating, accelerated rejection, assessing the side-effects and implications of immunosuppression in pregnancy and learning more about the remote effects of pregnancy on both renal prognosis and the offspring.
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PMID:Pregnancy in renal allograft recipients: problems, prognosis and practicalities. 792 20

Obstetrical sonography has helped diagnose and define the features of some congenital malformations and tumors. We present five fetal neuroblastomas detected by routine prenatal sonography. All were adrenal tumors diagnosed between 26 and 39 weeks gestation. All 5 tumors were completely resected postnatally and the patients have remained disease free from 2 months to 10 years after resection without adjuvant therapy. A literature review collated 16 other cases of fetal neuroblastoma detected by sonography between 29 and 38 weeks gestation. These cases included 1 cervical, 1 thoracic, and 14 adrenal tumors. Thirteen neonates had Evans stage I or II tumors, and three had more advanced disease. Eleven mothers did not have hypertension or preeclampsia during the pregnancy, and the neonates all had stage I or II disease. Four mothers had hypertension or preeclampsia. Three of these neonates had stage IV or IVS disease with liver metastases, and all three had fetal hydrops. Review of the congenital neuroblastoma literature documented 71 cases diagnosed soon after birth, and several of these cases had unusual features that could have been detected by prenatal ultrasound. Four of the tumors were so large that dystocia resulted and fetal dismemberment was required for delivery. Eight of the tumors metastasized to the placenta, and 1 metastasized to the umbilical cord with subsequent fetal death. We conclude that fetal neuroblastoma can be diagnosed by prenatal sonography. Accurate staging is difficult by sonography, but in mothers with no preeclampsia symptoms the chance of widely disseminated disease is small.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Fetal neuroblastoma: prenatal diagnosis and natural history. 830 85

Peripartum emergencies occur in patients with no known risk factors. When the well-being of the fetus is in question, the fetal heart rate pattern may offer etiologic clues. Repetitive late decelerations may signify uteroplacental insufficiency, and a sinusoidal pattern may indicate severe fetal distress. Repetitive variable decelerations suggesting umbilical cord compression may be relieved by amnioinfusion. Regardless of the etiology of the nonreassuring fetal heart pattern, measures to improve fetal oxygenation should be attempted while options for delivery are considered. Massive obstetric hemorrhage requires prompt action. Clinical signs, such as painless bleeding, uterine tenderness and nonreassuring fetal heart patterns, may help to differentiate causes of vaginal bleeding that may or may not require emergency cesarean delivery. The causes of postpartum hemorrhage include uterine atony, vaginal or cervical laceration, and retained placenta. The challenge of managing shoulder dystocia is to effect a rapid delivery while avoiding neonatal and maternal morbidity. The McRoberts maneuver has been shown to be the safest and most successful technique for relieving shoulder dystocia. Eclampsia responds best to magnesium sulfate, supportive care and supplemental hydralazine or labetalol as needed for severe hypertension.
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PMID:Common peripartum emergencies. 1039 86

According to the World Health Organization, 585,000 women die each year from a pregnancy-related cause, 99% of whom are from developing countries. The first International Conference on Safe Motherhood in 1987 sensitized the world community to this drama. Ever since, maternal mortality and its medical causes are better known. The maternal mortality ratio is highest in West Africa (1,020 maternal deaths per 100,000 live borns) when it is 27/100,000 in industrialized countries. Direct obstetric causes account for 80% of the deaths: hemorrhage, infection, dystocia, hypertension and abortion. Indirect causes are essentially anemia, malaria, hepatitis C and AIDS. Severe maternal morbidity is 6 to 10 times more frequent than maternal mortality but it also leads to handicaps which end up often in women's social rejection. However, WHO estimates that 95% of these deaths and handicaps are avoidable, and at a low cost.
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PMID:[Pregnancy and delivery in western Africa. High risk motherhood]. 1050 33

Obesity-related metabolic and functional disorders may disturb adaptation process taking place in pregnant women body. Insufficient adaptation may lead to development of several medical complications during pregnancy, labor, delivery, and puerperium. Maternal obesity is associated with increased frequencies of hypertension, preeclampsia, gestational diabetes mellitus, fetal macrosomia, congenital malformations, labor abnormalities (including prolonged second stage of labor, meconium-stained amniotic fluid, FHR abnormalities and shoulder dystocia), postdatism, and cesarean delivery. Operative complications among obese women undergoing cesarean delivery include increased blood loss, prolonged operative time, and increased rates of postoperative infection, thrombophlebitis. Treatment of these complications increases hospital stays and costs. Obese women should be carefully examined by dietetician before conception and cared for dietetically and medically during gestation.
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PMID:[Obesity as an obstetric risk factor]. 1089 90

We prospectively studied pregnancy outcome in 428 women with gestational diabetes mellitus (DM) and 196 women with pregestational DM, with particular reference to the influence of maternal obesity and excessive weight gain. These were consecutive singleton pregnancies delivered in our institution over 5 years. After controlling for multiple risk factors, including maternal BMI and pregnancy weight gain, women with pregestational DM were at increased risk (compared to those with gestational DM) for Caesarean delivery (OR 3.6, 95%CI 2.3-5.6), shoulder dystocia or cephalopelvic disproportion (OR 2.2, 95%CI 1.3-3.6), and gestational hypertension or toxaemia (OR 3.0, 95%CI 1.7-5.4). The offspring of these women were also at increased risk for admission to the neonatal intensive care unit (OR 4.0, 95%CI 2.3-6.8), large-for-gestational-age birthweight (OR 3.5, 95%CI 2.2-5.6), and preterm birth before 37 weeks (OR 3.8, 95%CI 2.5-5.9). Maternal obesity, and, to a lesser degree, excessive weight gain, were also independent risk factors for all these adverse maternal and neonatal outcomes, regardless of the type of DM, except for shoulder dystocia/cephalopelvic disproportion.
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PMID:Maternal and neonatal outcomes in pregestational and gestational diabetes mellitus, and the influence of maternal obesity and weight gain: the DEPOSIT study. Diabetes Endocrine Pregnancy Outcome Study in Toronto. 1143 30

Developing countries exhibit the highest adolescent fertility rate in the world. Undesirable outcome frequency during adolescents' pregnancy and delivery is debated. The aim of this study is to determine the incidence of these events and the factors predicting their occurrence among pregnant Senegalese adolescents and their newborn. The study was conducted between August 1st, 1999 and July 31st, 2000 in a national sample of 435 women attending prenatal clinics after a 20-week gestation. The data were collected by interviews: sociodemographic characteristics, obstetrical antecedents, current pregnancy history before inclusion in the study; the clinical characteristics were determined at inclusion. Then pregnancy and delivery complication occurrences were observed for mothers and their newborn during follow-up. Logistic regression analyses were performed to determine the factors associated with each complication, controlling the effects of other sociodemographic and clinical factors. The most frequent pregnancy complications were pregnancy-induced hypertension and toxaemia (17.5%). Anemia occurred in 25% of the women. At delivery, at least one of dystocia, eclampsia, or placenta haemorrhage complications occurred in 46% of women. The caesarian rate was 20% and the mortality rate was 71%. When planned, caesarian interventions lowered mortality. Forty percent of the newborns presented a neonatal distress while 17.9% of them weighed less than 2,500 g. The pregnancy-induced hypertension and toxaemia incidence rates were higher when the weight at onset of pregnancy was unknown (OR = 3.7 [1.9-7.5] for hypertension and 3.1 [1.3-7.6] for toxaemia). When a woman with a narrow pelvis was less than 1.50 m tall, the delivery was more frequently assisted by forceps and extracting action in breech delivery. Dystocia, eclampsia, placenta haemorrhage and premature delivery were associated with high mortality. Overall, complications were not more frequent in the youngest (16 years and below), as suggested in previous studies. Those results suggest that undesirable events occur frequently during adolescents' pregnancy and delivery, and in their newborn, while attendance in prenatal clinics is adequate. The prognostic factors of these complications are identified. These complications can be avoided by improving ante- and perinatal care quality.
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PMID:[Prognostic factors of pregnancy and delivery complications in Senegalese adolescents and their newborn]. 1186 Nov 97


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