Rupture Risk Up With Single Closure
Single-layer closure from a prior cesarean delivery increases risk of symptomatic uterine rupture in a subsequent trial of labor, compared with double-layer closure, Dr. Martine Goyet said at the annual meeting of the Society for Maternal-Fetal Medicine. Dr. Goyet and colleagues conducted a multicenter, case-control study to compare the two closure techniques. They reviewed records from 1993 to 2003 for nine maternity wards. “Single-layer closure was the only significant negative factor associated with uterine rupture in a multivariate analysis [odds ratio 2.31],” said Dr. Goyet of the department of obstetrics and gynecology, Hôpital Sainte-Justine, Montreal. “Prior vaginal delivery was the only positive significant factor [OR 0.49].” They identified 96 cases of symptomatic uterine rupture, including emergency laparotomy, using ICD-9 codes and perinatal databases. They also identified three matched controls for each case. The controls were women who underwent a trial of labor before each uterine rupture case; the control group totaled 288. Maternal age and parity did not significantly differ between groups. Cases had a history of one low-transverse cesarean delivery and uterine rupture with an attempted trial of labor. The researchers excluded women with a history of more than one cesarean delivery, prior myomectomy, or multiple gestations. Women who had uterine rupture were more likely to have had a single-layer closure than controls (37% vs. 20%); induction of labor with an unfavorable cervix (38% vs. 23%); gestational age of 41 weeks or more (26% vs. 17%); birth weight of 4,000 g or greater (23% vs. 13%); and no prior vaginal delivery (87% vs. 73%), according to a univariate analysis. Women who had uterine rupture also tended to have a shorter interval between deliveries (less than 24 months), Dr. Goyet said.
Herpes Hepatitis Diagnosis Lifesaving
The diagnosis of herpes simplex hepatitis in pregnancy is one that can't afford to be missed, Dr. Eileen Hay said at the annual meeting of the American College of Gastroenterology. That's because treatment with acyclovir or vidarabine is lifesaving—and without it, one-half of affected mothers will die of fulminant hepatitis, stressed Dr. Hay, professor of medicine at the Mayo Medical School, Rochester, Minn. Herpes hepatitis is a rare disorder. In pregnancy, it occurs in the third trimester. It is usually but not always preceded by a flulike viral prodrome. The typical mucocutaneous herpetic lesions aren't always present. The characteristic features of this infection are the third-trimester presentation, marked elevation of transaminases (with levels often in the thousands) along with coagulopathy and encephalopathy, and no jaundice. Liver biopsy shows hepatocytes with the classic viral inclusion bodies of herpes simplex virus. It's necessary to consider delivery only in the very rare instance where the patient shows no response to antiviral therapy, Dr. Hay said.
Smoking Boosts Pelvic Prolapse Risk
Tobacco smoking is an independent risk factor for pelvic organ prolapse, data from the Pelvic Organ Support Study suggest. The findings from this multicenter, cross-sectional, observational study—known as POSST—contrast with those from the Women's Health Initiative, which suggested that smoking was protective against pelvic organ prolapse, Dr. Cecilia K. Wieslander reported at the annual meeting of the American Urogynecologic Society. Of 906 women included in the POSST analysis, 773 were nonsmokers (including 173 former smokers) and 133 were current smokers. On multivariate analysis, smoking was an independent, noninteractive risk factor for pelvic organ prolapse of stage II or greater (odds ratio 2.37), said Dr. Wieslander, a fellow in obstetrics and gynecology at the University of Texas Southwestern Medical Center at Dallas. Even among nulliparous smokers, the prevalence of prolapse was significantly greater, compared with the prevalence in nonsmokers (28% vs. 12%, adjusted odds ratio 1.95). In nonsmokers with one vaginal delivery, the prevalence of prolapse increased from 12% to 27%, so the risk associated with smoking in nulliparous women is greater than the risk associated with one vaginal delivery in nonsmokers. The findings, which are consistent with laboratory data showing that smoking-induced activation of vaginal macrophage elastase may contribute to the pathogenesis of organ prolapse, suggest that smoking is a modifiable risk factor for pelvic organ prolapse. However, further study of dose response is needed to evaluate the effects of secondhand smoke exposures, to determine if symptoms associated with smoking—such as chronic cough—are a cause of pelvic organ prolapse, and to determine if other illnesses with effects similar to those of smoking—such as inflammation—can contribute to pelvic organ prolapse, Dr. Wieslander said.