Background Choice of delivery route after previous cesarean delivery can be difficult because both trial of labor after cesarean delivery and elective repeat cesarean delivery are associated with ...risks. The major risk that is associated with trial of labor after cesarean delivery is uterine rupture that requires emergency laparotomy. Objective This study aimed to estimate the occurrence of uterine rupture during trial of labor after cesarean delivery when lower uterine segment thickness measurement is included in the decision-making process about the route of delivery. Study Design In 4 tertiary-care centers, we prospectively recruited women between 34 and 38 weeks of gestation who were contemplating a vaginal birth after a previous single low-transverse cesarean delivery. Lower uterine segment thickness was measured by ultrasound imaging and integrated in the decision of delivery route. According to lower uterine segment thickness, women were classified in 3 risk categories for uterine rupture: high risk (<2.0 mm), intermediate risk (2.0–2.4 mm), and low risk (≥2.5 mm). Our primary outcome was symptomatic uterine rupture, which was defined as requiring urgent laparotomy. We calculated that 942 women who were undergoing a trial of labor after cesarean delivery should be included to be able to show a risk of uterine rupture <0.8%. Results We recruited 1856 women, of whom 1849 (99%) had a complete follow-up data. Lower uterine segment thickness was <2.0 mm in 194 women (11%), 2.0–2.4 mm in 217 women (12%), and ≥2.5 mm in 1438 women (78%). Rate of trial of labor was 9%, 42%, and 61% in the 3 categories, respectively ( P <.0001). Of 984 trials of labor, there were no symptomatic uterine ruptures, which is a rate that was lower than the 0.8% expected rate ( P =.0001). Conclusion The inclusion of lower uterine segment thickness measurement in the decision of the route of delivery allows a low risk of uterine rupture during trial of labor after cesarean delivery.
OBJECTIVE:To evaluate the effects of prior single-layer compared with double-layer closure on the risk of uterine rupture.
METHODS:A multicenter, case–control study was performed on women with a ...single, prior, low-transverse cesarean who experienced complete uterine rupture during a trial of labor. For each case, three women who underwent a trial of labor without uterine rupture after a prior low-transverse cesarean delivery were selected as control participants. Risk factors such as prior uterine closure, suture material, diabetes, prior vaginal delivery, labor induction, cervical ripening, birth weight, prostaglandin use, maternal age, gestational age, and interdelivery interval were compared between groups. Conditional logistic regression analyses were conducted.
RESULTS:Ninety-six cases of uterine rupture, including 28 with adverse neonatal outcome, and 288 control participants were assessed. The rate of single-layer closure was 36% (35 of 96) in the case group and 20% (58 of 288) in the control group (P<.01). In multivariable analysis, single-layer closure (odds ratio OR 2.69; 95% confidence interval CI 1.37–5.28) and birth weight greater than 3,500 g (OR 2.03; 95% CI 1.21–3.38) were linked with increased rates of uterine rupture, whereas prior vaginal birth was a protective factor (OR 0.47; 95% CI 0.24–0.93). Single-layer closure was also related to uterine rupture associated with adverse neonatal outcome (OR 2.89; 95% CI 1.01–8.27).
CONCLUSION:Prior single-layer closure carries more than twice the risk of uterine rupture compared with double-layer closure. Single-layer closure should be avoided in women who could contemplate future vaginal birth after cesarean delivery.
LEVEL OF EVIDENCE:II
Objectives Preeclampsia is a leading cause of maternal and perinatal morbidity. Work-related factors may influence the occurrence of this disorder. This case-control study estimated the associations ...between work-related physical and psychosocial factors and the risk of preeclampsia and gestational hypertension. Methods The eligible women consisted of a random sample of the women who delivered a singleton live birth in 1997-1999 in six regions of Quebec and worked during pregnancy. Cases of preeclampsia (N=102) and gestational hypertension (N=99) were compared with normotensive controls (N=4381). Information on occupational exposures at the onset of pregnancy was collected during phone interviews a few weeks after delivery. Detailed information was obtained on work schedule, postures, physical exertion, work organization, noise, vibration, and extreme temperature. Adjusted odds ratios (aOR) were estimated through polytomous logistic regression. Results Women standing daily at least 1 hour consecutively without walking experienced a higher risk of preeclampsia aOR 2.5, 95% confidence interval (95% CI) 1.4-4.6, as well as women climbing stairs frequently (aOR 2.3,95% CI 1.2-4.1) and women working more than 5 consecutive days without a day-off (aOR 3.0,95% CI 1.0-9.5). Squatting or kneeling, pushing or pulling objects, whole-body vibration, forced pace, job strain, and no control on breaks were positively, but nonsignificantly, associated with preeclampsia. The associations were weaker for gestational hypertension. Conclusions These findings suggest that being exposed to physically demanding and stressful occupational conditions at the onset of pregnancy increases the risk of preeclampsia.
BACKGROUND: This study was carried out to identify risk factors associated with urinary incontinence in women three months after giving birth. METHODS: Urinary incontinence before and during ...pregnancy was assessed at study enrolment early in the third trimester. Incontinence was re-assessed three months postpartum. Logistic regression analysis was used to assess the role of maternal and obstetric factors in causing postpartum urinary incontinence. This prospective cohort study in 949 pregnant women in Quebec, Canada was nested within a randomised controlled trial of prenatal perineal massage. RESULTS: Postpartum urinary incontinence was increased with prepregnancy incontinence (adjusted odds ratio adj0R 6.44, 95% CI 4.15, 9.98), incontinence beginning during pregnancy (adjOR 1.93, 95% CI 1.32, 2.83), and higher prepregnancy body mass index (adjOR 1.07/unit of BMI, 95% CI 1.03,1.11). Caesarean section was highly protective (adjOR 0.27, 95% CI 0.14, 0.50). While there was a trend towards increasing incontinence with forceps delivery (adjOR 1.73, 95% CI 0.96, 3.13) this was not statistically significant. The weight of the baby, episiotomy, the length of the second stage of labour, and epidural analgesia were not predictive of urinary incontinence. Nor was prenatal perineal massage, the randomised controlled trial intervention. When the analysis was limited to women having their first vaginal birth, the same risk factors were important, with similar adjusted odds ratios. CONCLUSIONS: Urinary incontinence during pregnancy is extremely common, affecting over half of pregnant women. Urinary incontinence beginning during pregnancy roughly doubles the likelihood of urinary incontinence at 3 months postpartum, regardless whether delivery is vaginal or by Caesarean section.
In many industrialized countries, the proportion of infants born before term (at less than 37 weeks of gestation) has increased in the past 20 years. In Canada, for instance, the proportion of ...infants born at less than 37 weeks of gestation increased from 6.3 percent to 6.8 percent of all live births between 1981 and 1992.
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With the possible exceptions of France
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and Finland,
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other industrialized countries have also seen an increase in the frequency of preterm births.
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The increase in preterm births in Canada is particularly enigmatic, because the proportion of live-born infants weighing less than . . .
Sciatica due to a herniated nucleus pulposus is an important medical and socioeconomic problem.
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Although the majority of patients recover with conservative management, 10 to 15 percent need ...surgery.
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Epidural corticosteroid injections were first used to treat sciatica in the early 1950s, as reported by Lièvre et al.
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,
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Of 12 controlled trials that have subsequently been reported, half found that the injections were more effective than the reference treatment,
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and the other half found them to be no better or worse.
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A critical analysis of these studies showed that most had methodologic deficiencies.
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Reviews of the literature . . .
OBJECTIVE:To estimate the effect of low-dose aspirin started in early pregnancy on the incidence of preeclampsia and intrauterine growth restriction (IUGR).
DATA SOURCES:A systematic review and ...meta-analysis were performed through electronic database searches (PubMed, Cochrane, Embase).
METHODS OF STUDY SELECTION:Randomized controlled trials of pregnant women at risk of preeclampsia who were assigned to receive aspirin or placebo (or no treatment) were reviewed. Secondary outcomes included IUGR, severe preeclampsia and preterm birth. The effect of aspirin was analyzed as a function of gestational age at initiation of the intervention (16 weeks of gestation or less, 16 weeks of gestation or more).
TABULATION, INTEGRATION, AND RESULTS:Thirty-four randomized controlled trials met the inclusion criteria, including 27 studies (11,348 women) with follow-up for the outcome of preeclampsia. Low-dose aspirin started at 16 weeks or earlier was associated with a significant reduction in preeclampsia (relative risk RR 0.47, 95% confidence interval CI 0.34–0.65, prevalence in 9.3% treated compared with 21.3% control) and IUGR (RR 0.44, 95% CI 0.30–0.65, 7% treated compared with 16.3% control), whereas aspirin started after 16 weeks was not (preeclampsiaRR 0.81, 95% CI 0.63–1.03, prevalence in 7.3% treated compared with 8.1% control; IUGRRR 0.98, 95% CI 0.87–1.10, 10.3% treated compared with 10.5% control). Low-dose aspirin started at 16 weeks or earlier also was associated with a reduction in severe preeclampsia (RR 0.09, 95% CI 0.02–0.37, 0.7% treated compared with 15.0% control), gestational hypertension (RR 0.62, 95% CI 0.45–0.84, 16.7% treated compared with 29.7% control), and preterm birth (RR 0.22, 95% CI 0.10–0.49, 3.5% treated compared with 16.9% control). Of note, all studies for which aspirin had been started at 16 weeks or earlier included women identified to be at moderate or high risk for preeclampsia.
CONCLUSION:Low-dose aspirin initiated in early pregnancy is an efficient method of reducing the incidence of preeclampsia and IUGR.
We assessed the effect of the method of feeding on respiratory and gastrointestinal illnesses during the first 6 months of life among 776 infants born in New Brunswick, Canada. During a 1-year ...period, these infants were drawn from the offspring of a population of primiparous women in the province who, after at least 36 weeks of pregnancy, gave birth to one normal infant weighing 2500 gm or more. Data were collected by means of a self-administered standardized questionnaire mailed to every mother a week before her infant reached 6 months of age. The crude incidence density ratio (IDR) revealed a protective effect of breast-feeding on respiratory illnesses (IDR = 0.66; 95% confidence interval CI, 0.52 to 0.83), on gastrointestinal illnesses (IDR = 0.53; 95% CI, 0.27 to 1.04) and on all illnesses (IDR = 0.67; 95% CI, 0.54 to 0.82). The protective effect of breast-feeding on respiratory illnesses persisted even after adjustment for age of the infant, socioeconomic class, maternal age, and cigarette consumption (adjusted IDR = 0.78; 95% CI, 0.61 to 1.00). Moreover, if we distinguished ear infection from other respiratory illnesses, we observed a separate protective effect for these two types of events. The results of this retrospective cohort study suggest a protective effect of breast-feeding in our population during the first 6 months of life. (J P
EDIATR 1995;126:191-7)
The objective of this case-control study was to evaluate whether occupational conditions during pregnancy are associated with preterm delivery (PTD). Women whose work conditions changed following the ...use of a legally justified preventive measure (withdrawal from work or job reassignment) were also compared with those whose work conditions did not change. Cases (n = 1,242) and controls (n = 4,513) were selected from 43,898 women who had single livebirths between January 1997 and March 1999 in Québec, Canada. They were interviewed by telephone after delivery. Results showed association of PTD with demanding posture for at least 3 hours per day, whole-body vibrations, high job strain combined with low or moderate social support, and a cumulative index composed of nine occupational conditions. The adjusted odds ratio increased from 1.0 to 2.0 for PTD (ptrend < 0.0001) and from 1.0 to 2.7 for very PTD (<34 weeks; ptrend = 0.0015) as the number of conditions increased from zero to four or more. The associations for PTD and very PTD with most of the above-mentioned work conditions were weaker when exposures were eliminated following recourse to a legally justified preventive measure. This study provides relevant information on the possible influence of preventive measures on the risk of PTD in pregnant workers.
Background: There is concern about possible effects of disinfection by-products on reproductive outcomes. The purpose of this study was to evaluate the association between maternal exposure to ...chlorination by-products and the risk of delivering a small for-gestational-age (SGA) neonate. Methods: We conducted a population-based case-control study in the Québec City (Canada) area. Term newborn cases with birth weights <10th percentile (n = 571) were compared with 1925 term controls with birth weights ≥10th percentile. Concentrations of trihalomethanes and haloacetic acids in the water-distribution systems of participants were monitored during the study period, and a phone interview on maternal habits was completed within 3 months after childbirth. We estimated chlorination by-products ingestion during the last trimester of pregnancy and trihalomethanes doses resulting from inhalation and dermal exposure. We evaluated associations between chlorination by-products in utero exposure and SGA by means of unconditional logistic regression with control of potential confounders. Results: When total trihalomethanes and the 5 regulated haloacetic acids concentrations were divided into quartiles, no clear dose-response relationship was found with SGA. However, increased risk was observed when haloacetic concentrations were above the fourth quartile and when either trihalomethanes or haloacetic acids concentrations were above current water standards (adjusted OR= 1.5 95% confidence interval = 1.1—1.9 and 1.4 1.1—1.9, respectively). Inhalation and dermal absorption of trihalomethanes did not contribute to this risk, but a monotonic dose-response was found with haloacetic acids ingestion. Conclusion: Oral exposure to high levels of chlorination by-products in drinking water could be a risk factor for term SGA.
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