Henk C.S. Wallenburg

OBJECTIVE: To determine risk factors for the occurrence of third degree perineal tears during vaginal delivery. DESIGN: A population-based observational study. POPULATION: All 284,783 vaginal deliveries in 1994 and 1995 recorded in the Dutch National Obstetric Database were included in the study. METHODS: Third degree perineal rupture was defined as any rupture involving the anal sphincter muscles. Logistic regression analysis was used to assess risk factors. MAIN OUTCOME MEASURES: An overall rate of third degree perineal ruptures of 1.94% was found. High fetal birthweight, long duration of the second stage of delivery and primiparity were associated with an elevated risk of anal sphincter damage. Mediolateral episiotomy appeared to protect strongly against damage to the anal sphincter complex during delivery (OR: 0.21, 95% CI: 0.20-0.23). All types of assisted vaginal delivery were associated with third degree perineal ruptures, with forceps delivery (OR: 3.33, 95%-CI: 2.97-3.74) carrying the largest risk of all assisted vaginal deliveries. Use of forceps combined with other types of assisted vaginal delivery appeared to increase the risk even further. CONCLUSIONS: Mediolateral episiotomy protects strongly against the occurrence of third degree perineal ruptures and may thus serve as a primary method of prevention of faecal incontinence. Forceps delivery is a stronger risk factor for third degree perineal tears than vacuum extraction. If the obstetric situation permits use of either instrument, the vacuum extractor should be the instrument of choice with respect to the prevention of faecal incontinence.

Reported central hemodynamics obtained with a Swan-Ganz pulmonary artery thermodilution catheter in preeclamptic patients show marked disparity, which has been interpreted to indicate a variable hemodynamic expression of the disease. However, the variability also may be due, at least in part, to the pharmacological treatment that most of the women studied received during Swan-Ganz measurements. To evaluate the effects of treatment on hemodynamics, we compared the results of Swan-Ganz measurements in 87 preeclamptic women who had received no treatment at all with those obtained in 47 preeclamptic women who had received various drugs and intravenous fluids. Control values were obtained in 10 normotensive pregnant volunteers. Measurements were performed between 25 and 34 weeks of gestation. The median (range) cardiac index in the untreated patients of 3.3 (2.0-5.3) l.min-1.m-2 was significantly lower than that in the treated patients of 4.3 (2.4-7.6) l.min-1.m-2 and in the normotensive pregnant women of 4.2 (3.5-4.6) l.min-1.m-2. The systemic vascular resistance index in the untreated group of 3,003 (1,771-5,225) dyne.sec.cm-5.m2 was significantly higher than that of 2,212 (1,057-3,688) in the treated and of 1,560 (1,430-2,019) dyne.sec.cm-5.m2 in the normotensive control group. The median (range) pulmonary capillary wedge pressure in the untreated group was 7 (-1-20) mm Hg and did not differ from that of 7 (0-25) mm Hg in the treated group. Variability of all hemodynamic variables was much lower in untreated than in treated patients.(ABSTRACT TRUNCATED AT 250 WORDS)

OBJECTIVE: To test the null hypothesis that the course and outcome of pregnancy in patients with severe pre-eclampsia receiving temporising haemodynamic treatment does not depend on the presence or absence of the syndrome of haemolysis, elevated liver enzymes, and a low platelet count (HELLP). DESIGN: A case-controlled study. SETTING: High risk obstetric unit, University Hospital Rotterdam-Dijkzigt, Rotterdam. SUBJECTS: One hundred and twenty-eight consecutive pre-eclamptic patients with HELLP, gestational age less than 34 weeks, matched for maternal and gestational age with 128 pre-eclamptic patients without HELLP. INTERVENTION: Both groups were treated with volume expansion and pharmacologic vasodilatation under invasive haemodynamic monitoring with the aim of prolonging gestation and enhancing fetal maturity. MAIN OUTCOME MEASURES: Maternal and perinatal outcome in patients with and without HELLP. RESULTS: Except for variables pertaining to HELLP, clinical and laboratory data and median prolongation of pregnancy did not differ between both groups. Complete reversal of HELLP occurred in 43% of patients. Perinatal mortality was 14.1% in HELLP patients and 14.8% in patients without HELLP. No maternal complications occurred. CONCLUSION: We cannot reject the null hypothesis. Our data do not support a general recommendation of prompt termination of pregnancy in HELLP. Temporising treatment may improve fetal and neonatal as well as maternal outcome.