morphine and Fever

Recent reports indicate that cocaine metabolites have biologic activity and could be toxic. To explore this possibility, two studies were initiated. The first study aimed to define the distribution of cocaine species by quantifying levels of cocaine and its metabolites norcocaine, benzoylecgonine, and benzoylnorecgonine in newborn cord blood and meconium. The second study sought to determine whether they produced a clinical effect. Compared to cord blood, meconium had a greater number of metabolites and a higher concentration of cocaine metabolites, including the previously undetectable norcocaine and benzoylnorecgonine derivatives. Benzoylecgonine was the most common species found in both sources and was usually lower in concentration in blood. An inverse relation existed between meconium benzoylecgonine levels and the serum catabolic enzyme pseudocholinesterase, implying genetic variability in cocaine metabolism. To determine whether cocaine and/or its metabolites could be linked to a distinct clinical state, a second study focusing on newborn behavior was performed with an independent large cohort of cocaine-exposed infants. Neonates with increased signs of "neuroexcitation" had benzoylecgonine and no cocaine in urine, whereas lethargic neonates had detectable urinary cocaine. These findings support the hypothesis that cocaine metabolites, especially benzoylecgonine, may play a role in altering newborn behavior and produce a clinical syndrome distinct from that related to the parent compound.

Topics: Butyrylcholinesterase; Central Nervous System Diseases; Cocaine; Female; Fetal Blood; Fever; Humans; Infant, Newborn; Maternal-Fetal Exchange; Meconium; Neonatal Abstinence Syndrome; Pregnancy; Prospective Studies; Respiratory Distress Syndrome, Newborn

Misoprostol is an effective agent for the induction of labor. Existing guidelines recommend oral misoprostol solution 25 μg every 2 hours. However, more research is required to optimize the use of oral misoprostol solution for the induction of labor.. The purpose of this study was to compare efficacy and safety of hourly titrated-dose oral misoprostol solution with static-dose oral misoprostol solution every 2 hours for labor induction.. In this randomized controlled study, oral misoprostol solution was administered as (1) 20 μg hourly (≤4 doses) that was increased in the absence of regular uterine contractions to 40 μg hourly (≤4 doses) and then to 60 μg hourly (≤16 doses) or (2) 25 μg every 2 hours until active labor began (≤12 doses). A sample size of 146 women was planned with the use of a projected 95% rate for the primary endpoint (vaginal delivery within 24 hours) for hourly titrated-dose misoprostol and 80% rate for static-dose misoprostol every 2 hours. Safety outcomes included maternal morbidity and adverse neonatal outcomes.. From December 2013 to July 2015, 146 women were assigned randomly to treatment. Demographic and clinical factors were similar between groups, except for age. Vaginal delivery was achieved within 24 hours in 47 women (64.4%) who received hourly titrated-doses of misoprostol solution and 48 women (65.8%) who received 2-hourly static-dose misoprostol solution (P=1.00). Rates of vaginal delivery within 24 hours did not differ significantly between treatment groups for women who were nulliparous (P=1.00) or who had postterm pregnancies (P=.66), a Bishop score of ≤3 (P=.84), or oxytocin augmentation (P=.83). Cesarean deliveries were performed within 24 hours in 9 women who received hourly titrated-dose misoprostol solution and 2 women who received 2-hourly static-dose misoprostol solution (P=.056). Pyrexia and meconium-stained liquor occurred more frequently with the hourly titrated-dose regimen.. The static-dose oral misoprostol solution every 2 hours has similar efficacy as hourly titrated-dose misoprostol solution but with fewer side-effects and lower complication rates.

Topics: Administration, Oral; Adolescent; Adult; Cervical Ripening; Delivery, Obstetric; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Fever; Humans; Labor, Induced; Meconium; Misoprostol; Oxytocics; Pregnancy; Time Factors; Young Adult

The purpose of our study was to evaluate the safety and efficacy of transcervical amnioinfusion during labour complicated by meconium-stained amniotic fluid, in a setting with limited peripartum facilities, to lower the incidence of caesarean section.. A prospective study was conducted in a teaching hospital in north India, which enrolled 292 patients admitted in labour. Patients were randomly divided into two groups after taking their consent. One group received transcervical amnioinfusion, whilst in the other group amnioinfusion was not done. Caesarean sections were performed in either group if there were foetal heart rate abnormalities (bradycardia or irregularity for 10-20 min) or slow progress of labour. The outcomes studied were the incidence of caesarean sections, duration of maternal hospital stay, maternal febrile morbidity (temperature of >38 degrees C, 24 h after delivery), low Apgar score (at 1 and 5 min), respiratory death, MAS and perinatal mortality.. There was a statistically significant reduction in the incidence of caesarean sections in the study group compared to the control group (31 vs. 61%). Amnioinfusion was associated with improved neonatal outcome as evidenced by statistically improved Apgar score at 1 min in newborns in the study group compared to the control group (10 vs. 37.2%). Amnioinfusion during labour was not associated with any significant maternal and neonatal complications. The mean hospital stay of the mother was decreased significantly in the study group patients compared to the control group.. Transcervical amnioinfusion in labour for meconium-stained amniotic fluid is a simple, safe and easy-to-perform procedure. It can be performed safely in a setup with limited peripartum facilities, especially in developing countries, to decrease intrapartum operative intervention and reduce foetomaternal morbidity and mortality.

Topics: Adolescent; Adult; Amnion; Apgar Score; Cesarean Section; Female; Fetal Distress; Fever; Hospitals, Teaching; Humans; Incidence; India; Infant Mortality; Infant, Newborn; Infusions, Parenteral; Length of Stay; Meconium; Meconium Aspiration Syndrome; Obstetric Labor Complications; Pregnancy; Pregnancy Outcome; Prospective Studies; Young Adult

To assess the effect of amnioinfusion during labour with meconium stained amniotic fluid on caesarean section rate and perinatal outcome.. Prospective randomised controlled study.. A tertiary care teaching hospital in India.. Women in labour at term with meconium stained amniotic fluid.. Two hundred women in labour with > or = 37 weeks gestation, single cephalic presentation with moderate or thick meconium were randomised to control and amnioinfusion groups at a 1:1 ratio. Amnioinfusion was performed using 500 mL of normal saline over a period of 30 minutes in a study group. The control group received routine care. Both groups had intermittent auscultation of fetal heart rate during labour.. The primary outcome measure was caesarean section rate. Secondary outcome measures were meconium aspiration syndrome, 1 minute and 5 minute apgar < 7, hypoxic ischaemic encephalopathy, neonatal intensive care unit admission, meconium at the level of vocal cords.. The caesarean section rate in the amnioinfusion group was less than the control group (RR 0.47; 95% CI 0.24-0.93). Amnioinfusion was associated with a significant decrease in the incidence of meconium at the vocal cords (P = 0.001); improvement in 1 minute apgar scores (P < 0.05), respiratory distress (P = 0.002) and fewer admissions to nursery compared with the controls. This sample size was inadequate to study the impact on meconium aspiration syndrome.. Amnioinfusion in an under resourced labour ward decreases caesarean section rates and fetal morbidity.

Topics: Adult; Amnion; Cesarean Section; Extraction, Obstetrical; Female; Fetal Distress; Fever; Humans; Infant, Newborn; Meconium; Meconium Aspiration Syndrome; Pregnancy; Pregnancy Outcome; Prospective Studies; Puerperal Disorders; Risk Factors

A baseline fetal heart rate between 110 and 160 bpm is considered normal. However, among normal fetuses the average baseline heart rate has been shown to diminish progressively and the 90th centile of the fetal heart rate at 40 weeks of gestation has been consistently found at around 150 bpm. The aim of our study was to assess the labor and neonatal outcome of fetuses at 40 gestational weeks or beyond, whose intrapartum baseline fetal heart rate was between 150 and 160 bpm.. In all, 1004 CTG traces were included in the analysis, 860 in Group 110-149 bpm and 144 in Group 150-160 bpm. Group 150-160 bpm had a significantly higher incidence of meconium-stained amniotic fluid (odds ratio [OR] 2.6; 95% CI 1.8-3.8), maternal intrapartum hyperpyrexia (OR 4.7; 95% CI 1.1-14.6), urgent/emergent cesarean section for suspected fetal distress (OR 13.4; 95% CI 3.3-54.3), Apgar <7 at 5th min (OR 9.13; 95% CI 1.5-55.1) and neonatal acidemia (OR 3.5; 95% CI 1.5-55.1). Logistic regression including adjustiing for potential confounders showed that fetal heart rate between 150 and 160 bpm is an independent predictor of meconium-stained amniotic fluid (adjusted odds ratio [aOR] 2.2; 95% CI 1.5-3.3), cesarean section during labor for fetal distress (aOR 10.7; 95% CI 2.9-44.6), neonatal acidemia (aOR 2.6; 95% CI 1.1-6.7) and adverse composite neonatal outcome (aOR 2.6; 95% CI 1.2-5.6).. In fetuses at 40 weeks or beyond, an intrapartum fetal heart rate baseline ranging between 150 and 160 bpm seems associated with a higher incidence of labor complications.

Topics: Adult; Cesarean Section; Female; Fetal Distress; Fever; Gestational Age; Heart Rate, Fetal; Humans; Infant, Newborn; Meconium; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Pregnancy Trimester, Third; Pregnancy, Prolonged; Retrospective Studies

To determine the intrapartum and perinatal results associated with different degrees of staining of meconium stained amniotic fluid (MSAF).. In a retrospective cohort study of all singleton deliveries over a period of one year (2015) in a tertiary hospital, we compared different degrees of MSAF (yellow, green and thick) to clear amniotic fluids, and analysed in each group maternal, intrapartum and neonatal variables as well as umbilical cord blood gas analysis.. Of the 3590 deliveries included, 503 (14%) had MSAF. The incidence of MSAF rises with gestational age at delivery, reaching 20.7% in gestations above 41 weeks compared to 4.3% below 37 weeks. As the amniotic fluid staining progresses we found a higher proportion of intrapartum fevers (p < 0.001), pathological fetal heart rate patterns (p < 0.05), operative vaginal deliveries and cesarean sections (p < 0.001), as well as the need for advanced neonatal resuscitation (p < 0.001). There was also a correlation between MSAF and low Apgar scores at five minutes (p < 0.001) and fetal-neonatal mortality (p < 0.001) but there was not a higher proportion of neonatal intensive care admissions (p > 0.05). We have observed a similar distribution of umbilical artery pH ranges in all groups (p > 0.05).. MSAF was associated with an increase in the rate of pathological fetal heart rate patterns, intrapartum fevers, operative vaginal and cesarean section deliveries, need for neonatal resuscitation, low Apgar scores and higher fetal-neonatal mortality. Moreover, we found that the risks increase as the staining and consistency of the amniotic fluid evolves so it should alert the obstetrician and paediatrician to the potential adverse outcomes.

Topics: Amniotic Fluid; Apgar Score; Blood Gas Analysis; Female; Fetal Blood; Fever; Heart Rate, Fetal; Humans; Infant, Newborn; Meconium; Pregnancy; Pregnancy Outcome; Retrospective Studies

To investigate risk factors for neonatal arterial ischemic stroke (NAIS), and compare them with those present in term controls and infants with hypoxic-ischemic encephalopathy (HIE).. Antepartum and intrapartum data were collected at presentation from 79 infants with NAIS and compared with 239 controls and 405 infants with HIE. The relationships between risk factors and NAIS were explored using univariable and multivariable regression.. Compared with controls, infants with NAIS more frequently had a family history of seizures/neurologic diseases, primiparous mothers, and male sex. Mothers of infants with NAIS experienced more intrapartum complications: prolonged rupture of membranes (21% vs 2%), fever (14% vs 3%), thick meconium (25% vs 7%), prolonged second stage (31% vs 13%), tight nuchal cord (15% vs 6%), and abnorm8al cardiotocography (67% vs 21%). Male sex (OR 2.8), family history of seizures (OR 6.5) or neurologic diseases (OR 4.9), and ≥1 (OR 5.8) and ≥2 (OR 21.8) intrapartum complications were independently associated with NAIS. Infants with NAIS and HIE experienced similar rates though different patterns of intrapartum complications. Maternal fever, prolonged rupture of membranes, prolonged second stage, tight nuchal cord, and failed ventouse delivery were more common in NAIS; thick meconium, sentinel events, and shoulder dystocia were more frequent in HIE. Abnormal cardiotocography occurred in 67% of NAIS and 77.5% of infants with HIE. One infant with NAIS and no infant with HIE was delivered by elective cesarean (10% of controls).. NAIS is multifactorial in origin and shares risk factors in common with HIE. Intrapartum events may play a more significant role in the pathogenesis of NAIS than previously recognized.

Topics: Cardiotocography; Case-Control Studies; Dystocia; Female; Fetal Membranes, Premature Rupture; Fever; Genetic Predisposition to Disease; Humans; Hypoxia-Ischemia, Brain; Infant, Newborn; Infarction, Middle Cerebral Artery; Labor Stage, Second; Longitudinal Studies; Male; Meconium; Nuchal Cord; Pregnancy; Pregnancy Complications; Retrospective Studies; Risk Factors; Seizures; Sex Factors

To determine the antecedents, outcomes, and effects of treatment of fever commencing during term labour without prolonged rupture of membranes (ROM).. A retrospective database and chart review sought associations between maternal, fetal, and labour variables and fever by comparing women whose membranes had been ruptured for less than 24 hours and who were febrile with those who were not. The strength of significant associations was then compared between febrile women who received acetaminophen or antibiotics and febrile women who did not.. We found 16 322 control subjects and 161 cases. On multivariable analysis, fever was associated with epidural analgesia (adjusted odds ratio [AOR] 5.5; 95% confidence interval [CI], 4.0-7.0), length of stage 2 (AOR 1.003 per minute; 95% CI, 1.001-1.005), length of ROM (AOR 1.15 per hour; 95% CI, 1.10-1.20), meconium in the amniotic fluid (AOR 1.7; 95% CI, 1.2-2.2), intervention for nonreassuring electronic fetal monitoring (EFM) (AOR 5.2; 95% CI, 4.4-6.0), intervention for failure to progress in labour (AOR 3.0; 95% CI, 2.1-3.9), and neonatal intensive care unit (NICU) admission (AOR 5.7; 95% CI, 5.1-6.3). A nonstatistically significant trend toward a decrease in failure to progress with acetaminophen administration was noted.. Fever during labour is associated with longer labour, longer ROM, and use of epidural analgesia. For a given length of labour, women with fever are more likely to experience intervention for failure to progress, intervention for nonreassuring EFM, and infant NICU admission.

Topics: Acetaminophen; Amniotic Fluid; Analgesia, Epidural; Female; Fever; Humans; Intensive Care, Neonatal; Meconium; Obstetric Labor Complications; Pregnancy; Retrospective Studies; Time Factors

To determine whether women who receive continuous epidural analgesia for labor and delivery are more likely to receive antibiotic therapy compared to those parturients who do not use epidural analgesia, a chart review was performed for 300 women 100 in each group using narcotics alone epidural alone, or parenteral narcotics followed by epidural analgesia. While only 2% of women with narcotics alone developed an intrapartum temperature > or = 37.8 degrees C, 16% and 24% of women with epidural use alone or in addition to narcotics did so, respectively. Antibiotic administration was increased among women utilizing epidural analgesia, exclusively or following parenteral narcotics. No parturient with culture or pathological evidence of chorioamnionitis had maternal temperature elevation as an isolated finding. A probable causal relationship between maternal temperature elevation and epidural use in labor is supported. Rather than treating all women with temperature elevations and epidurals for presumed chorioamnionitis, it is reasonable to target treatment to those with fetal tachycardia, meconium stained fluid, or abnormal amniotic fluid studies.

Topics: Adult; Amniotic Fluid; Analgesia, Epidural; Analgesia, Obstetrical; Analgesics, Opioid; Anti-Bacterial Agents; Chorioamnionitis; Delivery, Obstetric; Female; Fetal Diseases; Fever; Humans; Injections, Intravenous; Labor, Obstetric; Meconium; Placenta; Pregnancy; Probability; Retrospective Studies; Tachycardia