II-2.

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With over one-third of pregnancies in the United States being delivered by cesarean and the growing knowledge of morbidities associated with repeat cesarean deliveries, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists convened a workshop to address the concept of preventing the first cesarean. The available information on maternal and fetal factors, labor management and induction, and non-medical factors leading to the first cesarean were reviewed as well as the implications of the first cesarean on future reproductive health. Key points were identified to assist with reduction in cesarean rates including that labor induction should be performed primarily for medical indication; if done for non-medical indications, the gestational age should be at least 39 weeks or more and the cervix should be favorable, especially in the nulliparous patient. Review of the current literature demonstrates the importance of adhering to appropriate definitions for failed induction and arrest of labor progress.

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OBJECTIVE To estimate whether maternal carriage of the prothrombin gene G20210A mutation is associated with pregnancy loss, preeclampsia, placental abruption, or small for gestational age (SGA) neonates in a low-risk, prospective cohort. METHODS This was a secondary analysis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development factor V Leiden study, a multicenter, prospective, observational cohort of 5,188 unselected singleton gestations. A total of 4,167 first-trimester samples were available for analysis and were tested for the prothrombin G20210A mutation. Obstetric complications were compared between women with and without the prothrombin G20210A mutation by univariable and multivariable analysis. RESULTS A total of 157 (3.8%) women had the prothrombin gene mutation (156 heterozygous and one homozygous). Carriers of the prothrombin G20210A mutation had similar rates of pregnancy loss, preeclampsia, SGA neonates, and abruption compared with noncarriers. Results were similar in a multivariable analysis controlling for age, race, prior pregnancy loss, prior SGA neonates, and family history of thromboembolism. Three thromboembolic events occurred in women testing negative for the mutation. CONCLUSION There was no association between the prothrombin G20210A mutation and pregnancy loss, preeclampsia, abruption, or SGA neonates in a low-risk, prospective cohort. These data raise questions about the practice of screening women without a history of thrombosis or adverse pregnancy outcomes for this mutation. LEVEL OF EVIDENCE II

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The fluoroquinolones are antibiotic agents that act by inhibiting bacterial DNA gyrase. Because they are able to cross the placenta, they may have mutagenic or carcinogenic effects on the developing fetus. The present in vitro study examined the transfer of 3 therapeutically important fluoroquinolones-ciprofloxacin, ofloxacin, and levofloxacinthrough the isolated, perfused human placenta. Placental cotyledons from normal human term placentas were perfused with M199 medium enriched with bovine serum albumin and glucose. Perfusion rates were 12 mL/min in the maternal circulation and 6 mL/min in the fetal circulation. Six placentas were studied for each of the 3 fluoroquinolones after they were added to the maternal circulation. Antipyrine, which crosses the placenta by simple diffusion, served as a reference drug. Concentrations of all agents were measured by high-performance liquid chromatography.After 30 minutes, antipyrine had reached a steady state in the fetal compartment. The mean transplacental transfer percentage of antipyrine was 10.0% for ciprofloxacin, 13.4% for ofloxacin, and 13.2% for levofloxacin. Ciprofloxacin crossed the placenta, reaching a steady state at 30 minutes in both the maternal and fetal compartments. Ofloxacin and levofloxacin also reached a steady state after 30 minutes. The mean transplacental transfer percent of ciprofloxacin was 3.2% and the transplacental transfer index (the ratio of transplacental transfer between ciprofloxacin and antipyrine) was 0.34. The respective figures for ofloxacin were 3.7% and 0.33, and for levofloxacin, 3.9% and 0.34. The placental transfer of each of the fluoroquinolone drugs was significantly smaller than was observed for antipyrine.In this in vitro study, only a small proportion of 3 fluoroquinolone drugs passed into the fetal compartment. Possibly there is a barrier to fluoroquinolone transport in the human placenta. OBSTETRICSVolume 61, Number 2 OBSTETRICAL AND GYNECOLOGICAL SURVEY