Labor analgesia for patients with preterm premature rupture of membranes.

OBJECTIVE: Cervical examination is relatively contraindicated in women with preterm premature rupture of membranes (PPROM), limiting our ability to determine the onset of labor by traditional definition (contractions with cervical change). We sought to determine whether two maternal requests for analgesia within 3 h predicted delivery within 24 h to allow appropriate epidural placement. STUDY DESIGN: We performed a retrospective chart review of all patients with PPROM for a period of 18 months. Our primary outcome was the percentage of women with PPROM (<34 weeks) who delivered within 24 h from the second analgesia request. RESULT: Among women with PPROM, 63% delivered within 24 h from their second request for analgesia and 98% delivered within 48 h. CONCLUSION: Two medication requests within 3 h for regular, painful contractions can be used as an indicator of onset of labor in women with PPROM to allow for labor analgesia.

Transcervical Foley catheter for preinduction cervical ripening in an outpatient versus inpatient setting.

OBJECTIVE: To compare use of the Foley catheter for preinduction cervical ripening in an inpatient versus outpatient setting. METHODS: A randomized trial was conducted from May 1998 to December 1999. Women with a term gestation in the vertex presentation, a reactive nonstress test, an amniotic fluid index above the fifth percentile, and a Bishop score of no more than 5 were included. The primary outcome variable was a change in Bishop score. A Foley catheter with a 30-mL balloon was placed through the cervix on gentle traction in each group. The outpatient group was then discharged home with written instructions and returned in the morning for induction. The inpatient group was admitted to labor and delivery, with induction started upon extrusion of the Foley. RESULTS: Sixty-one women were randomized into the outpatient group, and 50 women into the inpatient group. Maternal age, gravidity, previous cesarean delivery, and gestational age did not differ between the groups. The median Bishop score at entry was 3.0 for each group (P =.97). The mean change in Bishop scores after catheter placement was not different between the inpatient and outpatient groups (3.0 versus 3.0; P =.74). The maximum dose of oxytocin, time of oxytocin, epidural rate, induction time, 1-minute and 5-minute Apgar scores, and cord pH were not significantly different. The outpatient group on average avoided 9.6 hours of hospitalization. There were no adverse events or maternal morbidity in either group. CONCLUSIONS: The Foley bulb is as effective in the outpatient as the inpatient setting for preinduction cervical ripening.

Intracervical fibrin sealants: a potential treatment for early preterm premature rupture of the membranes.

OBJECTIVE: We report our experience with a transvaginally applied intracervical fibrin sealant at <24 weeks' gestation. STUDY DESIGN: This is an observational study of a referred patient population, with preterm premature rupture of the membranes at <24 weeks' gestation. RESULTS: Twelve women consented to our protocol. The mean gestational age at preterm premature rupture of membranes was 19 weeks 4 days (range, 13-23 weeks); the mean gestational age at treatment was 20 weeks 5 days (range, 17-23 weeks). All women had a diminution in the amount of amniotic fluid leakage with an increase in amniotic fluid index. Among the 12 pregnancies (13 fetuses), there were 7 surviving neonates. Two women had apparent "resealing" of the membranes. CONCLUSION: Fibrin sealants in midtrimester rupture of the membranes may lead to improved outcomes and now warrant formal evaluation.

A prospective, randomized comparison of Foley catheter insertion versus intracervical prostaglandin E2 gel for preinduction cervical ripening.

OBJECTIVE: The objective of this study was to compare intracervical prostaglandin E2 gel with insertion of a Foley bulb for efficacy in preinduction cervical ripening. STUDY DESIGN: Women who came to the hospital for induction of labor with a Bishop score

Factors affecting fellowship satisfaction, thesis completion, and career direction among maternal-fetal medicine fellows.

OBJECTIVE: To determine fellowship satisfaction through a survey of maternal-fetal medicine fellows. METHODS: We constructed a survey using multiple choice, Likert scale, ordinal, and categorical scale questions. The questions focused on faculty involvement, mentorship, research time and productivity, education, fellowship selection, ultimate goals of fellows, and satisfaction. We sent the survey in two mailings to all maternal-fetal medicine fellows during April and May 1996. RESULTS: One hundred thirty-eight surveys were mailed, and 136 were returned (98.5% return rate). Twenty-seven percent of fellows did not believe they would complete their thesis by the end of their fellowship. No statistically significant relationship was noted between the fellows' predicted thesis completion and the availability of funding, support for statistical analysis, the presence of animal research facilities, age, number of dependents, or year of fellowship. The presence of a mentor on the maternal-fetal medicine faculty increased the likelihood of thesis completion from 52.3% to 83.5% (P < .001). Similarly, the presence of a faculty advisor increased the likelihood of thesis completion from 58.9% to 83.5% (P = .001). Thirty-two percent of the respondents did not have a mentor on the faculty, and 41% did not have a faculty advisor. Forty percent indicated that they were too involved in clinical pursuits to perform research. This group was significantly more likely to believe that their theses would not be completed (63% versus 80%, P = .029). Overall, 22% of the fellows would not recommend their fellowships. Fellows with a mentor (88.2% versus 55.8%; P < .001) or faculty advisor (87.3% versus 64.9%; P = .002) were more likely than those without to recommend their fellowship. CONCLUSION: A mentor or faculty advisor plays a significant role in the training of maternal-fetal medicine fellows and is associated with a higher incidence of satisfaction with the fellowship program, thesis completion, and entrance into academic practice.

Tocolysis of preterm contractions does not improve preterm delivery rate or perinatal outcomes.

To determine whether hospital admission and parenteral tocolysis of patients with threatened preterm labor results in a decreased preterm delivery rate and improved perinatal outcome, we performed a prospective cohort study comparing tocolytic treatment versus no tocolytic treatment. Women between 20 and 37 weeks' gestation who presented with at least eight uterine contractions per hour and a cervical examination <2 cm dilated, <80% effaced, and no cervical change over a 2-hr period were entered into the study. Exclusion criteria included cervical change, multiple gestation, chorioamnionitis, rupture of membranes, placenta previa or abruption, undiagnosed vaginal bleeding, and prior tocolytic therapy in the current pregnancy. Seventy-five patients were admitted to the hospital for tocolysis (tocolysis cohort) and 81 were observed and discharged to home (observation cohort). There was no significant difference in mean gestational age at delivery, mean birth weight, or in preterm delivery rate between the two cohorts. Four of the eight women in the observation cohort who delivered preterm had a history of preterm delivery. We conclude that discharging women with preterm contractions without objective evidence of labor does not result in an increase in preterm births. More importantly, tocolysis did not decrease the preterm delivery rate in this cohort.

Uterine rupture during preinduction cervical ripening with misoprostol in a patient with a previous Caesarean delivery.

We report a case of uterine rupture in a patient with a previous low transverse Caesarean delivery, in which transvaginal misoprostol was used for preinduction cervical ripening.

An analysis of neonatal morbidity and mortality in maternal (in utero) and neonatal transports at 24-34 weeks' gestation.

Sophisticated neonatal transport has improved the safety of transporting preterm infants, but may not substitute for the benefits of in utero transport. To describe gestational age trends and assess differences in complications between maternal (in utero) and neonatal transports, we analyzed maternal and neonatal transports, over 3 years, to the only tertiary center in the region. Those who delivered between 24 and 34 weeks' gestation were included in the analysis. Gestational age trends for each complication are described, showing, in general, decreasing morbidity with gestational age in both groups. These trends were usually parallel, but not equal. A significantly greater mean neonatal intensive care unit (p = 0.003) and total length of stay (p = 0.006) as well as longer ventilator time (p = 0.01) and oxygen therapy exposure (p = 0.018) were noted in those transported neonatally. The incidence of respiratory distress syndrome (p < 0.001), bronchopulmonary dysplasia (p = 0.027), intraventricular hemorrhage (p = 0.041), intraventricular hemorrhage grades III and IV (p = 0.008), patent ductus arteriosus (p = 0.032), and mortality (p = 0.001) were all significantly greater among the neonatal transports. The differences were not significant for retinopathy of prematurity, hyperbilirubinemia, necrotizing enterocolitis, periventricular leukomalacia, and culture proven sepsis. Specialized neonatal transport and advanced neonatology techniques have not removed the significant advantage of decreased morbidity, mortality, and length of hospital intervention resulting from maternal (in utero) transport.

Placental abruption following placement of disposable intrauterine pressure transducer system.

There have been few reported complications of intrauterine pressure monitoring. We present four cases of placental abruption following insertion of a disposable intrauterine pressure transducer system (INTRAN). All four patients had placental abruptions, which were evident soon after insertion of the disposable intrauterine pressure transducer system (all of our cases had predisposing factors or signs of placental abruption at presentation). Whether there was a preexisting placental abruption, which was caused, revealed, or worsened by insertion of the disposable intrauterine pressure transducer system is unclear. We encourage careful patient selection with gentle insertion of the system opposite the placental site.

Routine urine drug screening at the first prenatal visit.

OBJECTIVE: The purpose of this study is to determine whether routine urine drug screening at the first prenatal visit will identify and permit early intervention for those at risk for poor outcome. STUDY DESIGN: Comparisons of maternal and neonatal outcomes between 166 randomly chosen patients with positive and 150 randomly chosen patients with negative drug screens identified by the enzyme multiplied immunoassay test were made by unpaired t test, chi 2 test, probit analysis, and tests of independent Poisson distributions. RESULTS: Forty percent of those identified denied drug use. Antepartum (p less than 0.01) and postpartum (p less than 0.05) complications were increased among drug users. Birth weight (p less than 0.001), gestational age (p less than 0.03), and head circumference (p less than 0.05) were decreased among neonates. CONCLUSION: Because of difficulty in identifying illicit substance--using patients, consideration should be given to the implementation of routine urine drug screening at the first prenatal visit in populations with a high rate of illicit substance use.

Medical management of pheochromocytoma in pregnancy.

A pregnant patient presented with a history of diagnosed pheochromocytoma. Despite excision of the extra-adrenal tumor before pregnancy, the patient's urine catecholamine levels and blood pressure remained elevated. Subsequent attempts at localizing the tumor, including repeat laparotomy, were unsuccessful. The patient was medically managed with alpha blockade from the first trimester and was delivered by cesarean section after demonstration of fetal lung maturity at 35 weeks' gestation. She represents one of the few reported cases of successful medical management of pheochromocytoma throughout the entire course of a pregnancy.

Ultrasonic ratio of fetal thoracic to abdominal circumference: an association with fetal pulmonary hypoplasia.

Real time ultrasound was used in pregnant women who were considered to be at risk for development of pulmonary hypoplasia (n = 26). The population consisted of women who had either premature rupture of membranes (n = 16) or oligohydramnios (n = 10). The ratio calculated by comparing the fetal thoracic circumference to abdominal circumference was obtained in all cases within 10 days of delivery. This ratio correlated strongly with neonatal outcome. Multivariate regression models of neonatal outcome were developed to analyze the relationship of gestational age at which premature membrane rupture occurred, the duration of premature rupture, date of birth, and prenatal diagnosis. The addition of the thoracic circumference to the abdominal circumference ratio increased significantly the proportion of explained variability. Application of this ratio should be considered in evaluating fetal status in oligohydramnios and in the expectant management of premature rupture of membranes.

Hemoglobin SD disease associated with cholecystitis and cholelithiasis in pregnancy.

A black multipara was shown, by hemoglobin electrophoresis, to have hemoglobin SD disease. The patient exhibited a typically mild anemia that probably was secondary to folate and iron deficiencies as well as to hemoglobinopathic hemolysis. The course of her pregnancy was complicated by pyelonephritis and hyposthenuria, both of which have been reported in association with hemoglobin SD disease in pregnancy. The patient also was shown to have acute cholecystitis probably superimposed on a chronic cholelithiasis. This latter complication was probably the result of hemolysis due to hemoglobin SD disease. The patient was treated medically with good results, and, despite poor compliance and heroin addiction, delivered a viable infant at term.