Characteristics of uterine activity in gestations less than 20 weeks.

Ambulatory tocodynamometry has been used for some time to record uterine activity during pregnancy. Most studies, however, have been performed in the third trimester (more than 24 weeks). The current study was initiated to assess uterine activity at earlier gestational ages. One hundred thirty-seven patients were studied between 14-19 weeks' gestation (inclusive). Seven patients who were being monitored were noted to have preterm labor, and six of these seven were found to have increased uterine activity before the diagnosis of preterm labor. There was no difficulty encountered in the vast majority of cases in recording objective, accurate uterine activity information even at these early gestational ages. There was an increase in the uterine activity (during the 18th and 19th weeks) in patients destined to develop preterm labor later in gestation as compared with the contraction pattern of those who labored at term. This study demonstrates that accurate uterine activity information can be gained at these early gestational ages and that when increased contraction frequency is present, it is related to preterm labor.

Significance of opaque discolored amniotic fluid at second-trimester amniocentesis.

From June 1978 to December 1983, 100 patients with viable pregnancies involving opaque, discolored, second-trimester amniotic fluid were identified. During this period 7018 genetic amniocenteses were performed for an incidence of discolored fluid of 1.4%. Compared with case matched control subjects there were no statistically significant differences in the incidence of elevated amniotic fluid alpha-fetoprotein, preterm labor, fetal distress during labor, intrauterine growth retardation, or stillbirth. The rate of spontaneous abortion (7 versus 0%; P less than .05) was increased in the discolored fluid group. The patients with discolored fluid also had an increased incidence of prior vaginal bleeding (P less than .001).

Correlation of uterine activity using the Term Guard monitor versus standard external tocodynamometry compared with the intrauterine pressure catheter.

Uterine activity monitoring to detect preterm contractions and thus to manage patients in active labor is valuable to the clinician. Uterine activity measured by external devices using the guard ring principle or by standard tocodynamometers has been shown to be accurate concerning the frequency of uterine activity as compared with intrauterine pressure catheter-derived data in the third trimester. In this study, 26 women from 19-34 weeks in documented preterm labor had their uterine activity measured by a standard in-hospital monitor and a Term Guard tocodynamometer simultaneously. The standard monitor reflected 16-91% of the frequency of contractions noted by the Term Guard device, with a reduction in the correlation at gestational ages under 30 weeks. In another 20 patients between 17-36 weeks' gestation, these two methods of external tocodynamometry were compared with a transcervical catheter which measured actual intrauterine pressure and frequency of contractions. There was a good correlation between the Term Guard device and transcervically measured contractions (94.6%). At gestational ages of 28 weeks or less, there was poor performance from standard devices (less than 38% correlation with the intrauterine pressure catheter). These data have important implications for clinicians who monitor preterm patients on an ambulatory basis for early detection of preterm labor and also have clinical impact for the management of patients at early gestational ages in active labor.

Group B streptococcal sepsis and death in utero following funipuncture.

The technique of umbilical cord puncture for diagnosis and therapy, which has been shown to be feasible and relatively safe for both mother and fetus, is being used increasingly. The fetal loss rate with this technique has been estimated to be approximately 1%. A case is presented of fetal death from group B beta-streptococcal sepsis after funipuncture, the first report of this complication.

Successful pregnancy outcome following mid-gestational uterine rupture and repair using Gore-Tex soft tissue patch.

The first reported gestational use of the Gore-Tex soft tissue patch (expanded polytetrafluoroethylene) for uterine repair and support is presented in a pregnant woman whose partially dehisced, congenitally abnormal uterus was operated upon at 19 weeks' gestation. Use of the expanded polytetrafluoroethylene Gore-Tex soft tissue patch for assisted uterine integrity in combination with a program of uterine tocolysis and close maternal/fetal surveillance averted a pregnancy loss.

Plasma and amniotic fluid concentrations of fibronectin during normal pregnancy.

To ascertain the influence of pregnancy on plasma concentrations of fibronectin, we quantified plasma concentrations of fibronectin in 22 normal, pregnant women during the first, second, and third trimesters; at the time of delivery; and at six weeks and eight months postpartum, using a rapid, immunoturbidimetric procedure. Mean plasma concentrations of fibronectin rose significantly throughout pregnancy, and were significantly greater than umbilical cord plasma concentrations. Maternal plasma concentrations of fibronectin at six weeks postpartum were similar to those observed at the time of delivery, but returned to concentrations observed in nonpregnant women by eight months postpartum. No significant differences between concentrations of fibronectin in amniotic fluid obtained during the second and third trimesters of pregnancy were observed. Six-week postpartum values appeared to depend upon the type of infant feeding as values rose in bottle feeding but fell in breast-feeding mothers.

Management of cardiovascular disease in pregnancy.

Pregnancy itself poses risks of morbidity and mortality to even the young, healthy woman. The nature of these risks may vary from country to country and, within the United States, from state to state. Hemorrhage, eclampsia, and infection, in general, are common obstetric risks. One of the most important nonobstetric causes of maternal death, and the focus of this article, is heart disease.

Fetal echocardiography.

Fetal echocardiography has become an essential tool for the thorough evaluation of the fetus at risk for congenital heart disease. This examination is now a part of standard medical practice and should no longer be considered investigational. Widespread use of fetal echocardiography is providing valuable insights into fetal cardiac embryology and physiology that have not been previously possible.

Severe medical illness complicating cesarean section.

The care of the perioperative cesarean birth patient who has serious medical illnesses has changed in the past decade. The increasing sophistication of monitoring has allowed the obstetrician and anesthesiologist better to modify certain physiologic parameters that are important in the care of the patient whose physiology has been altered by surgery or disease. As an increasing segment of the obstetric population becomes older, and with better survival of medical diseases, the profession as a whole will be challenged by these patients. It will become more important that a certain subset of physicians develop the skills necessary to undertake the care of these patients and that the special needs of these patients be recognized.

Obtaining the four-chamber view to diagnose fetal cardiac anomalies.

Four-chamber view screening of the fetal heart was greeted with significant optimism in the mid-1980s. This screening technique was initially expected to detect most congenital heart disease in utero; however, recent studies demonstrate a 4% to 40% sensitivity of four-chamber view screening. It is therefore probable that the dream of antepartum diagnosis of most congenital heart disease in utero will remain unfulfilled. This is particularly true with increasing funding constraints for health care provision imposed by both the federal government and third-party payors.

A program of uterine activity monitoring and its effect on neonatal morbidity.

In a recent study 34 patients at high risk for preterm delivery who received uterine activity monitoring were compared with 33 similar patients who attempted to detect contractions by palpation. The incidence of preterm delivery was significantly reduced among those using the uterine activity detection device, although all patients in both groups had the same prenatal care and educational intervention. When short-term neonatal morbidity associated with preterm delivery was compared between the two groups, adverse effects decreased significantly among those in the monitored group (p = 0.001). The majority of short-term morbidity in both groups was noted in those delivering preterm and thus was gestational age related. No significant difference was found in neonatal morbidity between the groups when the infants were delivered at less than 37 weeks' gestation. Uterine activity monitoring, which is effective in preventing preterm birth, is also efficacious in decreasing short-term neonatal morbidity.

Meperidine and normeperidine distribution in the rhesus monkey.

Previous work has shown that both meperidine and normeperidine are transferred across the placenta to the fetus. Little is known in primates, however, about the tissue deposition of these compounds. Four pregnant, dated rhesus monkeys within one week of term were anesthetized for cesarean delivery. An equal mixture of meperidine and normeperidine was administered as an intravenous bolus 10 minutes before delivery (1.25 mg/kg). The infants were then sacrificed at 20 minutes after birth and the concentration of the compounds in various organ systems were analyzed by gas-liquid chromatography and mass spectroscopy (GLC-MS). The infant serum 20 minutes after delivery revealed a meperidine concentration of 2.23 micrograms/ml and a normeperidine level of 0.67 micrograms/ml (3:1). In contrast, the tissues analyzed showed a much higher concentration of the metabolite in the liver (1:7), gallbladder (1:3), and brain (1:2). Other tissues, such as muscle and kidney, demonstrated equal levels of the two compounds. The authors conclude that normeperidine is quickly transferred to fetal tissues and to a greater degree than the parent compound in certain organs. The increased distribution, particularly in the brain, could account for the toxic actions in the cerebrum of the derivatives of meperidine.

Cost effectiveness of ambulatory uterine activity monitoring.

A cost analysis is presented comparing 34 patients who received uterine activity monitoring versus 33 patients who attempted to detect uterine activity by palpation. All patients were at high risk for preterm delivery and were given the same educational information and prenatal care regarding signs and symptoms of preterm labor. The results revealed an increase in newborn days (640) and cost to those patients who were in the self-palpation group ($13,364) compared to monitored parturients (268 days and $8,633). The difference was attributed to neonatal morbidity from an increased number of preterm deliveries greater than 26 weeks but less than 37 weeks (P = 0.04). The increase in NICU days was significant (P = 0.03). No difference in normal newborn costs for infants delivered after greater than 33 weeks could be detected between the two groups, but morbidity was increased among control infants delivering between 34 and 36 weeks. Uterine activity monitoring to prevent preterm birth appears to be medically effective and reduces cost.

Pregnancy in a woman with an automatic implantable cardioverter-defibrillator. A case report.

Two years after insertion of an automatic implantable cardioverter-defibrillator, a 33-year-old woman had an uneventful cesarean delivery.

Leuprolide acetate depot for the treatment of uterine leiomyomas. Changes in bone density, uterine volume and uterine vascular resistive index.

This study measured the changes in uterine volume, uterine vascular resistive index and lumbar vertebral bone density before and after a six-month course of leuprolide acetate depot in women with uterine leiomyomas. All nine patients studied were black. The high baseline bone density of black women may provide a greater scope for the use of gonadotropin agonists as compared to women in the general population. A significant reduction in uterine volume was achieved in the patients with leuprolide therapy. Uterine vascular resistive indices were not altered consistently following leuprolide therapy in women with leiomyomas.

Prophylactic intrapartum amnioinfusion for patients with oligohydramnios. A prospective randomized study.

This prospective study evaluated whether prophylactic saline amnioinfusion among patients with amniotic fluid index (AFI) < or = 5.0 cm decreases the incidence of adverse fetal outcomes. Randomization of 53 patients with decreased AFI at term, resulted in 21 patients' receiving prophylactic saline amnioinfusion early in labor, prior to development of an abnormal fetal heart rate tracing. For the treatment group the mean AFI on admission was 3.0 cm, and the postamnioinfusion AFI was 8.9 cm. For 32 comparison (noninfusion) patients, the mean AFI was 2.9 cm; the group consisted of 17 patients randomized to receive no amnioinfusion (control group) and 15 patients who refused to participate in the study. There was no statistically significant difference between the amnioinfused and nonamnioinfused patients with regard to age, parity, gestational age, AFI at admission or duration of first or second stage of labor. Amnioinfusion resulted in no statistically significant reduction in the incidence of recurrent variable decelerations/bradycardia (26.3% vs. 46.6%), intrapartum resuscitation with terbutaline (5.2% vs. 10.0%), cesarean section for fetal distress (9.5% vs. 9.3%), fetal-acidosis (10.5% vs. 12.0%) or Apgar scores < 7 at five minutes (5.2% vs. 0%) in patients with oligohydramnios.

Cervical pregnancy managed without hysterectomy. A case report.

A woman with a cervical pregnancy was treated without a hysterectomy. Hemorrhage from the implantation site was controlled by placement of a Foley catheter balloon in the cervix. Placement and inflation of a Foley catheter balloon in the cervix after cervical dilation and curettage appears to be a simple and effective means of managing postoperative hemorrhage secondary to cervical pregnancy.

TC-83 Venezuelan equine encephalitis vaccine exposure during pregnancy.

A human pregnancy exposed to TC-83 live attenuated Venezuelan equine encephalitis (VEE) virus vaccine resulted in hydrops fetalis and fetal demise. Maternal seroconversion and the finding of a diffuse mononuclear cell infiltrate on postmortem examination are suggestive of a causative role for TC-83 vaccine.