Genetic amniocentesis: a twelve years' experience.

The first 2,013 fetuses in 2,000 patients undergoing genetic amniocentesis at our institution were analyzed for the incidence of abnormal findings and for the safety and accuracy of the procedure. One percent of the patients were found to have aneuploid fetuses and another 1% were found to have elevated amniotic fluid concentrations of alpha-fetoprotein. Advanced maternal age was the indication for amniocentesis in 84% of the women with aneuploid fetuses. Thirty-two (1.6%) of the pregnancies ended in spontaneous abortion and 35 (1.7%) were terminated because of abnormal results of the prenatal diagnostic procedure. Our error rate was 0.15%, and tissue culture was successful in 97.7% of the procedures. During the latter part of our experience concurrent ultrasonography was utilized with the amniocentesis, resulting in a reduction in blood-tinged specimens from 15.0% to 5.2%. In experienced hands, midtrimester amniocentesis for the purpose of prenatal diagnosis of genetically determined defects is a safe, accurate, and valuable procedure for the identification of fetal abnormalities.

Pregnancy outcome in 211 patients with mild chronic hypertension.

The purpose of the present clinical investigation was to determine the risks associated with mild chronic hypertension in pregnancy. Two hundred eleven consecutive pregnancies complicated by mild chronic hypertension (diastolic blood pressure, 90 to 110 mmHg) were analyzed. All patients were followed closely throughout pregnancy with frequent prenatal visits and serial assessment of fetal status. Antihypertensive drugs were discontinued at the time of the first prenatal visit. Only 13% of these patients required antihypertensive medications later in pregnancy. There were 2 stillbirths and 4 neonatal deaths for an overall perinatal mortality of 28.1/1000. However, the majority of deaths (5 of 6) occurred among the 21 patients with superimposed preeclampsia. This subgroup was also characterized by a high rate of growth-retarded infants (32%). For patients without superimposed preeclampsia, 5.3% of the infants were small for gestational age and there was only one perinatal death. Thus, for patients with mild chronic hypertension, discontinuance of antihypertension medications does not adversely affect the antepartum course or perinatal outcome. In fact, in the absence of superimposed preeclampsia, the perinatal mortality for these patients approaches that of the general obstetric population. Therefore, in pregnancies complicated by mild chronic hypertension, factors other than increased blood pressure per se might be responsible for the poor perinatal outcome reported in such pregnancies.

Quantitative analysis of amniotic fluid phospholipids in diabetic pregnant women.

Controversy exists regarding the fetal lung maturity profiles in diabetic and normal pregnancies. Diabetic and control patients at term were compared. A comprehensive lung profile was obtained using high performance liquid chromatography, lecithin:sphingomyelin ratio by conventional thin-layer chromatography, and the Lumadex foam stability index. There was no statistically significant difference in the phospholipids measured by any of the three techniques despite the fact that the control patients had a significantly higher mean gestational age at amniocentesis. As expected, the diabetic pregnancies had a significantly higher mean birth weight. There was no case of respiratory distress syndrome in either group. The present data do not allow rejection of the null hypothesis of no difference in amniotic fluid phospholipids, between diabetic and normal pregnancy, at term.

Relationship of hypertensive disease to abruptio placentae.

The purpose of the present retrospective study was to examine the relationship between hypertension and abruptio placentae. Two hundred sixty-five consecutive cases of abruption were reviewed, with an emphasis on the occurrence and severity of hypertensive disease. The results confirm a close relationship between abruptio placentae and hypertension. The incidence of abruption was highest with eclampsia (23.6%), followed by chronic hypertension (10.0%) and preeclampsia (2.3%). In addition, those with eclampsia and chronic hypertension had a significantly higher perinatal mortality than those without these conditions. These data demonstrate that hypertension is associated with an increased risk of abruption. Furthermore, the degree of this increased risk is clearly dependent upon the specific type of hypertensive disorder.

Plasma volume determination in pregnancies complicated by chronic hypertension and intrauterine fetal demise.

Plasma volume determinations for 9 women with severe chronic hypertension who delivered live-born infants with birth weights appropriate for gestational age (AGA) were compared with those for 7 women with chronic hypertension whose pregnancies ended in intrauterine fetal demise. Plasma volume determinations using Evans blue dye dilution technique were performed at 20 to 25 weeks' gestation (12 patients) and at 26 to 29 weeks' gestation (16 patients). In addition, plasma volume measurements were performed at 8 weeks post partum in 5 patients who had intrauterine fetal demise. Analysis of the clinical course, laboratory findings, and pregnancy outcome revealed that the degree of plasma volume expansion was the factor most significantly differing between the 2 groups of patients. The plasma volumes of 9 women who delivered AGA infants were comparable with those values previously reported for normal singleton pregnancy. In contrast, each patient with intrauterine fetal demise demonstrated failure in plasma volume expansion at 20 to 25 weeks' gestation when compared with her own postpartum value. In each of the 6 patients who had a second plasma volume determination at 26 to 29 weeks' gestation, there was a decrease (mean decrease, 13.5%) from the value at 20 to 25 weeks. Plasma volume determinations may be very helpful in making clinical decisions regarding women with severe hypertension. Plasma volume determination may be most helpful in identifying a subgroup of women who are at particular risk for having infants with intrauterine growth retardation and intrauterine fetal demise.

Adhesion prevention by solutions of sodium carboxymethylcellulose in the rat. II.

In a rat model, sodium carboxymethylcellulose (SCMC) was compared with normal saline and 32% dextran 70 in the prevention of surgically induced intraperitoneal adhesions. The 32% dextran 70 was similar to normal saline in the initial prevention of adhesions, and both appeared less effective than SCMC. After lysis of the initial adhesions, SCMC was significantly more effective than 32% dextran 70 in the prevention of the reformation of adhesions. Possible mechanisms of action, complications of SCMC, and the need for further research in finding an ideal solution for use in adhesion prevention are discussed.

Henoch-Schonlein purpura associated with eclampsia. A case report.

A case of peripartum seizure activity presumed to represent eclampsia is presented. The postpartum diagnosis of Henoch-Schonlein purpura places the original diagnosis in question due to similarities in the manifestations of the two syndromes.

Eclampsia. V. The incidence of nonpreventable eclampsia.

The development of eclamptic convulsions is an obstetric complication that is generally considered to be avoidable. The purpose of this study was to investigate the perinatal events associated with 179 consecutive cases of eclampsia, in order to identify specific preventable factors. Based on a careful analysis of medical care received before the onset of eclampsia, the following factors were judged to be at least partially responsible for the failure to prevent eclamptic convulsions: physician error (n = 65), magnesium sulfate failure (n = 23), late-onset eclampsia (n = 22), early onset (less than 21 weeks) preeclampsia/eclampsia (n = 5), abrupt onset eclampsia (n = 32), and failure of patient to start prenatal care before the onset of eclampsia (n = 34). Fifty-six (31.3%) of the patients received obstetric care that met or exceeded all current standards for delivery of obstetric services. These cases were classified as "unavoidable."

Eclampsia. III. Neonatal outcome, growth, and development.

Infants of 72 recently managed women with eclampsia before delivery were studied. Infants with gestational age of 36 weeks or less (56%) were analyzed separately from those infants of more than 36 weeks' gestation (44%). In addition, premature infants of eclamptic mothers were compared with 40 premature infants whose mothers did not have any medical complications. Intrauterine growth retardation was symmetrical in all seven infants whose mothers had eclampsia prior to 32 weeks. All neurological abnormalities were associated with abruptio placentae or intrauterine growth retardation. Among the preterm infants of eclamptic mothers and those of normotensive mothers, there was no significant difference in any commonly acquired laboratory data. Neonatal complications in premature infants of eclamptic mothers were frequent. However, neonatal complications of the low-birth weight infants were strikingly similar regardless of the presence of eclampsia. It is possible that most neonatal complications are consequence of prematurity, instead of a sole consequence of eclampsia. Observations from follow-up data (up to 4 years of age) suggest normal growth and development for infants of mothers with uncomplicated eclampsia.

Chlamydia trachomatis infection in pregnancy and effect of treatment on outcome.

The effect of Chlamydia trachomatis on pregnancy outcome and the effect of treatment of positive cervical cultures was studied by culturing 11,544 women for chlamydia at their first prenatal visit. Chlamydia culture was positive in 2433 (21.08%) and prevalence was related to age and race. Of the positive cultures, 1110 were classified as untreated. The untreated group demonstrated a significant increase in the incidence of premature rupture of the membranes and low birth weight and a decrease in survival when compared with either those with positive cultures who received treatment (N = 1323) or those with negative cultures (N = 9111). Screening of populations at high risk of chlamydia is recommended and treatment of chlamydia-positive patients may improve pregnancy outcome.

Maternal and perinatal outcome of conservative management of severe preeclampsia in midtrimester.

Pregnancies complicated by severe preeclampsia in the second trimester are associated with a high incidence of perinatal morbidity and mortality. One way to possibly improve perinatal outcome in these pregnancies is to attempt to prolong the gestation with conservative management. Reported here the results of conservative management of 60 consecutive patients with severe preeclampsia in the second trimester (18 to 27 weeks' gestation). Although there were no maternal mortalities, the morbidity rate for the 60 patients was very high. Severe maternal complications included abruptio placentae (n = 13), eclampsia (n = 10), coagulopathy (n = 5), renal failure (n = 3), hypertensive encephalopathy (n = 2), intracerebral hemorrhage (n = 1), and ruptured hepatic hematoma (n = 1). In addition, perinatal outcome for these pregnancies was exceptionally poor, with 31 of the 60 pregnancies resulting in a stillborn infant, and 21 resulting in a neonatal death, for a total perinatal mortality rate of 87%. Thus, the results of this retrospective study do not support the use of conservative management for pregnancies complicated by severe preeclampsia in the second trimester.