Timing of delivery for pregnancies with congenital diaphragmatic hernia.

A recent report has suggested that delivery at early term ages may be associated with lower mortality among infants with congenital diaphragmatic hernia. We sought to confirm this finding by examining gestational age-specific mortality in the USA in term infants with isolated congenital diaphragmatic hernia, delivered following the spontaneous onset of labour. In the final population of 928 infants, neonatal and infant mortality decreased with advancing gestation, from 25 and 36% at 37 weeks of gestation, respectively, to 17 and 20% at 40 weeks of gestation, respectively. Log-binomial regression models showed that neonatal and infant mortality at 37 weeks of gestation were significantly higher than at 40 weeks. Further evidence, ideally from a randomised trial, is needed before recommendations for clinical practice on timing of delivery should be made.

Introital adenosis associated with Stevens-Johnson syndrome.

A 23-year-old woman presented with vulvar pain and dyspareunia 1.5 years after a Stevens-Johnson syndrome. A red friable lesion was identified at the vestibule and lower third of the vagina. The histologic diagnosis was adenosis with a tubal glandular epithelium. The possible histogenesis of this lesion is discussed with a review of the embryology of the lower genital tract.

Cost-effective criteria for glucose screening.

To study cost-effective screening criteria for gestational diabetes, a prospective study of 1012 patients was completed. All patients underwent a glucose screen between 26 and 30 weeks of gestation, consisting of a 50-g oral glucose load followed by a one-hour plasma glucose determination. Patients with a glucose screen greater than or equal to 130 mg/dL were studied with a standard three-hour oral glucose tolerance test. The incidence of gestational diabetes was 2.4% (24 of 1012). Only one gestational diabetic was identified with a glucose screen below 150 mg/dL. Twenty-two of the 24 cases were at least 24 years old. Twenty-one of the 24 (88%) gestational diabetes had a glucose screen greater than or equal to 150 mg/dL and were 24 years old or greater. The cost of the diagnosis in these latter patients was 40% of the cost of diagnosis of universal screening with a threshold of 130 mg/dL. It is concluded that screening with a threshold of 150 mg/dL only patients who are at least 24 years old should be considered an alternative to universal screening.

Screening for trisomy 21 with ultrasonographic determination of biparietal diameter/femur length ratio.

Ultrasonographic determination of biparietal diameter/femur length ratios performed at 16 or 17 weeks' gestation in fetuses with trisomy 21 were not statistically different from those of 155 normal fetuses. It appears that this test could not be used for screening for trisomy 21.

Efficacy of screening for gestational diabetes.

A cost analysis of glucose screening was studied prospectively in 434 patients. All patients underwent a 50-gm oral glucose load followed by a 1-hour plasma glucose screen test at 28 weeks (+/- 2 weeks). Patients with a screen test greater than or equal to 130 mg/dl plasma glucose were further tested with an oral glucose tolerance test. Also, previously described clinical risk factors for diabetes were documented on all patients. A 3.3% prevalence of gestational diabetes was found in 178 patients with risk factors, compared with 2.4% of 256 patients without risk factors, not a significant difference. Ten of the 12 gestational diabetics were at least 24 years old, so that screening only this subgroup would still retain a good sensitivity (83%) but at half the cost of universal screening. Screening on the basis of risk factors other than age is inefficient. Though testing only patients who are 24 years of age or older is more cost effective than universal screening, an individual decision must be made regarding its reduced sensitivity.

Epidural anaesthesia for elective caesarean section does not influence fetal umbilical artery blood flow indices.

This prospective study was completed to determine the influence of epidural anaesthesia on the fetoplacental circulation of normal subjects. Thirty-seven normal pregnant patients at term, undergoing elective Caesarean section, had Doppler measurements of the fetal umbilical artery blood flow velocity before and after epidural anaesthesia using lidocaine 2% without epinephrine. There were no differences in systolic/diastolic, resistance or pulsality indices following epidural anaesthesia. These results suggest that this technique has no adverse effect on fetoplacental circulation in normal non-labouring subjects.

Prenatal ultrasonic diagnosis of multiple bowel atresias.

This case illustrates the course of an obstructive process through spontaneous perforation resulting in decompression of dilated bowel loops. The resulting meconium peritonitis appeared as fetal ascites. Postnatal investigations and laparotomy confirmed the diagnosis of a rare form of multiple congenital atresias of the bowel.

Does the use of a tocolytic agent affect the success rate of external cephalic version?

OBJECTIVE: Our purpose was to study the effect of ritodrine tocolysis on the success rate of external cephalic version at > or = 36 weeks' gestation. STUDY DESIGN: This was a prospective, double-blinded, randomized study. All patients were > or = 36 weeks' gestation, confirmed by early ultrasonography. External cephalic version assessment included nonstress testing before and after external cephalic version and ultrasonographic evaluation of type of breech, estimated fetal weight, position of placenta and fetal spine, and amniotic fluid index. Patients were excluded if the breech was not mobile or if they had any contraindications to tocolysis or external cephalic version. After randomization 283 patients received either ritodrine (111 micrograms/min) or identical placebo by intravenous infusion for > or = 20 minutes. Up to three attempts at external cephalic version under ultrasonographic surveillance were performed. With an alpha error of 0.05 and a beta of 0.2, 264 patients were required to complete this study. RESULTS: There were no differences between study groups in maternal age, body mass index, gestational age, amniotic fluid index, position of fetal spine, and placental location. Statistical analysis controlled for parity because parity had a major influence on success rates. There was a higher success rate in the group receiving ritodrine tocolysis (52% vs 42%, p = 0.028). Ritodrine improved success rates in nulliparous patients (43% vs 25%, p = 0.026) but not in parous subjects (66% vs 58%, p = 0.385). CONCLUSION: Ritodrine tocolysis improves the success rate of external cephalic version performed at > or = 36 weeks in nulliparous patients.

The validity of the leukocyte esterase reagent test strip in detecting significant leukocyturia.

This prospective trial demonstrated that the best possible definition for a positive leukocyte esterase test (Chemstrip 9) is + or ++. With use of this definition, the sensitivity in detecting significant leukocyturia is 83% and the specificity is 70%. The use of this test strip could reduce screening costs in registering obstetric patients.

The accuracy of visual and meter determinations of blood glucose with the use of Chemstrip bG.

The 95% confidence intervals for the blood glucose determinations with use of the Chemstrip bG were +/- 28 mg/dl by visual reading and +/- 18 mg/dl by means of the Accu-Chek photometer. These rapid methods continue to be an important aid in the home care of pregnant diabetic women.