The value of a negative antepartum test: contraction stress test and modified biophysical profile.

OBJECTIVE: To examine the outcome of pregnancies in high-risk patients whose last antepartum fetal assessment was a negative contraction stress test (CST) or a negative modified biophysical profile. METHODS: Twenty-nine hundred ninety-four women who received modified biophysical profiles were compared with 2450 who had CSTs during the preceding 3 years. Pregnancy outcomes were evaluated in patients whose last test was negative. RESULTS: Seventeen hundred fifty-three patients had negative modified biophysical profiles as the last test before delivery, and 1337 had negative CSTs as the last test before delivery. Adverse perinatal outcomes included perinatal death or death before nursery discharge, cesarean delivery for fetal distress within the first 2 hours of labor, 5-minute Apgar score less than 7, neonatal seizures, or grade III or grade IV central nervous system hemorrhage. Adverse outcomes occurred in 90 patients (5.1%) whose last test before delivery was a negative modified biophysical profile and in 93 patients (7.0%) whose last test was a negative CST (P = .04, odds ratio 1.38, 95% confidence interval 1.01-1.88). Overall, there were 11 perinatal deaths, nine of which resulted from lethal congenital abnormalities. CONCLUSIONS: In this population, the frequency of adverse perinatal outcome following a negative modified biophysical profile was no greater than that following a negative CST. Further, the incidence of potentially preventable perinatal death following a negative modified biophysical profile or CST was less than one per 1000 tested high-risk pregnancies.

Effects of digital vaginal examinations on latency period in preterm premature rupture of membranes.

OBJECTIVE: To compare the clinical outcome in patients with preterm premature rupture of membranes (PROM) who had a sterile speculum examination with those having a digital vaginal examination. METHODS: We studied 271 singleton pregnancies complicated by preterm PROM from the Memorial Medical Center of Long Beach Perinatal Outreach program that met the criteria for expectant treatment from January 1986 to April 1990. Patients were not included in the study if they had multiple gestations, cerclage, advanced labor, or any indication for delivery on admission (eg, mature lung profile, chorioamnionitis). All subjects were maternal transports to our tertiary care facility and were managed similarly by our perinatal group. The women were questioned as to whether a digital vaginal examination had been performed before transport. Latency period and other obstetric characteristics were then compared. The latency period, defined as days from rupture of membranes until active intervention was initiated or labor began spontaneously, was also stratified by gestational age. RESULTS: One hundred twenty-seven subjects had a digital vaginal examination and 144 had a sterile speculum examination. A significantly (P less than .0001) shorter mean latency period (2.1 +/- 4.0 versus 11.3 +/- 13.4 days) was found in those who had a digital vaginal examination. In addition, a shorter latency period was noted for each gestational age. No difference in uterine activity or cervical dilatation and effacement was noted between the groups on admission. CONCLUSION: Digital vaginal examinations performed on patients whose pregnancies are complicated by preterm PROM appear to shorten significantly the latency period.

Renal failure in pregnancy.

The outcome for pregnancies in women with renal pathology has improved markedly as a result of many new technological changes. The kidney plays a critical role in both normal and complicated pregnancy. Only by understanding these various adaptations can one correctly manage patients whose pregnancies are complicated by some degree of renal impairment and achieve a safe and successful outcome for both mother and baby.

Acute pancreatitis caused by biliary ascaris in pregnancy.

Ascaris lumbroicoides is the most prevalent human parasite worldwide. Although usually asymptomatic, ascaris is responsible for a variety of severe complications such as intestinal obstruction, cholangitis, or hepatitis, which are caused by worm migration. This article is the second known case report of pancreatitis caused by biliary ascaris during pregnancy. We also review the pathophysiology of this disease and review the various treatment modalities available for pregnant patients. We believe that because of the growing influx of immigrants from endemic areas into the United States, the clinician needs a basic understanding of the etiology, diagnosis, and treatment of biliary ascarasis.

The risk of periventricular-intraventricular hemorrhage with vacuum extraction of neonates weighing 2000 grams or less.

OBJECTIVE: The objective of this retrospective study was to test the hypothesis that vacuum extraction of neonates with a birth weight < or = 2000 gm is associated with an increased risk of periventricular-intraventricular hemorrhage (PV-IVH). STUDY DESIGN: One hundred sixty-eight neonates weighing < or = 2000 gm were entered into this case control study. Fifty-six neonates delivered by silicone-rubber vacuum comprised the study group. For every infant born by vacuum-assisted delivery, two spontaneously delivered neonates served as controls (n = 112) and were matched for best obstetric gestational age (within 1 week), delivery date within 1 year, and birth weight < or = 2000 gm. Maternal and neonatal medical records were reviewed for demographic variables, antenatal complications, indication for vacuum-assisted delivery, neonatal birth weight, Apgar scores, umbilical cord blood gas values, and neonatal morbidity including the incidence of PV-IVH. All perinatal outcome variables were compared between the vacuum-assisted and spontaneously delivered groups. RESULTS: Both groups were similar with regard to maternal age, parity, antepartum complications, gestational age at delivery, neonatal birth weight, and gender. Both groups were also similar with regard to the incidence of 1-minute Apgar score < 5, small for gestational age, cephalhematoma, birth trauma, respiratory distress syndrome, hyperbilirubinemia, and sepsis. There was a significant increased incidence of 5-minute Apgar scores < 7 in the vacuum-assisted group (p = 0.04). No significant difference was observed in the incidence of PV-IVH grades 1 through 4 (21.4% vacuum group vs 16.1% control group, odds ratio 1.42, 0.58 to 3.45). CONCLUSION: Indicated use of the silicone-rubber vacuum to assist vaginal delivery of neonates weighing < or = 2000 gm does not appear to be associated with an increased risk of PV-IVH or other neonatal complications.

Intra-amniotic infection in patients with preterm prelabor rupture of membranes. Pathophysiology, detection, and management.

The recent increase in knowledge about infection and preterm delivery has engendered many new questions and should make us rethink our long held beliefs and management strategies. Although this article focused primarily on infection as an important factor in the pathogenesis of PPROM, multiple other causes do exist. The various serologic and amniotic fluid assays that can identify activation of the host immune and inflammatory responses as a consequence of the microbial invasion of the amniotic cavity detailed in the preceding paragraphs are very promising but not yet available for clinical use. These tests identify the fetus in the early stages of an infectious process, before the full clinical manifestations of chorioamnionitis. Should such fetuses be treated with antibiotics in an effort to sterilize the amniotic cavity? Should patients with documented microbial invasion be delivered immediately or is there room for a more conservative management with aggressive antibiotic in utero treatment, altering the natural course of PPROM, avoiding extremely preterm deliveries? Certainly many questions remain unanswered. Continuing the search for information on the relationship between infection and PPROM can only add hope to one day finding an option for prevention, because many and probably most cases of PPROM are apparently caused by infection, and the opportunity for preventing this problem most probably lies here.

Trisomy 13 in one fetus from a twin gestation after intracytoplasmic sperm injection. A case report.

BACKGROUND: Intracytoplasmic sperm injection (ICSI) is an assisted reproductive technique used in the treatment of severe male factor infertility. Reports of chromosomal aberrations in some fetuses conceived following ICSI have raised concern that the technique may contribute to the development of genetic disease. CASE: Trisomy 13 occurred in one of twin fetuses of a 28-year-old woman who underwent ICSI. This case is unique because it is the first reported one of an autosomal trisomy complicating one fetus from a twin gestation conceived by ICSI. It is also the first case describing an autosomal trisomy following ICSI in a woman under the age of 35. CONCLUSION: Chromosomal abnormalities associated with ICSI may be accounted for by factors other than advanced maternal age. Chromosomal aberrations may be related to the procedure itself. Therefore, patients should be advised of the possibility of aneuploidy in association with ICSI, and genetic amniocentesis should be considered regardless of maternal age.

Can shoulder dystocia be predicted? Preconceptive and prenatal factors.

OBJECTIVE: To evaluate the predictability of shoulder dystocia using preconceptive and prenatal risk factors. STUDY DESIGN: Data from 1,622 term patients with prenatal care prior to 20 weeks who delivered single, vertex fetuses during a consecutive 12-month period were analyzed. Two groups were chosen. The first group was patients whose fetuses experienced shoulder dystocia during delivery (cases). The second group (controls) consisted of the remaining patients, whose fetuses had not experienced shoulder dystocia. The two groups were compared with regard to demographics and pregnancy characteristics. RESULTS: Factors not significantly different between the two groups included were obesity, multiparity, history of diabetes, short maternal stature, postdatism and advanced maternal age. The incidence of macrosomia was significantly higher (P < .001) in cases (35.4%) than in controls (4.8%). Other factors associated with shoulder dystocia were previous shoulder dystocia, concurrent diabetes, prior delivery of a fetus > 4,000 g and excessive weight gain during pregnancy. Many factors previously associated with shoulder dystocia were found to be nonsignificant in our study. CONCLUSION: Macrosomia appears to be the single important factor associated with shoulder dystocia which, even in the presence of significant risk factors, remains largely unpredictable.

Management of preterm premature rupture of membranes.

The variables enumerated in the preceding paragraphs and the constantly changing and improving technology in neonatal care mean that the data on which to base the best management plans of PPROM are not yet available. Rather, we must be willing to revise our approach to the treatment of this entity constantly as new information is found. However, several important changes in the management of these patients over the last few years were implemented and have had a significant impact on the outcome of these neonates. The use of routine prophylactic intrapartum amnioinfusion is one of these. Although preliminary, the data on prophylactic antibiotic use are promising and have brought us closer to the concept of treating occult intraamniotic infections with antibiotics rather than immediate and indiscriminate delivery. The identification of several factors such as interleukin-1, neutrophil activating peptide-1/interleukin-8, and tumor necrosis factor (TNF) in patients with idiopathic preterm labor may allow us to determine the pathophysiologic mechanism by which preterm labor leading to PPROM is initiated and allow us to tailor treatment specifically. For instance, in such patients, uterine activity may respond to antibiotic therapy rather than the usual tocolytics. Unfortunately, measurements of such factors are not yet widely available and remain primarily research tools. However, these recent findings give us a glimpse of what lies ahead. It is entirely conceivable that a symposium on the management of PPROM eventually will have a section devoted to its prevention that is based on an understanding of its pathophysiology.

Septic shock in pregnancy associated with legionella pneumonia: case report.

We report the first case of legionella infection in pregnancy complicated by sepsis and hemodynamic compromise. Legionnaires' disease is rarely found in pregnancy, possibly because subacute infections may often be overlooked and empiric therapy of pneumonia in pregnancy may be curative without definitive etiologic diagnosis.

The presence of hepatitis B surface antigen and deoxyribonucleic acid in amniotic fluid and cord blood.

OBJECTIVE: It is uncertain whether neonatal infection with hepatitis B, despite treatment after delivery with immunoglobulin and vaccine, is the result of prior in utero transmission of the virus or treatment failure. Furthermore, the potential risk of hepatitis B transmission from the mother to the fetus at the time a genetic amniocentesis is performed is also a concern. In an attempt to better elucidate these controversies, amniotic fluid and cord blood specimens obtained from pregnant women positive for hepatitis B surface antigen were analyzed for the presence of hepatitis B surface antigen and hepatitis B deoxyribonucleic acid. STUDY DESIGN: This study was a prospective longitudinal analysis that identified hepatitis B surface antigen-positive patients who presented for amniocentesis. Cord blood was obtained from these patients at the time of delivery. Cord blood was also obtained from a group of hepatitis B surface antigen-positive patients for whom no amniocentesis was performed. All samples were analyzed for the presence of hepatitis B surface antigen and hepatitis B deoxyribonucleic acid. RESULTS: A total of 121 hepatitis B surface antigen-positive pregnant women were identified. In the 72 pregnancies in which amniocentesis was not performed, 18% of the cord blood samples were positive for hepatitis B surface antigen and 4% were positive for hepatitis B deoxyribonucleic acid. Of 47 amniocentesis fluid samples, 32% were positive for hepatitis B surface antigen but all were negative for hepatitis B virus deoxyribonucleic acid. Of 30 cord blood samples from patients who underwent an amniocentesis, 27% were positive for hepatitis B surface antigen, but all were negative for hepatitis B virus deoxyribonucleic acid. CONCLUSIONS: This study found that hepatitis B viral deoxyribonucleic acid is rarely present in cord blood and was not identified in amniotic fluid obtained by amniocentesis. This finding suggests that in utero transmission of the virus is rare prior to the onset of labor. These data further confirm the reports in the current literature that the risk of hepatitis B transmission to the fetus during amniocentesis is low. Because hepatitis B surface antigen can exist as an isolated entity devoid of nuclear material, in some cases this protein may be able to traverse the placental and amniotic membrane barrier in a manner similar to other proteins, such as alpha-fetoprotein. Recommendations for genetic amniocentesis in women positive for hepatitis B surface antigen are discussed.

Ultrasonographic detection of ureteral jets in normal pregnancy.

OBJECTIVE: Our purpose was to determine the impact of normal physiologic urodynamic alterations of pregnancy on the detection of ureteral jets into the bladder with use of transabdominal color Doppler ultrasonography. STUDY DESIGN: We conducted a prospective cohort study of 125 healthy asymptomatic gravid women without any history of past or current renal disease, all with singleton pregnancies between 13.4 and 37.7 weeks' gestation. Right and left ureteral jets were recorded over a 5-minute period with use of color Doppler transabdominal ultrasonography and a full bladder. Each kidney was graded by the severity of the hydronephrosis. No hydronephrosis was grade 0, mild hydronephrosis was grade 1, and moderate hydronephrosis was grade 2. There were no cases of severe hydronephrosis. RESULTS: There were 56 grade 0 cases on the right versus 93 grade 0 cases on the left (p < 0.0001), 53 versus 30 grade 1 cases (right vs left, p < 0.003) and 16 versus 2 grade 2 cases (right vs left, p < 0.0009). In the subgroup where both kidneys were grade 0 the mean number of right ureteral jets 5 mm was 14.7 versus 15.1 for the left ureteral jets (p = 0.73). In the grade 1 subgroup mean right versus left ureteral jets was 15.4 versus 16.6 (p = 0.65). For the grade 2 subgroup mean right versus left ureteral jets was 15.5 versus 21.0 (p = 0.32). There were 4 of 125 unilateral absent ureteral jets on the right versus 0 of 125 on the left (p = 0.122). CONCLUSION: Our data demonstrate that ureteral jets can be readily detected during pregnancy independent of the gestational age. In addition, it does not appear that the physiologic urodynamic alterations of pregnancy affect the frequency or symmetry of ureteral jets. Thus identification of ureteral jets can be used in the workup of suspected urolithiasis in pregnant patients.

The capture rate of at-risk term newborns for early-onset group B streptococcal sepsis determined by a risk factor approach.

OBJECTIVE: Currently, the Centers for Disease Control and Prevention, The American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend that health care providers for pregnant women implement 1 of 2 strategies for the potential prevention of early-onset neonatal group B streptococcal sepsis. Both algorithms recommend intrapartum antibiotic chemoprophylaxis for patients delivered of their neonates at <37 weeks' gestation. The basic difference lies in the management of the term pregnancy. One protocol suggests treatment of all patients with term pregnancies with a positive culture for group B Streptococcus obtained at 35 to 37 weeks' gestation. The second approach recommends treatment on the basis of risk factors of membrane rupture of >/=18 hours' duration or intrapartum temperature of >/=38 degrees C. The capture rate of at-risk neonates determined by the risk factor strategy is quoted as being approximately 70%; however, the basis for this percentage was from studies that used slightly different definitions than the current guidelines and never separated the term from the preterm newborn. Our objective was to prospectively collect every case of blood culture-proven early-onset neonatal group B streptococcal sepsis and determine whether risk factors, as currently defined, were present that might have warranted maternal intrapartum antibiotic chemoprophylaxis. STUDY DESIGN: A prospective study was initiated on July 1, 1987, and completed on December 31, 1996. Every patient that was delivered of a neonate in whom early-onset group B streptococcal sepsis developed was analyzed in detail for possible intrapartum risk factors. RESULTS: A total of 49 cases of early-onset group B streptococcal sepsis occurred in 46,959 deliveries. Of these 49 newborns, 9 (18%) were delivered at <37 weeks' gestation. The remaining 40 newborns were delivered at term, and only 12 (30%) were delivered with an intrapartum risk factor of either membrane rupture of >/=18 hours' duration or temperature of >/=38 degrees C or both. CONCLUSIONS: On the basis of the data from this study and the current literature, the risk factor approach with the current guideline recommendations would capture <50% of the term newborns in whom sepsis develops.

Gram stain results from amniocentesis in patients with preterm premature rupture of membranes--comparison of maternal and fetal characteristics.

A total of 108 patients with preterm premature rupture of membranes who had undergone amniocentesis were retrospectively analyzed. Seventy-seven patients had negative amniotic fluid Gram stains and were managed expectantly. Thirty-one patients had positive amniotic fluid Gram stains confirmed by subsequent cultures and were delivered of infants on that basis. A univariate comparison of various parameters revealed significant differences in maternal temperature, pulse, and white blood cell count. Patients with positive Gram stains had lower mean gestational age, higher baseline fetal heart rate, and nonreactive fetal heart rate tracings. On the basis of a multivariate stepwise discriminate analysis, fetal heart rate greater than 150 beats/min or nonreactive nonstress test were the best predictors of the Gram stain findings, with a sensitivity of 71%, specificity of 76%, and negative predictive value of 87%. These data suggest that in patients with preterm premature rupture of membranes and fetal tachycardia or nonreactive nonstress test, amniocentesis should be performed in the initial evaluation.

Perinatal outcome with the modified biophysical profile.

OBJECTIVE: Our purpose was to evaluate perinatal outcomes in high-risk pregnancies monitored with a modified biophysical profile. STUDY DESIGN: All non-insulin-dependent patients referred for antepartum fetal surveillance received a modified biophysical profile biweekly. A modified biophysical profile is a combination of a nonstress test and an amniotic fluid index. Patients with a singleton gestation and intact membranes were entered into a protocol of randomized backup testing for an abnormal modified biophysical profile. Those patients having a nonreactive fetal heart rate, significant variable decelerations, late decelerations, or an amniotic fluid index < or = 5.0 cm received either a contraction stress test or a biophysical profile immediately. Once randomized, a patient received the same backup test, when indicated, with subsequent testing. RESULTS: A total of 2774 patients had 17,429 tests with an uncorrected perinatal mortality rate of 2.9 per 1000. The overall incidence of an adverse perinatal outcome (i.e., perinatal death or nursery death before infant hospital discharge, cesarean delivery for fetal distress within the first 2 hours of labor, 5-minute Apgar score < 7, neonatal seizures or grade III or IV central nervous system hemorrhage) was 7.0%. When compared with patients having persistently normal modified biophysical profile, patients requiring a backup test had a significantly greater incidence of adverse perinatal outcome (9.3% vs 4.9%, p < 0.001, odds ratio 2.0, 95% confidence interval 1.5 to 2.7) and small-for-gestational-age infants (5.2% vs 2.4%, p < 0.001, odds ratio 2.2, 95% confidence interval 1.5 to 3.5). No differences in outcomes between patients randomized to a contraction stress test versus a biophysical profile could be identified either overall or in limiting the analysis to outcome after a negative last test. However, patients having contraction stress test as a backup test had a significantly higher rate of intervention for an abnormal test result than did those having a biophysical profile backup test (23.7% vs 16.6%, p < 0.002, odds ratio 1.6, 95% confidence interval 1.2 to 2.1). CONCLUSION: The modified biophysical profile is an excellent means of fetal surveillance and identifies a group of patients at increased risk for adverse perinatal outcome and small-for-gestational-age infants. There does not appear to be a significant benefit with the contraction stress test compared with the biophysical profile as a backup test. Further, the contraction stress test is associated with a higher rate of intervention for an abnormal test than is the biophysical profile.

Potential consequences of widespread antepartal use of ampicillin.

OBJECTIVE: Recommendations for the use of antenatal antibiotics in obstetrics have increased in the past few years, especially for prophylaxis against group B streptococci, for prolongation of the latency time in patients with preterm premature rupture of the membranes, and as an adjuvant treatment in preterm labor. Our objective was to determine whether the use of antenatal ampicillin affects the incidence of and resistance of early-onset neonatal sepsis with organisms other than group B streptococci. STUDY DESIGN: A prospective cohort study was performed between January 1, 1991, and December 31, 1996. Every case of blood culture-proven neonatal sepsis was prospectively surveyed. The type of bacteria isolated, drug resistance, antenatal antibiotic use and treatment indication, gestational age at delivery, and other antenatal and outcome variables were gathered. Early-onset neonatal sepsis was defined as disease onset within 7 days after birth. RESULTS: A total of 42 cases of early-onset neonatal sepsis among 29,897 neonates delivered were found during the 6-year period. Of these, 15 cases were due to group B streptococci and 27 were the result of non-group B streptococcal organisms (21 gram-negative rods and 6 gram-positive cocci). Among the 27 non-group B streptococcal cases, 15 mothers had received antenatal ampicillin and 13 of the 15 bacterial isolates from these neonates (87%) were resistant to ampicillin, versus only 2 ampicillin-resistant isolates (17%) among the 12 cases in which no antenatal antibiotics were administered (P = .0004). Of the 15 mothers who were treated with ampicillin, 13 received more than 1 dose. In evaluating each year of the study, the overall administration of antibiotics to pregnant women in the antenatal period increased from <10% in 1991 to 16.9% in 1996. The incidence of early-onset neonatal sepsis with group B streptococci decreased during this time, whereas the incidence of early-onset sepsis with non-group B streptococcal organisms, especially Escherichia coli, increased. CONCLUSIONS: The increased administration of antenatal ampicillin to pregnant women may be responsible for the increased incidence of early-onset neonatal sepsis with non-group B streptococcal organisms that are resistant to ampicillin. At this time penicillin G, rather than ampicillin, is therefore recommended for prophylaxis against group B streptococci. In addition, future studies are needed to determine whether alternate approaches, such as immunotherapy or vaginal washing, could be of benefit.

A "bloodless cesarean section" and perinatal transmission of the human immunodeficiency virus.

OBJECTIVE: Perinatal transmission of the human immunodeficiency virus is the main pathway for children to become infected with this virus; however, the relative contribution and timing of this transmission, whether transplacental or by exposure through the birth process, have not yet been elucidated. An obvious question is whether the mode of delivery has an impact on this transmission rate. However, a routine cesarean section will primarily diminish the duration of exposure of maternal bodily fluids to the neonate but does not prevent the baby from being exposed to maternal blood coming from the uterine incision. The purpose of this study was to determine whether the rate of perinatal transmission of human immunodeficiency virus could be significantly lowered by delivering the baby with minimal to no exposure to maternal blood or bodily fluids by the use of a surgical technique termed a "bloodless cesarean section." STUDY DESIGN: We performed a prospective cohort study in a group of pregnant women infected with human immunodeficiency virus and evaluated the rate of transmission of this virus to the neonate on the basis of the mode of delivery. One group of patients was delivered by means of a "bloodless cesarean section," in which the baby was delivered and not exposed to any maternal blood or bodily fluid. The control group gave birth either by vaginal delivery or by routine cesarean section. All of the newborns were followed up for a minimum of 15 months or until negative findings were confirmed. Multiple antenatal, intrapartum, and postdelivery variables were collected and analyzed. RESULTS: A total of 108 patients were included in this study and 14 neonates became infected with human immunodeficiency virus (13%). Three of 53 infants delivered by a bloodless cesarean section (5.7%) became infected compared with 11 of 55 control patients (20.0%). This was significant at P = .02 and represented an absolute difference in percentage between the 2 groups of 14.3%, which corresponds to a 71.5% relative reduction in transmission risk (z = 2.27, P = .012). Since the use of zidovudine greatly influences the perinatal transmission rate of human immunodeficiency virus, the study data were reanalyzed with the exclusion of patients who used antenatal or intrapartum zidovudine. Two of 32 infants in the bloodless cesarean section group (6.3%) were infected compared with 9 of 38 in the control group (23.7%). This was significant at P = .04 and revealed an absolute difference in percentage of 17.4%, which corresponds to a 73.4% relative reduction in transmission risk (z = 2.15, P = .016). There was no difference in the transmission rate between the bloodless cesarean section patients who did not use zidovudine (2/32, 6.3%) and the patients who did use zidovudine from the entire study population (3/38, 7.9%). CONCLUSION: In the absence of zidovudine usage, these data show that 70% to 75% of the perinatal transmission of human immunodeficiency virus to a newborn occurs from exposure to maternal blood and bodily fluids at the time of birth. This information is important for patients unable to take zidovudine or other antiretroviral agents, but more important, it introduces the concept of other treatment options for the future.

Meconium has no lecithin or sphingomyelin but affects the lecithin/sphingomyelin ratio.

OBJECTIVE: Although a few studies have evaluated the effect of meconium on the lecithin/sphingomyelin ratio for testing of fetal lung maturity, to date these studies have assessed only the lecithin-sphingomyelin ratio of amniotic fluid contaminated with meconium. The purpose of this study was (1) to determine whether meconium by itself has a lecithin/sphingomyelin ratio and, if so, (2) to determine whether the lecithin/sphingomyelin ratio is constant. STUDY DESIGN: A lecithin/sphingomyelin ratio was obtained by standard thin-layer chromatography on the first meconium stool of 20 neonates between 31 weeks and term. A quantitative assay was then performed on a sample from each gestational age (7 samples ranging from 31 weeks to term) to confirm the presence of lecithin and sphingomyelin. RESULTS: The 20 samples had atypical thin-layer chromatographic migratory patterns in the zones for lecithin and sphingomyelin. The presumed lecithin/sphingomyelin ratios ranged from 1.1 to 3.6, with no correlation with gestational age. However, the quantitative assay did not detect the presence of lecithin or sphingomyelin in any of the analyzed samples. CONCLUSIONS: Meconium does not appear to contain lecithin or sphingomyelin but has an unidentified moiety whose migratory pattern, as shown by qualitative standard thin-layer chromatography, is similar to that of lecithin with sphingomyelin. Therefore the presence of meconium in amniotic fluid may falsely raise or lower the lecithin/sphingomyelin ratio and confuse fetal lung maturity interpretations.

Droperidol and diphenhydramine in the management of hyperemesis gravidarum.

OBJECTIVE: Hyperemesis gravidarum is a common pregnancy complication requiring hospitalization. Continuous droperidol infusion and bolus intravenous diphenhydramine were instituted as treatment. We compared the number and length of hospitalizations for hyperemesis gravidarum, readmissions for this diagnosis, and pregnancy outcome in patients receiving this treatment protocol with a historic group of patients receiving other forms of parenteral therapy for hyperemesis gravidarum. STUDY DESIGN: All patients hospitalized with a diagnosis of hyperemesis gravidarum between January 1992 and January 1994 were offered the droperidol-diphenhydramine protocol. These patients were compared with patients admitted between January 1990 and January 1992 with a diagnosis of hyperemesis gravidarum but who were not treated with droperidol at any time or with diphenhydramine as primary therapy for the control of severe nausea and vomiting. Data regarding the number and length of hospitalizations and readmissions for hyperemesis gravidarum were compared, as were maternal and perinatal outcomes. RESULTS: Patients treated with the droperidol-diphenhydramine protocol had significantly shorter hospitalizations (3.1 +/- 1.9 vs 3.8 +/- 2.4 days, p = 0.028), fewer days per pregnancy hospitalized for hyperemesis (3.5 +/- 2.3 days vs 4.8 +/- 4.3 days, p = 0.018), and fewer readmissions with this diagnosis (15.0% vs 31.5%, p = 0.015). There were no significant differences in maternal or perinatal outcomes. CONCLUSION: Droperidol and diphenhydramine infusion is a beneficial, cost-effective therapy for the treatment of hyperemesis gravidarum.

The effect of colonization with group B streptococci on the latency phase of patients with preterm premature rupture of membranes.

OBJECTIVE: Our purpose was to determine whether colonization of pregnant women with group B streptococci shortens the latency time from rupture of membranes to delivery in patients with preterm premature rupture of membranes. STUDY DESIGN: All patients transferred to Long Beach Memorial Women's Hospital with the diagnosis of preterm premature rupture of the membranes were prospectively recorded. The patients included in the study were transferred between Jan. 1, 1986, and June 30, 1991. Data were collected in regard to various obstetric characteristics, the presence or absence of a digital vaginal examination, tocolytic usage, antibiotic usage, and results of the culture for group B streptococci. The latency period was defined as days from membrane rupture to delivery. Patients with multiple gestations, cerclage in place, advanced labor on admission, or an indicated delivery on admission were excluded from data analysis. Patients with a positive culture for group B streptococci were then compared with those having a negative culture in regard to latency time after membrane rupture. RESULTS: The study population was made up of 332 patients. Forty-three (13%) were positive for group B streptococci; they were compared with 289 that were culture negative. There was no difference in the latency period from membrane rupture to delivery when we controlled for digital vaginal examinations and antibiotic usage. In addition, all other comparisons between the two groups were not significant. CONCLUSION: When the presence of a digital vaginal examination, antibiotic usage, and tocolytic usage are controlled for, colonization with group B streptococci by itself does not appear to affect the latency time from premature rupture of membranes to delivery.