Sonographically documented disappearance of fetal ascites.

Two patients with sonographically documented fetal ascites are described. Workup for immunologic or nonimmunologic causes was negative. Subsequent sonar examinations demonstrated disappearance of fetal ascites. At delivery, previous abdominal distention was apparent. Fetal ascites of unknown etiology in the late second trimester does not necessarily have a poor prognosis. Serial sonographic examinations are indicated for follow-up of fetal ascites.

Pregnancy outcome following ultrasound diagnosis of macrosomia.

Both elective cesarean and early induction have been proposed for pregnancies in which the fetus is suspected to be macrosomic by ultrasound examination. We studied 242 nondiabetic women with estimated fetal weights (EFWs) by ultrasound of at least 4000 g or the 90th percentile for gestational age at 36 or more weeks' gestation. In 66 of 86 women (77%) delivering within 3 days of ultrasound examination, EFW exceeded birth weight. In only 41 of these 86 women (48%) were the EFWs within the corresponding 500-g category of birth weight. A trial of labor resulted in vaginal delivery in 76 of 106 women (72%). There were five cases of shoulder dystocia but no birth trauma. Estimated fetal weights and birth weights were not significantly different between the women who had a trial of labor and those who did not. Our results do not support cesarean delivery or early induction as a means of preventing infant morbidity when fetal macrosomia (weight of 4000 g or more or the 90th percentile for gestational age) is diagnosed by ultrasound.

Histologic chorioamnionitis and preterm delivery in different patient populations.

The placentas of 1843 deliveries were examined for the presence of histologic chorioamnionitis, which was classified as mild, moderate, or severe. Chorioamnionitis was present in 7.5% of patients who underwent cesarean before labor and in 18 and 32% of those delivering at term and preterm, respectively. Chorioamnionitis was severe in 74% of preterm but in only 15% of term deliveries. Premature rupture of membranes (PROM) was more frequent with preterm than with term delivery, with chorioamnionitis present in 42 and 15% of patients, respectively. Although chorioamnionitis was equally frequent in women with intact membranes delivering preterm and term, chorioamnionitis was severe in 63% of preterm and 14% of term deliveries (P less than .001). The frequency and severity of chorioamnionitis were related inversely to gestational age at preterm birth. Preterm delivery was more frequent in black than in white patients (19 versus 9%) and in indigent clinic versus private patients (13 versus 7.5%). However, there was no significant difference in frequency and severity of chorioamnionitis between black and white or between indigent clinic and private patients who delivered preterm. Among term births, chorioamnionitis was more often severe in black than in white patients. Chorioamnionitis in term deliveries was more frequent in clinic than in private patients; however, this was not true when only severe chorioamnionitis was considered. There were no differences in PROM between these patient populations. Thus, higher preterm birth rates in black and indigent clinic populations are not due to the more frequent occurrence of chorioamnionitis.

Evaluation of postterm pregnancies with maternal serum placental lactogen and alpha-fetoprotein concentrations.

Studies of maternal serum placental lactogen (hPL) levels in 70 women delivering beyond 42 weeks of gestation revealed significantly lower levels of hPL when the offspring had one or more of ten signs of postmaturity or distress. A sequential combination of hPL measurements and intrapartum fetal heart rate monitoring (FHRM) (performed in 61 patients) gave a high degree of prognosis (75% of abnormalities detected, 88% with normal tests having no abnormalities). Considered separately, neither maternal serum hPL levels nor FHRM predicted abnormalities in the offspring to the same high degree. On the other hand, hPL could not be correlated with staining, desquamation, and the presence of meconium in the amniotic fluid at delivery, these criteria being considered separately or in combination. Maternal serum alpha-fetoprotein (AFP) levels during late gestation showed considerable variation and did not permit distinction between pregnancies with or without an abnormality in the offspring.

Sinusoidal fetal heart rate pattern following intrauterine fetal transfusion.

Two patients with severe rhesus isoimmunization had sinusoidal fetal heart rate patterns following intrauterine fetal transfusion. A consistent temporal relationship between fetal transfusion and sinusoidal fetal heart rate pattern was observed. Survival of a fetus who had a sinusoidal fetal heart rate pattern after each of three transfusions suggests that this pattern may not be ominous when observed transiently after fetal transfusion.

Fetal acid-base state following spinal or epidural anesthesia for cesarean section.

The authors compared fetal acid-base state and maternal blood pressure response in 111 women undergoing repeat cesarean section with either epidural or spinal anesthesia. Fetal umbilical acidemia (umbilical venous pH less than 7.25 or umbilical arterial pH less than 7.20) was more commonly observed following spinal anesthesia with a preanesthetic fluid load of 500 to 999 ml (20% of cases) than with epidural anesthesia (4% of cases. P > .05, chi 2). The incidence of fetal acidemia following spinal anesthesia was similar to that following epidural anesthesia when 1000 to 1500 ml of fluid was infused prior to spinal anesthesia. The maximum reduction in systolic blood pressure following spinal anesthesia was not related to preanesthetic fluid load; however, in cases of severe hypotension the hypotensive episode was shorter and easier to treat when the preanesthetic fluid load was 1000 to 1500 ml rather than 500 to 999 ml. These data suggest that women receiving spinal anesthesia for repeat cesarean section should be given an intravenous fluid load of 1 liter or more.

Low incidence of positive amnionic fluid cultures in preterm labor at 27-32 weeks in the absence of clinical evidence of chorioamnionitis.

In order to determine the utility of amniocentesis for detecting subclinical chorioamnionitis in asymptomatic afebrile women in preterm labor with intact membranes, we enrolled 47 women between 27-32 weeks' gestation in a prospective study. After enrollment, 38 women fulfilled all clinical and laboratory criteria for the study; nine women were excluded because they had a leukocyte count exceeding 15,000/microL. None of the 38 asymptomatic afebrile women had a positive culture from the amnionic fluid for bacteria, fungi, Mycoplasma hominis, Ureaplasma urealyticum, Chlamydia trachomatis, or any viruses. Sepsis was not proved in any of the 38 infants delivered to these patients. There was a clear relationship between histologic evidence of chorioamnionitis and failure of tocolytic therapy. Fetal lung profiles were mature in 29% of the amnionic fluid samples from 30-32 weeks' gestation, but in none of the amnionic fluid samples before 30 weeks. Amniocentesis does not seem useful to detect chorioamnionitis in asymptomatic afebrile women with preterm labor and intact membranes at 27-32 weeks' gestation, and should be reserved for those cases in which information about fetal lung maturity would be helpful.

Effect of terbutaline on cardiovascular state and uterine blood flow in pregnant ewes.

The cardiovascular and uterine hemodynamic effects of terbutaline, a beta-adrenergic receptor stimulant and labor inhibiting agent, were evaluated in the chronically instrumented, near-term pregnant ewe. The administration of terbutaline in the dose range required for labor inhibition in this species resulted in a mild maternal tachycardia and increase in pulse pressure without significant changes in uterine blood flow; uterine vascular resistance; or systolic, diastolic, or mean blood pressures. With infusion rates of terbutaline in excess of those required for labor inhibition, significant increases in maternal heart rate, pulse pressure, and systolic blood pressure were observed. Diastolic blood pressure decreased significantly during the higher infusion rates; however, uterine blood flow was unaffected. The minimal cardiovascular and uterine blood flow was unaffected. The minimal cardiovascular and uterine hemodynamic effects noted with the administration of terbutaline in the dose range necessary for labor inhibition indicate that this agent may possess advantages over several others currently in use for the treatment of premature labor.

Comparison of continuous transcutaneous Po2 measurement with intermittent arterial Po2 determinations in fetal lambs.

This study determined the validity of transcutaneous Po2 (tcPo2) versus Pao2 determinations in the sheep fetus. In 7 fetal lambs catheters were placed in the carotid artery and the trachea, and ECG leads and a tcPo2 electrode were attached. Intermittently determined Pao2 values were compared to continuously recorded tcPo2 values. Fetal tcPo2 values ranging from 12 to 29 mmHg were achieved by changing the gas mixture the ewe breathed or by inflation of a balloon catheter in the maternal aorta. Transcutaneous Po2 correlated strongly with Pao2 (r = .91). These studies indicate that the tcPo2 electrode precisely and accurately reflects Pao2 in the fetal lamb. Limitations of tcPo2 measurements regarding prolonged attachment of the electrode to the fetal skin as well as fetal skin tolerance to the heat of the electrode have been identified. With this electrode the changes in oxygen tension can be compared with changes in fetal cardiovascular variables, eg, heart rate, blood pressure, and ECG, for a better understanding of the effects of hypoxemia on the fetus.

A blueprint for academic obstetrics and gynecology.

A consensus conference sponsored by the Council of University Chairs of Obstetrics and Gynecology in February 1997 formulated the organization's response to the many external issues affecting academic medicine and obstetrics and gynecology including 1) a new practice model based on "wellness," 2) reimbursement changes that have jeopardized traditional revenue sources, 3) an emphasis on quality assurance based on outcomes research and evidence-based medicine, 4) the concept of lifelong learning dictated by an expanding knowledge base and new technology, 5) insufficient resources for basic and clinical investigation in obstetrics and gynecology, 6) workforce statistics indicating stabilization in the number of subspecialists, 7) the increasing diversity of the United States population. Recommendations were developed that are intended to foster change and contribute to the design of academic programs. These include appropriate training for residents as providers of primary care, with an emphasis on continuity clinics, an interdisciplinary curriculum in women's health for medical students; promotion of gender, racial, and ethnic diversity at all levels of medical education and academic leadership; creation of clinical trials research units; and the development of expanded opportunities for research in obstetrics and gynecology supported by the National Institutes of Health.

Gaucher's disease in pregnancy.

Gaucher's disease is an autosomal recessive lysosomal storage disease, resulting from a deficiency of the enzyme glucocerebrosidase, important for the physiologic recycling of cell membrane lipids. The clinical symptoms and disease presentations of Gaucher's disease are heterogeneous, including hepatosplenomegaly, bone "crisis" and fracture, anemia, thrombocytopenia and in some forms, rapid neurological decompensation. Similarly, the genetic variability of Gaucher's disease is diverse, and in some aspects affects phenotypic expression. Type 1 Gaucher's disease, however, usually present with less severe symptoms, at more advanced age, and is particularly amenable to enzyme replacement therapy with alglucerase. In type 1 patients with Gaucher's disease reproductive age is commonly reached and childbearing frequently desired with need for appropriate prenatal diagnosis, counseling and careful obstetrical surveillance. Although pregnancy concurrent with Gaucher's disease has been reported in the medical literature, only one small series of alglucerase treated Gaucher's disease during pregnancy exists. Without treatment, pregnancy concurrent with Gaucher's disease has several risks including an increased severity of anemia and thrombocytopenia that can potentiate postpartum bleeding, significant increases in organomegaly and possibly an increased spontaneous abortion rate. It is yet to be shown whether alglucerase reduces the risk of these complications during pregnancy and whether its use has any adverse effect on fetal development.

Use of supine pressor test to prevent gestational hypertension in primigravid women.

The supine pressor (roll-over) test was performed on 62 nulliparous patients under 20 years of age at conception. The 28 patients (45%) with positive tests were treated to prevent the development of gestational hypertension. Four of those with a positive test and two of those with a negative test developed gestational hypertension. Compared with a composite of other reported studies of this test in which the patients were not treated, our results indicated a statistically significant reduction in the incidence of gestational hypertension. The supine pressor test appears to be useful clinically in young nulliparous women.

Evaluation of risk scoring in a preterm birth prevention study of indigent patients.

A total of 4591 indigent patients were scored for risk of preterm labor and birth by the Creasy et al. scoring system and delivered at greater than or equal to 20 weeks' gestation. Of 462 preterm deliveries (less than 37 weeks), only 39.6% were contributed by the 18.1% of patients who scored at high risk (score greater than or equal to 10). Of the 44 risk factors in the scoring system, 25 were not statistically significant by univariate chi 2 analysis. The spontaneous preterm birth rate was 8.0%. The positive predictive value of the Creasy et al. system was 18.3%. With multiple logistic analyses we excluded infrequent risk factors and identified five factors that remained significant (prepregnancy weight less than 45.5 kg, black race, single marital status, one preterm labor and delivery, preterm labor, and delivery greater than or equal to 2). With these five risk factors we created an equation that allowed identification of 12% of patients at high risk of preterm delivery with a positive predictive value of 21.9%. Because of the importance of previous preterm delivery, risk scoring of primigravid patients is of limited value.

Variable heart rate decelerations and transcutaneous PO2 during umbilical cord occlusion in fetal monkeys.

In five near-term monkeys under ketamine anesthesia, fetal heart rate, blood pressure, intrauterine pressure, and transcutaneous oxygen tension (tcPO2) were recorded continuously while the umbilical cord was occluded for 15 or 30 seconds. Fetal heart rate decreased 55 +/- 19 bpm, (mean +/- SD) and 78 +/- 20 bpm, respectively, with 15 and 30 second occlusions, while tcPO2 declined 6.0 +/- 1.6 and 11.5 +/- 3.3 torr, respectively. Fetal hypertension started promptly with cord occlusion and reached a maximum within 5 to 16 seconds; fetal blood pressure decreased thereafter and, in most instances, fell below the baseline until fetal heart rate began to recover. Fetal heart rate decreased within 1 to 2 seconds of cord occlusion, tcPO2 changes were the same, while heart rate changes were attenuated when the fetus was pretreated with 0.2 mg of atropine. These findings support a rapid and marked initial baroreceptor response, followed by a less marked chemoreceptor response. Thirty seconds following cord occlusion, PaO2 had returned to baseline, while tcPO2 was still 3 to 7 torr below baseline, indicating cutaneous vasoconstriction even though systemic blood pressure was normal. Relative heat output required to maintain the tcPO2 electrode temperature at 44 degrees C did not reflect alterations in skin perfusion during periods of cardiovascular change.

Prolonged in utero retention and mummification of a Macaca mulatta fetus.

An intrauterine mummified fetus in a Macaca mulatta was delivered surgically 708 days after onset of the last menstrual flow. Supracervical hysterectomy and left salpingo-oophorectomy were done. The fetus consisted of a compressed but complete skeleton and hairy skin adherent to the intact, thin uterine wall. Placenta and umbilical cord could not be identified.