The results of a five-year study of continuous fetal monitoring on an obstetric service.

A 5-year experience of the effects of fetal monitoring at the University of Utah College of Medicine (1971-1975) are reported. During this period there were 5087 deliveries, of which 4237 (83%) were monitored electronically during labor. During this time the primary cesarean section rate increased from 3.19% in the year before monitoring has begun to 10.5% in the last year of the period studied. This increase, however, was due primarily to a number of changes in obstetric practice and to an increase in the number of high-risk patients followed at our institution. The rate of primary cesarean section as compared to total deliveries due to fetal distress resulting from observations made with electronic monitoring was a fairly stable 3-3.5%. The number of cases of Apgar scores at 1 minute of 6 or less dropped markedly during the period of study and cases of 5-minute Apgar scores of 6 or less decreased slightly. The number of patients demonstrating early, late, and variable deceleration patterns remained fairly stable throughout the years of the study. Variable and late deceleration patterns correlated well with cord compression and small placentas, respectively.

Premature placental calcification in maternal cigarette smokers.

Ultrasonographic examinations, including placental grading, were done in 145 smoking and 100 nonsmoking low-risk obstetric patients at 37 weeks' gestation. Extensive calcification--grade III changes--occurred significantly more often in smokers than in nonsmokers (36 versus 14%; P less than .0001). Two groups of smokers, consuming five to 15 cigarettes per day or one or more packs per day, also had significant differences in grade III placenta when compared with nonsmokers. Smokers under age 20 years were more likely to have premature grade III changes; however, parity did not influence premature placental calcification in smokers and nonsmokers. The incidence of small for gestational age infants delivered was not significantly higher in smokers, and grade III placental changes appeared to occur no more often in SGA infants of smokers than of nonsmokers. Our findings suggest that the smoking gravida is at increased risk for premature placental calcification.

Ultrasonic recognition of the small-for-gestational-age fetus.

Sonar biparietal diameter, femur length, abdominal circumference, femur length/abdominal circumference ratio, ponderal index, and estimated fetal weight were obtained within ten days of delivery of small-for-gestational-age (SGA) (N = 102) and non-SGA (N = 204) newborns. The effectiveness of each ultrasound variable in the antenatal recognition of the SGA fetus was assessed. An abnormal abdominal circumference was the best predictor, confirming SGA in 98% of cases. Other variables (biparietal diameter, femur length, femur length/abdominal circumference ratio, ponderal index, or estimated fetal weight) were less accurate for predicting SGA. When we determined expected results based on a 10% prevalence of SGA, negative predictive value was greater than 92% for all variables studied; however, with the exception of estimated fetal weight and femur length, positive predictive values were disappointing, including abdominal circumference (21%). This report establishes the limits of ultrasound-derived growth variables in the antenatal identification of the SGA fetus.

A prospective comparison of terbutaline and magnesium for tocolysis.

OBJECTIVE: To compare the tocolytic efficacy and side effects of parenteral and oral magnesium and terbutaline. METHODS: Ninety-eight patients in labor between 23-35 weeks were prospectively entered into a controlled trial of intravenous and oral magnesium versus subcutaneous and oral terbutaline. Tocolytic effectiveness was judged by delay of delivery for 48 hours or 1 week, and to 37 weeks or more. The need to change therapy to the alternate drug was identified, as were side effects. Entrance characteristics of the population, initial pelvic examination, and concomitant infection or cervicovaginal isolates were noted. Outcomes included gestational age at delivery, birth weights, and Apgar scores. Outcome analysis was based on initial tocolytic therapy. RESULTS: Significantly more patients in the magnesium group delivered at 37 weeks or more: 34 of 46 versus 27 of 52 (P < .05). No significant differences were found for delivery by 48 hours or 1 week. The interval between treatment and delivery was greater for magnesium: 7.1 +/- 3.9 versus 5.0 +/- 3.2 weeks (P < .005). Failure to achieve 37 completed weeks was more often due to obstetric complications than to preterm labor itself. Tocolytic effectiveness was reduced if secondary therapy or re-treatment was required or if the patient had cervical dilatation of 3 cm or greater. Infectious complications were common but were not associated with tocolytic effectiveness. Side effects were more noticeable with oral magnesium and subcutaneous terbutaline. CONCLUSIONS: For short-term tocolysis, no significant difference was found between magnesium and terbutaline. Magnesium was associated with a higher term delivery rate. Idiopathic preterm labor accounted for only a small part of the overall prematurity in the study population.

Clinical chorioamnionitis is not predicted by an ultrasonic biophysical profile in patients with premature rupture of membranes.

A modified biophysical profile was assessed serially in 47 patients with premature rupture of membranes who were not in labor. This profile included fetal movement, fetal tone, fetal breathing, amniotic fluid volume, and placental grade. The most recent study, obtained within 2 days of delivery, was compared with pregnancy outcome as reflected by the development of chorioamnionitis and/or neonatal sepsis. No study patient received antibiotics, steroids, or tocolytics before labor. Neither the composite biophysical profile nor any of its components were found to be different between patients with and without clinical chorioamnionitis. Neonatal sepsis was not observed. These data do not support the use of the biophysical profile as a predictor of maternal infection.

Umbilical cord blood gas assessment of twins.

Umbilical cord arterial and venous blood gas values were compared in 63 twin pairs, of which 57 pairs had birth weights of 1500 g or more each. Small differences between the first and second twins existed for PO2, PCO2, and pH. However, bicarbonate values did not differ significantly. These cord gas differences represent minor respiratory aberrations, as reflected by a tendency toward carbon dioxide retention by the second twin. Route of delivery, time interval between deliveries, and nonvertex presentations were not associated with significant deviations from these observed acid-base patterns.

Uncontrollable postpartum bleeding: a new approach to hemostasis through angiographic arterial embolization.

A case of severe postpartum hemorrhage is reported. Three separate surgical procedures failed to reveal the source of bleeding, and standard surgical techniques, including bilateral ligation of the hypogastric arteries, were unsuccessful in producing hemostasis. However, angiography successfully identified the specific bleeding vessel, and transcatheter embolization with Gelfoam fragments quickly and effectively stopped the hemorrhage. The authors consider angiographic embolization to be an effective alternative approach to the control of pelvic hemorrhage and recommend that the technique be considered prior to surgical intervention.

Renal disease in pregnancy.

Renal disease in pregnancy may be progressive but only rarely. The problems encountered that create maternal and fetal morbidity and mortality relate to the development of superimposed preeclampsia and renal failure. Diagnosis is important to differentiate the cause of renal pathology so that appropriate treatment can be undertaken. The use of medications in renal disease in the presence of hypertension is controversial; however, adequate therapy should be given if indicated. Most cases of renal disease in pregnancy do not require termination; however, counseling concerning pregnancy is needed initially or subsequently.

History and development of cesarean operation.

The history of cesarean birth has developed in spite of myths, physician differences, and early patient deaths and morbidity. The methods used today prevent maternal deaths and morbidity, and the cesarean operation is one of most common surgical procedures.

The use of oral prostaglandin E2 to induce labor at term.

Prostaglandin E2 (PGE2) was given to 60 patients to induce labor at term. Two dosage schedules were used: 30 patients were given 0.5 mg hourly and 30 patients were given 1.0 mg hourly. Membranes were ruptured when active labor had occurred. The Bishop score was used for inducibility quotient. In general, the higher the Bishop score, the shorter the delivery time. The 1.0 mg dosage schedule decreased the induction time in both nulliparas and multiparas. There were 55 vaginal deliveries. Five patients were delivered by cesarean section for obstetrical indications; two were in active labor. The overall success rate was 91.6%. No fetal distress occurred that could be attributed to the PGE2. Maternal complications consisted of nausea and vomiting.

Comparison of dynamic image and pulsed Doppler ultrasonography for the diagnosis of the small-for-gestational-age fetus.

OBJECTIVE: Because poor fetal growth is a significant cause of perinatal morbidity and mortality, a prospective study was undertaken to evaluate the ability of real-time ultrasonography and Doppler velocimetry to detect the small-for-gestational-age fetus. STUDY DESIGN: A prospective study of 136 women at risk for fetal growth abnormalities was conducted. Patients were delivered within 3 weeks and had live-born, nonanomalous, singleton infants. The relative estimated fetal weight (estimated fetal weight divided by the median birth weight for gestational age) and the systolic/diastolic ratio were measured and compared with receiver-operator characteristic curves. In this method the area under the curve is the index of performance. RESULTS: Forty-six infants were small for gestational age. Although both relative estimated fetal weight (area under the curve = 0.923) and systolic/diastolic ratio (area under the curve = 0.837) were significantly associated with the small for gestational age fetus, the former was more strongly correlated, p = 0.021. CONCLUSION: Relative estimated weight is more sensitive and specific and should be the preferred parameter when gestational age is known.