Closing the Rh immune globulin utilization gap.

A simple and effective system, designed to achieve 100% utilization of Rh immune globulin in a general hospital, is presented. During a one-year period, all Rh-negative women exposed to events capable of inducing Rh sensitization were identified. In every case the protection of these women was verified. Four major oversights were discovered and immediately corrected, resulting in adequate protection of all Rh-negative women at risk of Rh sensitization. The system is compared with two other successful programs currently in use. The role of the Pathology Department, as a fail-safe mechanism to close potential loopholes in a Rh prophylaxis program, is emphasized.

Measurement of fetal cells in the maternal circulation.

There is evidence that the quantitation of fetal-maternal hemorrhage may be useful in reducing some of the RhoGAM failures in preventing Rh sensitization. The Betke-Kleihauer technique is a well-established method that has been used to estimate the amount of transplacental hemorrhage. Recently, a kit (Fetaldex) has become available for use in the detection and quantitation of fetal-maternal hemorrhage. Using control blood smears, we compared the results of the Fetaldex kit with those results obtained by the Betke-Kleihauer technique. The data indicate that the Fetaldex method is as accurate as the Betke-Kleihauer technique in detecting and measuring fetal red cells in the maternal circulation.

Clinical evaluation of a "short" supine pressor test for pregnancy-induced hypertension.

A modified supine pressor test was performed on 304 apparently normal primigravidas between 28 and 32 weeks' gestation. The blood pressure was measured with the patient first in lateral position and within 2 minutes thereafter in the supine position. Of those patients showing an increase of at least 20 mmHg in the diastolic blood pressure while in the supine position, 13 of 76 (17%) developed pregnancy-induced hypertension. Of those patients without an increase of at least 20 mmHg in the diastolic blood pressure, 33 of 228 (14%) became hypertensive. The results of this study do not substantiate the use of the "short" supine pressor test as an accurate predictor of pregnancy-induced hypertension.

Detection of large fetal--maternal transfusions.

Two hundred consecutive Rh-negative women at risk of Rh sensitization were screened postpartum for large fetal--maternal transfusion by two acid elution techniques. The Nierhaus modification of the Betke-Kleihauer method and the Fetaldex test were compared. In 194 of 200 women, both procedures indicated the absence of significant fetal--maternal transfusion. In 6 women a large fetal--maternal hemorrhage was detected by the Betke-Kleihauer method and in 5 of these 6 by the Fetaldex test. The overall correlation between the two techniques was 99.5%. The Fetaldex test has advantages over the Betke-Kleihauer method and is well suited for routine use postpartum and for other situations where identification or quantitation of fetal cells is desirable.

Prediction of fetal lung maturity by amniotic fluid fluorescence polarization, L:S ratio, and phosphatidyl glycerol.

The relation of amniotic fluid fluorescence polarization (FP) to fetal lung maturity was examined in 186 pregnancies terminating within 48 hours of the fluid collection. Among the 9 babies who developed hyaline membrane disease (HMD), 8 were associated with FP values of 0.340 or more, and 1 had an FP value of 0.329. In 95 of these patients, the lecithin:sphingomyelin (L:S) ratio and the presence or absence of phosphatidyl glycerol (PG) were also determined. All 9 infants with HMD had L:S ratios less than 2.00 and no PG detectable in the amniotic fluid. Using an FP value of 0.325 or less, an L:S ratio of 2.00 or more, and the presence of PG as criteria for lung maturity, FP, L:S ratio, and PG did not differ significantly in the number of false predictions of HMD. Each test detected some mature infants who would have been incorrectly classified by at least 1 of the other tests. The status of all infants born at 33 weeks' gestation or later who did not develop HMD would have been correctly predicted by FP, L:S ratio, or both. These 3 tests, therefore, are complementary and can be used in combination to reduce the number of false predictions of HMD.

Influence of gestational age on prediction of fetal lung maturity by fluorescence polarization of amniotic fluid.

Compared are the amniotic fluid fluorescence polarization values and the neonatal outcomes of 201 pregnant women who delivered from 28 through 37 weeks of gestation within 48 hours of the fluorescence polarization determinations. Thirty-five neonates developed hyaline membrane disease. The corresponding fluorescence polarization values ranged from 0.275 to 0.391. Eight of those 35 tests results were less than 0.325. The predictiveness of the method was studied using different threshold fluorescence polarization values. At the authors' own threshold of less than or equal to 0.325, the overall predictive value was as follows: false mature predictions: 6.2%, false immature predictions: 62.5%, sensitivity: 77.1%, and specificity: 72.8%. However, the false mature prediction rate was 21 to 40% from week 28 through week 33 versus 3.4 to 5.8% from week 34 through week 37, depending on the selected cutoff fluorescence polarization value. The sensitivity and specificity before, at, or after week 34 were significantly different at all tested fluorescence polarization values (P less than .05 to P less than .01) with the exception of the sensitivity at 0.310 and at 0.316 (P = .057). Caution is advised against relying on the fluorescence polarization method to predict fetal lung maturity at least before 34 weeks of gestation.

Detection of macrosomia by the individual fetal growth curve assessment method.

The value of the Rossavik growth model [P = c(t)k + s(t)] was evaluated in 39 patients with singleton pregnancy who had neonatal weight outcome above the 90th percentile of our birth weight distribution for gestational age. Individual fetal growth curve standards for head and abdominal circumferences, femur diaphysis length, and weight were determined from the data of two scans obtained before 26.1 weeks' gestation and separated by an interval of at least 5 weeks. Projected crown-heel lengths were calculated from projected femur diaphysis length values. Comparisons between actual and predicted birth characteristics were expressed by the Growth Potential Realization Index (GPRI) and Neonatal Growth Assessment Score (NGAS). Excessive growth at birth was seen in almost all cases as indicated by high GPRI for weight and abdominal circumference and abnormal NGAS values. In eight of the 33 patients who delivered after 38 weeks, excessive growth was detected only by comparing birth characteristics to their predicted values at 38 weeks' gestation. Our data suggest that individual growth curve standards may identify several patterns of excessive fetal growth that could represent different pathophysiologic mechanisms, ie, failure to terminate growth after 38 weeks versus a defect in a still unknown growth regulator. The individual fetal growth curve standards method gives additional information and discriminates well between normal and excessive fetal growth.

Prenatal diagnosis of fetal pelvic kidney. A case report.

Published experience on prenatal diagnosis of pelvic kidney is limited. We present the ultrasonographic characteristics of a case of ectopic pelvic kidney and discuss the significance of prenatal diagnosis.

Laparoscopic supracervical hysterectomy vs. abdominal hysterectomy in a community hospital. A cost comparison.

OBJECTIVE: To evaluate the feasibility for an institution to offer laparoscopic supracervical hysterectomy as a cost-effective alternative to total abdominal hysterectomy (TAH) in a managed care environment. STUDY DESIGN: Retrospective study in which 138 consecutive laparoscopic supracervical hysterectomies performed between December 1992 and May 1996 were reviewed and compared to 354 consecutive TAHs performed during the same period. Operating time, use of operative room supplies, length of stay and actual total, fixed and variable costs of each case were calculated for the entire hospital stay and for each hospital cost center. Differences between costs were analyzed by ANCOVA using age, patient weight, specimen weight and number of operative procedures performed at the time of hysterectomy as covariants. RESULTS: The mean operative room time was significantly greater for laparoscopic supracervical hysterectomy than for TAH (167.4 [SD 51.2] vs. 103 minutes [30.3, P < .001]). In contrast, length of stay was significantly shorter for laparoscopic supracervical hysterectomy than for TAH (0.8 [SD 1.1] vs. 3.4 days [.9, P < .001]). The adjusted mean costs of both operative room time and supplies were significantly higher for laparoscopic supracervical hysterectomy than for TAH (P < .001). In contrast, the mean cost of length of stay for laparoscopic supracervical hysterectomy was significantly lower (P < .001). However, the adjusted mean total costs of the entire hospital stay were not significantly different: $2,716 for laparoscopic supracervical hysterectomy vs. $2,702 for TAH (F = .7, P = .8). The absence of significant differences between procedures resulted from our limited use of disposable supplies (no automated stapling device) and from shorter lengths of stay, which compensated well for the higher operative room costs of time and supplies incurred with laparoscopic supracervical hysterectomy. CONCLUSION: Laparoscopic supracervical hysterectomy is, at least in the short term, a cost-effective alternative to TAH in a managed care environment.

Sensitivity and specificity of the L/S ratio in relation to gestational age.

A review of the literature was made, and 762 titles relating to fetal lung maturity were screened. From these, 195 articles or abstracts on the L/S ratio were reviewed. Five articles met the following criteria: (1) L/S ratio by the method of Borer and Gluck including acetone precipitation; and silica-gel-H plates, (2) interval of the L/S ratio to delivery of 72 hours or less, (3) exclusion of diabetics (except for one patient with an L/S ratio greater than or equal to 2 whose baby developed hyaline membrane disease (HMD) who may have been diabetic), (4) HMD well defined and documented, and (5) a breakdown of the data by gestational age. From these five articles, the sensitivity, specificity, and predictive values were calculated for less than 34 weeks, 34 to 37 weeks, and greater than 37 weeks of gestational age. The sensitivity of the L/S ratio was good regardless of gestational age. The specificity was very poor before 34 weeks, somewhat better between 34 and 37 weeks, and best after 37 weeks. The predictive value of a negative test result was moderate before 34 weeks and became excellent after 37 weeks. The predictive value of a positive test result was moderate before 34 weeks and became very poor after 37 weeks. In conclusion, after 34 weeks, an L/S ratio of 2 or greater was a reliable indication of fetal lung maturity. However, an L/S ratio of less than two was only slightly better than an accurate assessment of gestational age at predicting HMD.

The prediction of fetal lung maturity by amniotic fluid fluorescence polarization in diabetic pregnancy.

Amniotic fluid fluorescence polarization was determined in 105 pregnant diabetic women who delivered between 31 and 41 weeks gestation within 48 hours of an amniocentesis. Seventy-seven of these 105 women had lecithin/sphingomyelin (L/S) ratio and phosphatidylglycerol (PG) determinations. Seven (6.6%) of the 105 neonates suffered from hyaline membrane disease (HMD). Fluorescence polarization at any cutoff value between 0.310 and 0.330 excluded reasonably well the possibility of HMD (false mature prediction rate, 2.7-3.4%). At these cutoff values, there was no difference in sensitivity and false mature prediction rate between fluorescence polarization and L/S ratio. However, PG determination was the most sensitive method and carried no false mature predictions.

Effect of timing of initial scan and interval between scans on Rossavik growth model specification.

The effect of the time of the initial scan and the interval between the two scans needed for Rossavik growth model specification was evaluated in 20 normally growing fetuses. Based on systematic and random prediction errors, determined by comparing predicted values to measured values obtained after 27 weeks, menstrual age, optimal results for all parameters studied were obtained with an initial scan at 18 weeks and an interval of 6 weeks between scans. For one-dimensional parameters--head circumference (HC), abdominal circumference (AC), and femur diaphysis length (FDL)--similar results were obtained with an initial scan at 15 weeks and an interval of 3 weeks, but systematic overestimations were seen with 9-week intervals for HC. Studies with three-dimensional parameters--head cube, abdominal cube, and estimated weight--indicated that the timing of the initial scan was not critical, although less variability was seen with the initial scan at 18 weeks. However, the use of 3-week and 9-week intervals (instead of 6 weeks) produced significant systematic errors that varied with the parameter studied. These results suggest that Rossavik growth model specification is possible under a variety of conditions, but both the timing of the initial scan and the interval between scans must considered for each parameter.

Improving the processes of care and outcomes in obstetrics/gynecology.

BACKGROUND: The obstetrics/gynecology department of York Hospital (York Health System, York, Pennsylvania) initiated a program to improve the processes of care and control costs for common women's and newborns' health care services. Twelve clinical policies were established between June 1993 and February 1995. CONDUCTING THE QUALITY IMPROVEMENT (QI) PROJECTS: Using the plan-do-check-act (PDCA) improvement cycle method, the QI group established clinical pathways for high-volume conditions or procedures known to have low rates of complications and clinical guidelines for those conditions or procedures not requiring coordinated efforts of a group of health care professionals. EXAMPLE--PYELONEPHRITIS IN PREGNANCY: The literature had indicated that the prevalence of pyelonephritis can be decreased by identifying and treating asymptomatic bacteriuria early in prenatal care. After the validity of the clinical policy was demonstrated in the resident service, the policy was extended to all private obstetric practices. Dissemination of the finding that most of the admissions for pyelonephritis were for referred patients (for whom we had no control over prenatal care) or for patients referred by private physicians who were not yet following the guidelines quickly led to complete compliance by our obstetricians and other health care providers referring patients to the York Health System. RESULTS: The 12 clinical policies resulted in the elimination of 113 admissions and 5,595 inpatient days and in the reduction of the cost of patient care by $1,306,214 for the years 1994-1995 and 1995-1996 combined, without apparent adverse effects on patient health. CONCLUSION: A voluntary clinical policies program can change the culture of a department and lead to cost-effectiveness and better quality of patient care.

Influence of the interval between time points on individual fetal growth curve standards derived from Rossavik models and two ultrasound scans before 26 weeks, menstrual age.

We studied the influence of the interval between the two scans used before 26 weeks' menstrual age to generate individual fetal growth curve standards utilizing the Rossavik growth model: P = c(t) kappa + s(t) (model specification functions previously reported). Intervals of 3 weeks to 12 weeks were suitable for predicting the growth of the abdominal and head circumferences and femur diaphysis length in individual fetuses. However, large systematic and random errors were found with intervals less than 5 weeks for three-dimensional parameters such as the head and abdominal cubes and estimated fetal weight. In addition, the data suggest that the systematic errors for these latter parameters may increase with intervals of 10 weeks or more. Overall, optimal individual fetal growth curve standards were best generated from two scans before 26 weeks' menstrual age separated by 5 weeks to 9 weeks.

Prediction of normal fetal growth by the Rossavik growth model using two scans before 27 weeks, menstrual age.

Individual growth curve standards for five fetal anatomic parameters (head and abdominal circumferences, head and abdominal cubes, and femur diaphysis length) and estimated fetal weight were prospectively developed in 70 pregnant women who delivered infants with growth considered appropriate-for-menstrual age. For this purpose, we used the Rossavik growth model (P = c(t) kappa + s(t], model specification functions previously reported, and the data of two scans before 27.0 weeks of menstrual age, separated by an interval of at least 5 weeks. The anatomic parameters and estimated weights of these fetuses in the last 14 weeks of gestation were found to have values close to their projected standards. Whereas there was a significant, although small, systematic error of overprediction for most of the parameters and estimated fetal weight, deviations between observed and expected values were, with few exceptions, within the ranges established by Deter for normal growth. This study demonstrates that the Rossavik growth model could be used to predict normal fetal growth in a sample of patients different from those from which the model was developed.

Evaluation of the dating of gestation via the growth adjusted sonographic age method.

We compared the actual delivery dates of 248 normal pregnant women to the estimated dates of confinement (EDC) calculated from one biparietal diameter measurement (BPD) between 18 and 26 weeks of gestation and to the EDCs corrected by the growth adjusted sonographic age ( GASA ) method. The dating of gestation by those two ultrasound methods also was compared to the calculation of the gestational age from the last menstrual period in a subgroup of 61 women with highly reliable clinical data. The GASA method had no advantage over the dating of gestation using one single BPD measurement obtained before 26 weeks, nor over the dating of gestation using reliable menstrual data.

Relationship between Grade III placentas and biparietal diameter determinations.

Grade III placentas were found in 133 (12 per cent) of 1,082 pregnant women evaluated ultrasonographically after 20 weeks of gestation. Associated biparietal diameter measurements ranged from 7.2 to 10 cm. In 11 women with no complications known to accelerate fetal lung maturity or to induce premature placental maturation, grade III placentas were observed between 30 and 33 weeks of gestation. Gestational ages determined according to the growth adjusted sonographic age method of Sabbagha were accurate within one to three days. Considering the risk of hyaline membrane disease at those gestational ages, a grade III placenta cannot be equated with fetal lung maturity. Criteria other than placental grading should be used to assess the pulmonary status of the fetus.

Detection of intrauterine fetal growth retardation with abdominal circumference and estimated fetal weight using cross-sectional growth curves.

The usefulness of a cross-sectional growth curve method in the detection of intrauterine growth retardation by ultrasonography was evaluated for abdominal circumference and estimated fetal weight. The patient sample consisted of 771 women with singleton pregnancy who delivered within seven days of an ultrasound scan. One hundred fifty-one (19.6%) women had infants with birth weight below the 10th percentile for menstrual age. Of these infants, 72.2% were symmetrically growth retarded on the basis of their neonatal ponderal index. The neonatal weight outcomes were correlated with the abdominal circumference and estimated fetal weight percentile values. Both measurements were more specific than sensitive and had much higher negative than positive predictive values. The sensitivity was influenced by menstrual age, and severity and type of intrauterine growth retardation. Overall, estimated fetal weight was more accurate than abdominal circumference, but the difference was too small to be clinically important. Both measurements were better suited to confirm than to detect, exclude, or predict intrauterine growth retardation. Normal results predicted a normal neonatal weight outcome with a very high probability when the prevalence of the condition was low. In spite of the limitations of the cross-sectional method, both tests had strengths that can be advantageously used to enhance clinical decision making in the management of intrauterine growth retardation.

Effect of the pretest probability of intrauterine growth retardation on the predictiveness of sonographic estimated fetal weight in detecting IUGR: a clinical application of Bayes' theorem.

Four hundred and five women with singleton pregnancies and fetal age determination by crown-rump length were classified on the basis of their prenatal clinical findings into four risk categories for intrauterine growth retardation (IUGR), defined as a neonatal weight below the 10th percentile of age-dependent birth weight distribution curve. The incidence of IUGR in these four groups were 3.5% (very low risk), 20.6% (low risk), 49.6% (intermediate risk), and 88.0% (high risk). Severe growth retardation (birth weight less than 2.5th percentile) increased from 0% to 76.0% as the incidence of IUGR increased throughout the risk groups. The effect of these pretest risks on the prediction of severe IUGR by sonographic estimated fetal weight (EFW) was evaluated. The positive predictive value of the test, as well as the probability of having a growth-retarded infant after a normal EFW was obtained were considerably higher when the pretest probability of IUGR increased. In the very low risk group, the probability of severe IUGR was negligible regardless of the EFW. When the EFW was less than 10th percentile of our age-dependent EFW curve, the probability of severe IUGR in the other risk groups was high enough to warrant fetal well-being surveillance and/or timely interruption of gestation as appropriate. However, when the pretest probability was high, the risk of severe IUGR in spite of an EFW within the 10th percentile to 90th percentile remained sufficient to require fetal well-being surveillance as well. The study shows that placing ultrasound results in the context of the pretest risk of IUGR may improve clinical decision making in pregnancies complicated by fetal growth retardation.

Comparison of fetal cerebellar measurements by two different techniques.

We examined 53 fetuses between 15 and 40 weeks of gestation with transverse and coronal sections of the head in order to evaluate the accuracy and reproducibility of the coronal cerebellar diameter. Intraobserver coefficient of variation was less than or equal to 2.2% and the mean interobserver difference was 2.2% (range, 0 to 6%). A positive linear correlation exists between transverse and coronal measurements (coronal diameter = 1.02 x transverse diameter - 0.48; R2 = 0.99; P less than 0.0001). We conclude that the coronal cerebellar diameter is reproducible and accurate and when indicated clinically can be used instead of the transverse cerebellar diameter when the latter is not obtainable because of fetal position.