Intrapartum fever, epidural analgesia and histologic chorioamnionitis.

OBJECTIVE: Our objective was to determine whether epidural analgesia and histologic chorioamnionitis were independent predictors of intrapartum fever. STUDY DESIGN: This secondary analysis, retrospective cohort study included term parturients with placental examination during 2005. Logistic regression used fever (⩾38 °C) as the dependent variable. Significance was defined as P⩽0.05. RESULT: There were 488 (76%) of 641 term parturients with placental examination and epidural. Independent predictors of intrapartum fever were epidural odds ratio (OR)=3.4, confidence interval (CI): 1.70, 6.81, histologic chorioamnionitis OR=3.18, 95% CI: 2.04, 4.95, birthweight OR=2.07, 95%CI: 1.38, 3.12, vaginal exams OR=1.15, 95% CI:1.06, 1.24, duration ruptured membranes OR=1.03, 95% CI: 1.01,1.05, parity⩾1 OR=0.44: 0.29, 0.66 and thick meconium OR=0.35: 95%CI: 0.24, 0.85. CONCLUSION: Epidural analgesia and histologic chorioamnionitis were independent predictors of intrapartum fever. Modification of labor management may reduce the incidence of intrapartum fever.

A review of thromboembolic complications in pregnancy.

Combined with the enlarging uterus compressing the venous system of the pelvis and the vessel trauma incurred in delivery, an increase in clotting factor production in pregnancy predisposes the gravid patient to the peril of thromboembolism. When a patient has an inherited thrombophilia and becomes pregnant, this combination of risk factors in the presence of pregnancy may be the tipping point, pushing the coagulation cascade into an activated state. All thrombophilias, deep vein thrombosis, and pulmonary embolism are factors associated with complications in pregnancy that may lead to catastrophic consequences. This review report on the most frequent thromboembolic complications in pregnancy.

University hospital-based prenatal care decreases the rate of preterm delivery and costs, when compared to managed care.

OBJECTIVE: Our purpose was to compare the rate of recurrent preterm delivery and the combined costs of mother/infant care for patients with a history of preterm delivery cared for in an inner city hospital house staff (HS) clinic versus an inner city managed care organization (MCO). METHODS: A retrospective cohort study was conducted. The groups consisted of 96 patients with a history of preterm delivery who were cared for by the HS clinic and 164 patients cared for in a neighborhood MCO. All patients with a history of previous preterm delivery who delivered at the Johns Hopkins Hospital between 1 January 1994 and 31 December 1996 were included in the study. The groups were examined regarding source of prenatal care for the subsequent pregnancy (HS vs. MCO), baseline demographics, intensity of prenatal care, maternal and neonatal outcomes and total cost of the provision of care. RESULTS: There were no differences in baseline demographics between the groups. There was a higher rate of recurrent prematurity for patients cared for by the MCO (HS, 24% vs. MCO, 36%, p = 0.04). Mean total mother/infant costs were also higher in the MCO group ($13565) when compared to the HS group ($9082), (p = 0.02). CONCLUSION: While some MCOs may provide cost savings for some low-risk populations, our study demonstrates that this health-care delivery system resulted in greater total expenditures for patients with a history of preterm delivery.

Low 1-hour glucose screens and small for gestational age infants.

OBJECTIVE: To determine whether a 1-hour glucose screen done at 26 to 29 weeks' gestation that is below the fifth percentile is predictive of having a small for gestational age (SGA) infant. STUDY DESIGN: Pregnancies with 1-hour glucose screens were analyzed retrospectively. A total of 600 cases had values below the fifth percentile (< 71 mg/dl). A total of 6784 controls had values between the 25th and 75th percentiles. Infants were classified as being SGA if they had birth weights less than the 10th percentile adjusted for gestational age and infant gender. The Student's t-test, Fisher's exact test, and logistic regression were used for statistical analysis. RESULTS: The incidence of SGA infants differed significantly between cases and controls, 16.2% versus 12.0% (p = 0.0043). This association remained significant after adjustment for race (p = 0.02). CONCLUSION: A 1-hour glucose screen with a result that is less than the fifth percentile is an independent risk factor for having an SGA infant.

Bilateral ovarian stromal hyperplasia concealing a nonhilar, pure stromal-Leydig cell tumor. A case report.

BACKGROUND: Of ovarian stromal tumors containing Leydig cells, nonhilar, pure stromal-Leydig cell tumor is rare. CASE: An obese, diabetic, borderline hypertensive 41-year-old woman with a five-year history of oligomenorrhea and amenorrhea presented with complaints of masculinization. Physical examination revealed hirsutism and an enlarged clitoris. The only abnormal serum marker was elevated testosterone. At laparotomy both ovaries were enlarged and suspected to have bilateral stromal hyperthecosis. Histology revealed stromal hyperplasia along with a 1.5-cm, testosterone-producing pure stromal-Leydig cell tumor of the right ovary. CONCLUSION: Bilateral ovarian enlargement secondary to stromal hyperplasia in patients with masculinizing signs can conceal a small, unilateral pure stromal-Leydig cell tumor.

Helical CT amniography of congenital diaphragmatic hernia.

OBJECTIVE: Accurate prenatal diagnosis of congenital diaphragmatic hernia is important for perinatal planning and potential fetal surgery. We describe the application and usefulness of helical CT amniography in the evaluation of suspected congenital diaphragmatic hernia in three fetuses. CONCLUSION: Helical CT amniography is an efficient means for evaluation of congenital diaphragmatic hernia. Accurate diagnosis was made in all three patients.

Third-trimester rudimentary horn pregnancy. A case report.

BACKGROUND: Müllerian ducts fuse in the midline to form the uterus at about 10 weeks' gestation. Rudimentary horn pregnancies are unusual occurrences. CASE: A 34-year-old woman presented at 24 weeks' gestation for prenatal care. Rudimentary horn pregnancy was diagnosed. Shortly afterwards the patient developed an acute abdomen, followed by emergency delivery. Though the risks of complications were high, none occurred. CONCLUSION: The incidence of rudimentary horn pregnancy is 1/100,000-150,000. Surgery is the treatment of choice. The prognosis is poor.

Incidence of atypical glandular cells of uncertain significance in cervical cytology following introduction of the Bethesda System.

OBJECTIVE: To establish the frequency of the atypical glandular cells of uncertain significance (AGCUS) category, and its subcategories, as defined by the Bethesda System (TBS). METHODS: Our computerized records of cervical/vaginal cytology specimens submitted from January 1, 1993, through December 31, 1995, were retrospectively reviewed for specimens diagnosed as AGCUS. When appropriate, our subcategory of "AGCUS favor premalignant/malignant lesion" was further qualified as "favor endocervical adenocarcinoma in situ" or "suspicious for endometrial carcinoma." The number of specimens and patients diagnosed for each subcategory were grouped by calendar year. Differences in frequency between time periods were tested for statistical significance using chi 2 analysis. RESULTS: AGCUS was diagnosed in 1181 of 177,715 submitted specimens (0.66%). The frequency of subcategories was as follows: "favor reactive" (65%), "unable to further classify" (30%), "favor premalignant/malignant" (2.9%), "suspicious for endometrial carcinoma" (1.9%), and "favor endocervical adenocarcinoma in situ" (0.4%). From 1993 to 1995 there was an increase in the rate of diagnosis of AGCUS (0.55 to 0.73%; P < 0.001) and a decrease in the percentage of specimens with AGCUS subclassified as "favor premalignant/malignant" (6.2 to 0.5%; P < 0.001). Other subcategories showed no significant change in frequency over this time period. The rate of biopsy-proven preinvasive or invasive lesions in AGCUS patients also showed no significant change from year to year over this time period. CONCLUSION: The AGCUS diagnosis can be anticipated at a low but consistent rate from a cytology laboratory using TBS. Any comparison of laboratories should take into consideration the change in reporting frequencies that occurs as part of the "learning curve" following introduction of TBS reporting. Uniform diagnostic criteria and additional reports with large numbers of cytologic specimens will be needed to establish the expected frequency of AGCUS and its subcategories.

Deviation in amniotic fluid optical density at a wavelength of 450 nm in Rh-immunized pregnancies from 14 to 40 weeks' gestation: a proposal for clinical management.

OBJECTIVES: Our purpose was to study deviations in values of amniotic fluid optical density at 450 nm in Rh-immunized pregnancies in the second and third trimesters and to propose a clinical management plan. STUDY DESIGN: A total of 789 amniotic fluid single and serial values of deviations in optical density at 450 nm were performed on Rh-immunized pregnancies from 14 to 40 weeks' gestation. The relationship of the deviations in amniotic fluid values of optical density at 450 nm to varying degrees of fetal disease were examined. RESULTS: In Rh-negative fetuses (unaffected) amniotic fluid values rise until 22 to 26 weeks before decreasing to term. In fetuses at risk of dying in utero, values are higher and trends rise. A clinical management plan was devised on the basis of the amniotic fluid findings of deviations in optical density at 450 nm. CONCLUSIONS: A clinical management scheme consisting of four zones is outlined. Rh-negative fetuses have minimal invasive procedures. Fetuses at risk of death undergo early cordocentesis for evaluation and therapy. Values that fall in between can be separated into two zones on the basis of the degree of risk.