Delayed-interval delivery: extended series from a single maternal-fetal medicine practice.

OBJECTIVE: Our purpose was to review the extended experience of a single maternal-fetal medicine practice with delayed-interval delivery. STUDY DESIGN: We completed a retrospective review of our maternal-fetal medicine practice database from January 1991 through March 1999. Patients were derived from both primary and consultative practices. All patients were managed with tocolysis, antibiotics, and cerclage after delivery of the first fetus(es). Retained siblings were investigated by amniocentesis to exclude intra-amniotic infection. RESULTS: Twenty-four consecutive patients had attempted delayed-interval delivery. Exclusion criteria for delayed-interval delivery included monochorionicity, abruptio placentae, severe preeclampsia, and the need for hysterotomy. The mean latency interval was 36 days, with a range of 3 to 123 days. Additionally, patients with previous cerclage(s) had significantly shorter mean latency intervals than patients without previous cerclage(s). Patients with long latency intervals (> or =49 days) had earlier births of the first fetus. CONCLUSION: Selected multichorionic pregnancies may benefit from delayed-interval delivery. Patients with previous cervical cerclage(s) during the index pregnancy are less likely to achieve significant latency intervals. Even modest intervals between births of siblings at critical gestational ages can improve neonatal survival and decrease neonatal morbidity.

A multicenter controlled trial of fetal pulse oximetry in the intrapartum management of nonreassuring fetal heart rate patterns.

OBJECTIVE: Recent developments permit the use of pulse oximetry to evaluate fetal oxygenation in labor. We tested the hypothesis that the addition of fetal pulse oximetry in the evaluation of abnormal fetal heart rate patterns in labor improves the accuracy of fetal assessment and allows safe reduction of cesarean deliveries performed because of nonreassuring fetal status. STUDY DESIGN: A randomized, controlled trial was conducted concurrently in 9 centers. The patients had term pregnancies and were in active labor when abnormal fetal heart rate patterns developed. The patients were randomized to electronic fetal heart rate monitoring alone (control group) or to the combination of electronic fetal monitoring and continuous fetal pulse oximetry (study group). The primary outcome was a reduction in cesarean deliveries for nonreassuring fetal status as a measure of improved accuracy of assessment of fetal oxygenation. RESULTS: A total of 1010 patients were randomized, 502 to the control group and 508 to the study group. There was a reduction of >50% in the number of cesarean deliveries performed because of nonreassuring fetal status in the study group (study, 4. 5%; vs. control, 10.2%; P =.007). However, there was no net difference in overall cesarean delivery rates (study, n = 147 [29%]; vs. control, 130 [26%]; P = .49) because of an increase in cesarean deliveries performed because of dystocia in the study group. In a blinded partogram analysis 89% of the study patients and 91% of the control patients who had a cesarean delivery because of dystocia met defined criteria for actual dystocia. There was no difference between the 2 groups in adverse maternal or neonatal outcomes. In terms of the operative intervention for nonreassuring fetal status, there was an improvement in both the sensitivity and the specificity for the study group compared with the control group for the end points of metabolic acidosis and need for resuscitation. CONCLUSION: The study confirmed its primary hypothesis of a safe reduction in cesarean deliveries performed because of nonreassuring fetal status. However, the addition of fetal pulse oximetry did not result in an overall reduction in cesarean deliveries. The increase in cesarean deliveries because of dystocia in the study group did appear to result from a well-documented arrest of labor. Fetal pulse oximetry improved the obstetrician's ability to more appropriately intervene by cesarean or operative vaginal delivery for fetuses who were actually depressed and acidotic. The unexpected increase in operative delivery for dystocia in the study group is of concern and remains to be explained.

Selective delivery in a twin gestation.

One or more infants of a multifetal pregnancy occasionally require delivery selectively because of in utero risk of fetal death in circumstances in which the sibling fetus appears well. At 26 weeks 5 days of gestation a small fundally placed twin in a dichorionic gestation had an estimated fetal weight of 650 g with decreased amniotic fluid and ominous Doppler velocity findings in his umbilical artery. A normally grown presenting sibling had reassuring fetal surveillance data. Over a 2-week interval the growth-restricted twin showed no growth, and his status deteriorated. He was selectively delivered by hysterotomy. Selective delivery may offer parents of multifetal gestations an additional option when 1 or more of their fetuses are at high risk for in utero death.

Delayed-interval delivery in multifetal pregnancy.

OBJECTIVE: Our goal was to review a single subspecialty practice experience with a uniform approach to delayed-interval delivery. STUDY DESIGN: A 66-month retrospective review of our maternal-fetal medicine practice database was completed. Fifty-nine sets of twins or triplets delivered at < 30 weeks' gestation were identified. No cases of twins or triplets who came to our care, either in consultation or as primary providers, were excluded. RESULTS: Forty-three patients were excluded as candidates for delayed-interval delivery because of monochorionicity, abruptio placentae, severe preeclampsia, and the need for hysterotomy. Sixteen pregnancies were identified as candidates for delayed-interval delivery, and we actually attempted to delay delivery in 9 of them. The details of the interval deliveries are summarized; there was a mean latency interval of 34 days with a range of 3 to 76 days. Pregnancies in which delayed-interval deliveries wer attempted were significantly less mature at the time of presentation than those managed by delivery of all infants initially. Perinatal mortality was significantly lower in the retained fetuses. CONCLUSIONS: This retrospective consecutive case review from a single maternal-fetal practice documents that selected multichorionic pregnancies may benefit from delayed-interval delivery. Modest intervals between siblings during critical gestational ages can improve newborn survival and decrease neonatal morbidity.

Pregnancy outcome following donor embryo replacement.

OBJECTIVE: To investigate the occurrence of adverse perinatal outcome among donor embryo pregnancies. STUDY DESIGN: Thirty-five pregnancies following donor embryo replacement were delivered between 1990 and 1994. Thirty-two pregnancies following standard in vitro fertilization (IVF) in women of 34 years of age or older were delivered during the same time period. All pregnancies meeting study criteria and who conceived through the same assisted reproductive technology program were included. Patients electing multifetal pregnancy reduction in either group were excluded. RESULTS: The patients were similar with regard to age and parity. There was no difference in the mean number of embryos transferred between the groups or between those conceiving singleton or multiple gestations. The occurrence of spontaneous abortion was 34% in the donor embryo group and 25% in the control IVF group. Of the continuing pregnancies, there was a trend toward more cesarean births in the donor embryo group, but it was not statistically significant. Birthweights and gestational ages also were not different between the groups. Preterm birth occurred in approximately one-third of the pregnancies in each group owing largely to the number of multiple gestations. The incidence of preeclampsia was 26% among donor embryo pregnancies and 29% among control group pregnancies. Adverse outcome defined as preterm birth with or without preeclampsia occurred in over one-third of the pregnancies in each group. CONCLUSION: There is no increase in adverse perinatal outcome among donor embryo pregnancies compared to age-like control IVF pregnancies. Modest increases in the occurrence of adverse outcome among such pregnancies cannot be excluded by the data in the current report.

Palliative fetal surgery for diaphragmatic hernia.

Congenital diaphragmatic hernia is associated with a poor prognosis in spite of advances in antenatal detection and newborn care. Open fetal surgery has been suggested as a strategy for salvaging selected fetuses at high risk for pulmonary hypoplasia as a result of this lesion. We report a strategy for palliative fetal surgery with definitive repair postponed to the newborn period.

Rapid cytogenetic assessment of fetal blood samples.

OBJECTIVE: To obtain a timely fetal karyotype in selected circumstances by investigating the usefulness of fetal blood samples. METHODS: Forty-five patients had fetal blood sampling for a variety of abnormalities including hydrocephalus, oligohydramnios, fetal growth retardation, nonimmune hydrops, duodenal atresia, polyhydramnios, and multiple anomalies. Four cytogenetic techniques were attempted in determining fetal karyotype: a direct harvest of lymphocytes in the fetal blood sample, a 24-hour incubation of fetal lymphocytes without mitogen, and a 48- and 72-hour mitogen-stimulated incubation followed by harvest and analysis. RESULTS: Ten of these 45 cases showed diagnostic cytogenetic abnormalities. Twenty-nine cases had results reported within 30 hours of obtaining the specimen following analysis of unstimulated cultures. One-half of the abnormal results were reported within 30 hours of receiving the specimen. CONCLUSION: Unstimulated lymphocyte cultures from fetal blood samples may provide rapid cytogenetic diagnosis and alter obstetric management in selected circumstances.

Fixed mini-dose warfarin for prophylaxis of thromboembolic disease in pregnancy: a safe alternative for the fetus?

BACKGROUND: Fixed mini-dose warfarin has been used for thromboprophylaxis in high-risk nonpregnant patients with encouraging results. The usefulness of this strategy in pregnant women requires documentation of fetal safety. CASE: A woman with antithrombin III deficiency suffered a venous thrombosis during early pregnancy and could not be successfully managed long term with heparin. One milligram of warfarin daily was used for prophylaxis, and serial fetal blood samples were used to monitor the fetal coagulation status. No apparent coagulation abnormalities were demonstrated in the fetus at 33, 36, and 38 weeks' gestation. The woman suffered no further thromboses throughout the remainder of her pregnancy and puerperium. CONCLUSIONS: The efficacy of fixed mini-dose warfarin for prophylaxis in pregnancies at risk for thromboembolic disease will require further investigation. This fetus did not appear vulnerable to coagulation abnormalities as a consequence of the warfarin regimen.

Percutaneous, ultrasound-directed ablation of ectopic pregnancy with methotrexate. A report of three cases.

The early diagnosis of unruptured ectopic pregnancy has been facilitated by the availability of high-resolution ultrasound and sensitive quantitative assays for beta-human chorionic gonadotropin. Nonsurgical treatment of selected patients has been advocated. Three patients with fairly advanced unruptured ectopic pregnancies were treated with ablation with methotrexate using an ultrasound-directed, percutaneous technique. That approach appears to be reasonable and safe in selected patients, though the subsequent reproductive performance is unknown.

Amniotic fluid glucose concentration as a marker for intra-amniotic infection.

This study evaluated the use of amniotic fluid (AF) glucose concentration as a rapid indicator of intra-amniotic infection. Amniotic fluid glucose concentrations were measured in 86 pregnancies and compared with AF cultures. There were 14 positive cultures with a mean AF glucose of 7.1 mg/dL (range 1-24) and 72 negative cultures with a mean AF glucose of 30.4 mg/dL (range 5-66), a significant difference (P less than .001). An AF glucose of less than or equal to 5 mg/dL had a positive predictive value of 90%; an AF glucose of greater than 20 mg/dL had a 98% negative predictive value. Amniotic fluid glucose can be obtained rapidly and inexpensively, and may be of use in the diagnosis of intra-amniotic infection.

Multifetal reduction of triplets and pregnancy outcome.

Multifetal pregnancy reduction has been suggested as a strategy to improve pregnancy outcome in grand multiple gestations of three or more fetuses. We prospectively investigated multifetal pregnancy reduction in 13 women with triplet pregnancies in the first trimester following ovulation induction, in vitro fertilization, or gamete intrafallopian transfer procedures. Eleven women whose triplet pregnancies followed similar reproductive technologies and who declined or were not offered the procedure were managed expectantly. Mean (+/- standard deviation) infant birth weight was 2227 +/- 478 g in the multifetal reduction group and 2239 +/- 399 g in the group managed expectantly. Gestational age was 35.5 +/- 2.3 weeks in the study group and 35.7 +/- 2.5 weeks in the triplets managed expectantly. Newborn hospital days as well as newborn and maternal complications were not statistically different between the management groups. Maternal interventions included tocolytic medication, home uterine activity monitoring, and extended hospitalization, and were more common in the triplets managed expectantly than in the study group of triplets reduced to twins. Multifetal pregnancy reduction for triplet pregnancies does not necessarily improve pregnancy outcome, though it may be offered on the basis of parental choice.

Occlusion of umbilical artery in acardiac, acephalic twin.

In the acardiac, acephalic twin malformation the normal co-twin is put at risk because of the extra cardiac work-load. Surgical procedures may be hazardous to the mother. We describe a novel approach--the insertion of a helical metal coil to induce thrombosis in the umbilical artery of the acardiac twin--which immediately interrupted flow. The co-twin was delivered at 39 weeks and his neonatal course has been normal.

Fetal blood sampling in the management of intrauterine thyrotoxicosis.

Graves disease is an autoimmune disorder caused by thyroid-stimulating immunoglobulins (Igs) which result in an excess production of thyroid hormones. These Igs are passively transferred to the fetus and may produce intrauterine thyrotoxicosis. Thyrotoxic fetuses are at risk for preterm delivery, intrauterine growth retardation, and perinatal death. Our patient had markedly elevated thyroid-stimulating Igs and had given birth to a preterm thyrotoxic infant in a previous pregnancy. We managed her third pregnancy with serial assessment of fetal thyroid hormones by funipuncture to identify the hyperthyroid fetus and modulate propylthiouracil therapy. We believe that this approach in selected patients with Graves disease may improve the outcome of these pregnancies.

Selective embryocide in the nonsurgical management of combined intrauterine-extrauterine pregnancy.

Early diagnosis of ectopic pregnancy has provided the opportunity for nonsurgical management in selected cases. We used selective embryocide to manage the ectopic embryo in a patient with a combined intrauterine-extrauterine gestation following in vitro fertilization. The intrauterine pregnancy continued to term without incident.