Reconsideration of head compression and intraventricular hemorrhage in the vertex very-low-birth-weight fetus.

The relationship between fetal head compression and the occurrence of intraventricular hemorrhage was examined in 101 very-low-birth-weight (500 to 1500 g) vertex neonates. Peripartum events related to head compression, including parity, rupture of membranes, labor, episiotomy, use of forceps, and cesarean birth were not significantly related to intraventricular hemorrhage. A birth weight of less than 1250 g, neonatal depression (one minute Apgar score less than 7), respiratory distress syndrome, and neonatal mortality were significantly associated with intraventricular hemorrhage (P less than .05). These findings suggest that head compression in the vertex very-low-birth-weight fetus, as encountered in current obstetric practice, is not a major determinant of intraventricular hemorrhage. When premature delivery is inevitable, focusing on efforts to avoid a depressed one-minute Apgar score appears to be a more promising approach for the prevention of intraventricular hemorrhage than routinely using cesarean birth.

Amniotic fluid volume as a risk factor in preterm premature rupture of the membranes.

During a prospective study evaluating the expectant management of preterm (26 to 34 weeks) premature rupture of membranes (PROM), the authors compared maternal and neonatal outcome of 17 patients with a marked reduction in amniotic fluid volume with 22 subjects having identifiable pockets of amniotic fluid after membrane rupture. The results demonstrated no significant differences in maternal age, gravidity, cervical dilatation, incidence of labor on admission, use of tocolytics, steroid usage, interval from membrane rupture to delivery, or cesarean section rate. The gestational age at which PROM occurred (31.4 +/- 1.9 versus 29.8 +/- 2.2 weeks) was significantly (P less than .05) more advanced in the adequate fluid patients when compared with the reduced fluid group. Clinical amnionitis was a far more common occurrence in the reduced fluid patients when compared with the adequate fluid group (47 versus 14%, respectively, P less than .05) as was postpartum endometritis (59 versus 18%, P less than .05). The incidence of overt neonatal sepsis was similar between the adequate fluid (14%) and reduced fluid (18%) patients. These results suggest that when a marked reduction in amniotic fluid after PROM is identified, patients are at a three-times greater risk for antepartum amnionitis and postpartum endometritis.

Perinatal outcome of broken marriage in the inner city.

OBJECTIVE: To test the hypothesis that the erosion of family structure, epidemic substance abuse, and increased low birth weight (LBW) rates are interrelated. METHODS: In this cohort study, we analyzed information coded prospectively in a computerized perinatal data base. Separated, divorced, and widowed mothers were grouped as broken marriages. The setting was a predominantly urban, indigent population in a tertiary care hospital. The analysis included singleton pregnancies of 14,896 women receiving prenatal and intrapartum care at our hospital from 1986-1991. The main outcome measures included LBW, prematurity, small for gestational age, neonatal mortality, and neonatal intensive care unit admissions. RESULTS: Married mothers fared better than single mothers, but risks for adverse perinatal outcomes for women with broken marriages were consistently as high or higher than for single mothers. The rate of LBW infants was 43% higher in the broken marriage group than in the married group. The increased frequency of LBW among infants born into broken marriages was attributable mainly to reduced growth rather than to prematurity and was associated with substance abuse. CONCLUSION: Our findings indicate that mothers from broken marriages are at relatively higher risk for LBW infants than married mothers (odds ratio 1.5). Broken marriage warrants emphasis as an important perinatal risk factor.

Risks preceding increased primary cesarean birth rates.

Recent increases in cesarean birth rates are of concern to obstetricians and to the public. Previous studies often focused on indications for abdominal delivery, described in such broad categories as repeat cesarean, breech presentation, dystocia, and fetal distress, without detailed information concerning medical/obstetric risk factors. In this study of 2744 consecutively delivered mothers who received antenatal care, the problem was approached differently by evaluating approximately 100 pregnancy risk factors recorded in a computerized uniform perinatal record system before making a decision for delivery. Excluding repeat cesareans, relative risks for primary cesarean birth were calculated for each risk factor. For the large majority of patients, the need for primary cesarean birth could not be predicted before the onset of labor. Approximately 70% of primary cesareans could be accounted for on the basis of single pregnancy risks--antepartum problems, 11%; abnormal fetal presentation, 30%; abnormal labor, 14%, and fetal distress, 15%. This leaves 30% of primary cesareans without a single major preceding risk. Along with the facts that 80% of primary cesareans in this series were performed for normal-size infants and that dystocia appears to account for a 3.4-fold greater proportion of cesareans in the national experience than in the current study, this suggests that critical evaluation and study of obstetric management of dystocia may be most fruitful in responding to the question of rising cesarean birth rates.

Painless abruptio placentae.

Three cases of abruption of a posteriorly inserted fundal placenta are described. This condition is characterized by vaginal bleeding associated with backache, a nontender uterus, and if unrecognized, high fetal mortality. Ultrasonography permits early recognition and definitive diagnosis. Fetal survival is ensured by closely supervised monitoring and early recourse to cesarean section.

Efficacy and safety of Laminaria digitata for preinduction ripening of the cervix.

Twenty-five study patients in whom laminaria tents had been used for the preinduction ripening of the cervix were compared with 28 control patients in a retrospective study. Both groups had comparable indications for induction, parity, mean maternal age, mean birth weight, and gestational age. Although laminaria appeared to be effective in reducing the duration of induction, no difference in the incidence of cesarean birth was apparent between the laminaria and nonlaminaria groups. Maternal endometritis was present in 15 of 25 mothers in the laminaria group, and in 3 of 28 in the control group (P less than .05). All 9 mothers who had cesarean deliveries in the study group had endometritis, whereas it occurred in only 3 of 11 in the control group (P less than .005). Six of the 16 patients in the study group who delivered vaginally had endometritis, whereas none of 17 in the control groups has it (P less than .01). Five of 25 neonates in the study group has sepsis, but there was no evidence of sepsis in the 28 control neonates (P less than .05). Three of the 5 septic neonates died. There were no neonatal deaths in the control group. The findings suggest that laminaria use in associated with significant risk of maternal and neonatal infectious morbidity.

Anicteric presentation of fatal herpetic hepatitis in pregnancy.

Herpes simplex virus hepatitis in pregnancy was first reported in 1969. Seven other cases have since been reported, and this communication describes two additional cases. The clinical presentation and laboratory profiles of these two cases parallel those described. Unreported, however, is the sharp contrast between the presentation of pregnant patients with herpes simplex virus hepatitis and the presentation of pregnant patients with other life-threatening forms of hepatitis. Nine of ten patients reported to date have been anicteric with peak total bilirubin levels of less than 1.3 mg/dL before cesarean section or laparotomy. That this presentation may not be unique to pregnancy is suggested by three case reports of fatal, anicteric herpes simplex virus hepatitis in previously healthy, nonpregnant adults. The cause of this phenomenon is unknown.

Amnioinfusion: does the choice of solution adversely affect neonatal electrolyte balance?

OBJECTIVE: To determine whether various solutions commonly used in amnioinfusion during labor affect neonatal electrolyte and blood gas values. METHODS: Amnioinfusion for thick meconium or severe variable fetal heart rate decelerations is used at our institution according to a standardized protocol. During alternating 3-week periods, the only solution made available for amnioinfusion was either normal saline or Ringer's lactate. Bolus volume, rate, and duration of infusion were determined by the individual physicians. At delivery, cord blood was collected for electrolyte and blood gas determination. These values were compared between the two solution groups and to a non-infused control group. RESULTS: Complete data on neonatal electrolytes and blood gas values were available on 53 infusion patients (20 Ringer's lactate, 33 normal saline) and 39 non-infusion patients. Comparing infusion to non-infusion patients and those infused with Ringer's lactate to those with normal saline, we found no significant difference in demographics, neonatal outcome variables, duration of labor, neonatal electrolytes, and cord blood gas values. Infusion variables (bolus volume, infusion rate, hours infused, and total volume infused) did not differ between solutions. Total volume and hours of infusion were closely correlated with each other (r = 0.93, P < .001); both were correlated with neonatal chloride (r = 0.38 and r = 0.36, respectively; P < .005). No cases of hypernatremia or hyperchloremia were found in any of the groups. The type of solution used had no effect on the neonatal chloride trend. CONCLUSION: The use of both normal saline and Ringer's lactate for indicated amnioinfusion in labor appears to have no clinically significant effect on neonatal electrolytes.

Clinical interpretation of ultrasound measurements in preterm pregnancies with premature rupture of the membranes.

Interpreting ultrasound measurements in preterm pregnancies complicated by premature rupture of the membranes is problematic; the effects of physical compression and diminished fetal growth are unclear. To delineate these factors, we analyzed ultrasound scans from 397 preterm pregnancies, including 26 with premature rupture of the membranes. Mean biparietal diameter (BPD), abdominal circumference, femur length, and estimated fetal weight were all significantly smaller with premature rupture of the membranes than without. However, this reflected younger gestational age and diminished fetal growth, rather than physical compression. The reduction in abdominal circumference was greater than that in other indices, which further suggests compromised intrauterine growth. Clinical interpretation of ultrasound measurements should consider the increased likelihood of growth retardation with preterm premature rupture of the membranes to avoid underestimating gestational age and/or missing the diagnosis of intrauterine growth retardation.

Determinants of morbidity in obese women delivered by cesarean.

Studies examining the increased surgical morbidity among obese gravidas have focused mainly on differences in outcome between obese and nonobese mothers. Little is known, however, about the cause for worsened operative outcome in obese mothers or the potential impact of perioperative interventions. To define more precisely the clinical determinants of postoperative morbidity, multivariate analysis was used to relate antepartum and intrapartum variables to three measures of morbidity in 107 consecutively delivered obese women undergoing cesarean. Although obesity is clearly an operative risk factor, this study suggested that among obese gravidas, varying degrees of maternal obesity and accompanying medical complications, such as diabetes and hypertension, were not associated with greater operative morbidity. Furthermore, neither choice of skin incision nor type of anesthesia appeared to be related to operative morbidity. However, two factors potentially under the control of the clinician, increased length of surgery and operative blood loss, were associated significantly with measures of operative morbidity. A finding of worsened outcome with prophylactic antibiotics and heparin requires further study.

Sickle cell E hemoglobinopathy and pregnancy.

The incidence of E hemoglobinopathies has been increasing in the United States. This is the first known case report of hemoglobin S/E in pregnancy. Management was based on the similarities of the S/E and S/beta-thalassemia hemoglobinopathies, and included partial exchange transfusion. Complications included fetal distress, congenital hydrocephalus, and cleft lip and palate. It appears that S/E and E/beta-thalassemia hemoglobinopathies may entail increased perinatal risks, but that favorable pregnancy outcomes may be anticipated with homozygous hemoglobin E or hemoglobin E trait.

Hemostasis in hypertensive disorders of pregnancy.

We studied parameters of hemostasis reported to be altered with "pure" preeclampsia in hypertensive disorders of pregnancy. Plasma fibronectin, antithrombin, and alpha-2 antiplasmin were measured in normal pregnancies (N = 26) and in pregnancies complicated by preeclampsia (N = 19), hypertension (N = 11), and chronic hypertension with superimposed preeclampsia (N = 11). Preeclampsia, both pure and superimposed, was associated with high fibronectin (P less than .001), low antithrombin III (P less than .001), and low alpha-2 antiplasmin (P less than .05) levels, suggesting endothelial injury, clotting, and fibrinolysis, respectively. Alpha-2 antiplasmin was increased with chronic hypertension (P less than .001), regardless of whether there was superimposed preeclampsia. Fibronectin appeared to be more closely linked with preeclampsia than antithrombin III or alpha-2 antiplasmin and may prove valuable in detecting preeclampsia when evaluating hypertension in pregnancy.

Perinatal characteristics of the phenotypically and chromosomally abnormal live-born.

Perinatal characteristics of 105 singleton live infants born during the last 5 years and suspected phenotypically of having karyotypic abnormalities were studied; 33 abnormal karyotypes were found. These pregnancies were compared with all pregnancies delivering at our hospital during the same time period. A retrospective analysis using our perinatal data base examined maternal age, gravidity, parity, race, mode of delivery, birth weight, gestational age at delivery, Apgar scores, and size for gestational age. Within the phenotypically abnormal group, karyotypically normal and abnormal infants showed no significant differences in primary cesarean rates, low Apgar scores, mean birth weight, or appropriateness of size for gestational age. Karyotypically abnormal infants were smaller than the general population (P less than .001) and had lower Apgar scores (P less than .05) but were just as likely to be full-term (66.7 versus 70.3%). These chromosomally abnormal pregnancies had a higher primary cesarean rate than the general population (30.3 versus 15.4%; P less than .001). Black infants undergoing genetic studies had a 37% rate of karyotypic abnormalities, which was significantly higher than the 12.5% rate in the white infants tested (P less than .05). The term black infant with phenotypic abnormalities suggestive of karyotypic abnormalities may be less likely to be recognized and appropriately tested. Increased awareness of phenotypic abnormalities with subsequent genetic testing seems warranted.

Oral contraceptives and the hemostatic system.

We studied 30 control women and 131 pill users to evaluate effects of birth control pills and clinical factors on hemostasis. When control patients were matched with an equal number of pill users, none of the direct markers of activated hemostasis (fibrinopeptide A, platelet factor 4, and beta thromboglobulin) were increased. Plasminogen, prekallikrein, and protein C (protective against clotting) were significantly higher in pill users. Fibrinogen, antithrombin, alpha-2 antiplasmin, and fibronectin were comparable. Among the 131 pill users, antithrombin levels decreased with a family history of thromboembolism. Fibrinogen and fibronectin were increased with obesity, but there was no evidence of activated hemostasis. Overall, pill use did not appear to result in hypercoagulability. Considering family history of thromboembolism might further improve the safety of oral contraceptive use.

Pseudocorpus luteum insufficiency: a study of cytosol progesterone receptors in human endometrium.

This prospective, controlled study of 38 women was designed to compare the number of endometrial cytosol progesterone receptor (PRc) binding sites in infertile women with documented luteal phase defect with those of similar women without luteal phase defect. A 25% reduction in PRc binding sites was observed in women with luteal phase defect (P less than .05). Considerable overlap was noted between luteal phase defect and control groups; thus, no definite range of binding site numbers was predictive of luteal phase defect. The results of this study, therefore, suggest that an end-organ receptor defect may exist in some women with luteal phase abnormalities.

Hemostasis and diagnosis of preeclampsia.

The diagnosis of preeclampsia, with all of its consequences, is at times difficult to establish, especially when the patient has underlying chronic hypertension and is not known from prior prenatal care visits. Many screening tests have been proposed. These should be sensitive, relatively specific, easy to perform, of low cost, and have a reasonable interval from prediction to disease onset. Laboratory assays would obviously be useful. We evaluated hemostasis tests for the diagnosis of preeclampsia, and compared fibronectin, antithrombin III and alpha 2-antiplasmin in 48 preeclamptics and 86 control nulliparas. Receive operator characteristic (ROC) curve analysis suggested that fibronectin is the most effective of these tests. A similar analysis comparing the results of previous studies using serum iron, angiotensin infusion, urinary calcium/creatinine ratio, the rollover test and uric acid suggested a possible role for fibronectin in the diagnosis of preeclampsia. While not ideal, there seems to be, at present, no other, easy to perform laboratory test that outperforms fibronectin in predicting preeclampsia.

Lysosomal enzyme activities in fresh and frozen chorionic villi and in cultured trophoblasts.

Fifteen lysosomal enzyme activities were compared in 14 presumed normal chorionic villus specimens that were each divided, processed and analyzed as fresh tissue, tissue frozen for 1 week, and cultures established from minced whole villi. Most of the activities determined in the chorionic villus tissue were not affected significantly by freezing. However, activities for most enzymes were significantly different from those determined in the cultured cells. Our experience with first trimester prenatal evaluations for several lysosomal disorders showed that the limited amount of tissue obtained is not always sufficient for thorough analysis and thus, cultured trophoblasts derived from the tissue specimen should also be examined. The results of this study stress the importance of using appropriate tissue-type and cell-type controls to establish the normal range in the respective analyses.

Parental perceptions of genetic risk: correlation with choice of prenatal diagnostic procedures.

Determinants of patients' decisions to have prenatal diagnosis, and by which test (amniocentesis or chorionic villus sampling), is not well understood. We have administered questionnaires to couples referred for genetic counseling and procedures for advanced maternal age and determined patients' responses, decisions, and attributable determinants of their choice. Differences in perception of risks between partners, and choice of procedure, correlated with socioeconomic, educational status and age.

Determining blood pressure in pregnancy. Positional hydrostatic effects.

OBJECTIVE: To evaluate positional hydrostatic effects on blood pressure determination during pregnancy. STUDY DESIGN: We studied 30 normotensive, pregnant women at 34-41 weeks of gestation. Blood pressures were taken in the sitting, left lateral, right lateral and supine positions with a two-minute stabilization period between positions. The bisacromial diameter was measured. Multivariate analysis of variance for repeated measures was used to evaluate the affect of position on blood pressure. RESULTS: Mean systolic pressure in the right arm was 2.6 mm Hg greater than that in the left arm (P < .05). There was no difference between the arms in diastolic blood pressure. Immediate blood pressure in the lower arm was no greater than in the higher arm in lateral positions, and there were no other significant positional effects. Observed blood pressures were significantly different than those theoretically expected on the basis of hydrostatic effects (P < .0001). CONCLUSION: Positional effects on blood pressure in the lateral positions do not appear immediately (within two minutes), indicating that hydrostatic pressure does not account for these changes. The well-documented blood pressure reduction from longer duration in the lateral position does not appear to be an artifact of hydrostatic effect. Repositioning pregnant women in the supine position to have the cuff at the level of the heart is unnecessary and often undesirable when fetal perfusion is an important consideration. We suggest that American Heart Association blood pressure guidelines stating that all measurements be taken with the cuff at the level of the heart to avoid hydrostatic pressure change be revised for pregnancy.

Effects of karyotype, gestational age and medium on the duration of amniotic fluid cell culturing.

Third-trimester genetic amniocentesis has often been underutilized because of the long period required to obtained results. While fetal cord sampling can be used to obtain rapid karyotypes, its availability is still very limited. With more defined media, the culture duration (CD) for amniotic fluid cells has decreased markedly. We investigated CD as a function of gestational age (GA) and karyotype and found that: (1) there is an inverse correlation of GA and CD; (2) aneuploid karyotypes, translocations and inversions all grow more slowly regardless of GA; (3) since late taps are performed most often on highly suspicious cases, the general impression of late-GA slow growth may be because of a higher likelihood of aneuploidy. Our data thus support increased utilization of third-trimester genetic amniocentesis in selected cases.