Window operation: an alternative treatment method for Bartholin gland cysts and abscesses.

Recently, we developed the "window operation" as a more effective way to treat Bartholin gland cysts and abscesses. The window operation was used to treat 25 Bartholin cysts and 22 Bartholin abscesses during a 3-year period from October 1, 1986 to September 30, 1989. Under local anesthesia, a small piece of skin including the cyst wall was excised in an oval shape, and suturing was performed along the excised margin. Postoperative antibiotics were given in cases of acute inflammation. A new mucocutaneous junction was observed at the 4-week postoperative checkup. No complications or recurrences have been observed during the study period. The window operation can be an alternative method of treatment for Bartholin gland cysts or abscesses.

Neonatal nucleated red blood cell and lymphocyte counts in fetal brain injury.

OBJECTIVE: To determine whether neonatal lymphocyte or nucleated red blood cell (RBC) counts can be used to date fetal neurologic injury. METHODS: Singleton, term infants with hypoxic-ischemic encephalopathy, permanent neurologic impairment, and sufficient laboratory data were divided into two groups: infants with preadmission injury, manifested by a nonreactive fetal heart rate (FHR) pattern from admission until delivery; and infants with acute injury, manifested by a normal FHR pattern followed by a sudden prolonged FHR deceleration. Lymphocyte and nucleated RBC values were compared with published high normal counts for normal neonates: 8000 lymphocytes/mm3 and 2000 nucleated RBCs/mm3. RESULTS: The study population consisted of 101 neonates. In the first hours of life, lymphocyte counts were elevated among injured newborns, and then the counts rapidly normalized. Brain-injured neonates were 25 times more likely to have a lymphocyte count greater than 8000 than were normal neonates (54 [62%] of 87 versus 6 [7%] of 84; odds ratio 25.5; 95% confidence interval 8.8, 80.1; P < .001). The mean lymphocyte count tended to be higher in the preadmission-injury group than in the acute-injury group. In comparison, nucleated RBC values were not correlated as strongly with neonatal hours of life; nucleated RBC counts tended to be higher and persist longer among neonates with preadmission injury than among those with acute injury. CONCLUSION: Compared with normal levels, both lymphocyte and nucleated RBC counts were elevated among neonates with fetal asphyxial injury. Both counts appear to be more elevated and to remain elevated longer in newborns with preadmission injury than in infants with acute injury. However, the rapid normalization of lymphocyte counts in these injured neonates limits the clinical usefulness of these counts after the first several hours of life.

Twice a cesarean, always a cesarean?

The cesarean delivery rate has quadrupled during the past two decades, resulting in considerable attention focused on alternatives to cesarean birth. One option, vaginal birth after one previous cesarean, has come to be recognized as an acceptable alternative to routine elective repeat cesarean delivery. The purpose of this report was to evaluate whether women with two previous cesareans can safely undergo a trial of labor. Between July 1, 1982 and June 30, 1986, data were collected prospectively on all women with previous cesareans. Those with a known classical incision or a medical or obstetric contraindication to a trial of labor were excluded from an attempted vaginal delivery. During this period, 67,784 patients were delivered, of whom 6250 (9.2%) had had a previous cesarean. Of the 6250 previous-cesarean patients, 1088 (17.4%) had had two previous cesareans; of these, 501 (46%) underwent a trial of labor and 346 (69%) delivered vaginally. Whereas the overall rate of uterine dehiscence was 3%, the rate in those women who attempted a vaginal delivery was 1.8%, versus 4.6% in those who did not. Overall, oxytocin was used in 284 (57%) and was associated with a dehiscence rate of 2.1%, versus 1.4% in the no-oxytocin group. Successful vaginal delivery was related significantly to the use of oxytocin and to a previous vaginal delivery. Trial of labor in patients with two previous cesareans appears to be a reasonable consideration.

Polyhydramnios and perinatal outcome.

Of 2081 high-risk pregnancy patients who underwent antepartum fetal surveillance tests, 72 (3.5%) patients demonstrated evidence of polyhydramnios using the amniotic fluid index to assess the amniotic fluid volume. In these patients, an increased incidence of fetal macrosomia, premature births, non-reactive nonstress tests, perinatal morbidity, and fetal anomalies was observed. These data suggest that if polyhydramnios is encountered during an ultrasound evaluation, consideration should be given to the possibility of latent or uncontrolled diabetes mellitus or fetal macrosomia or anomaly; fetal surveillance and genetic evaluation also should be considered.

Multiple pregnancy: antepartum management.

The critical aspects of twin pregnancy begin with early diagnosis. After that, diet, bed rest, and frequent visits to the physician's office will enhance fetal outcome. Additionally, frequent ultrasound evaluations to assess fetal growth and fetal surveillance are also invaluable adjuncts. Prompt treatment of any medical or obstetrical complications will contribute to an overall improvement in maternal and fetal outcome.

The low birth weight infant: is there a preferred route of delivery?

In the management of the preterm pregnancy, cesarean delivery cannot be supported in the delivery of the preterm (less than 1500 g) cephalic-presenting fetus. Although cesarean may be of benefit in the management of the preterm breech fetus (less than 1500 g), there is yet no perspective randomized clinical trial to support its use.

Intrauterine manometry: reapplication of an old concept.

Electronic fetal heart rate and uterine activity monitoring during labor requires expensive equipment and a source of electricity. However, it is not available to most of the women in the world. Intrauterine manometry provides a method which can be employed in underdeveloped settings to assess uterine contractions and to time auscultation. The vertical column of fluid in a standard intrauterine pressure catheter (IUPC) correlated well (R = 0.93) with the intrauterine pressure measurements obtained by a standard IUPC/pressure transducer system. Intrauterine manometry provides an alternative measure of uterine tone which may be employed in underdeveloped areas.

Intrapartum amniotic fluid volume at term. Association of ruptured membranes, oligohydramnios and increased fetal risk.

The amniotic fluid index (AFI), a semiquantitative technique for assessing amniotic fluid volume, has been shown to be a useful adjunct in antepartum surveillance. We evaluated the usefulness of the AFI in the early intrapartum period as it relates to subsequent fetal morbidity and fetal heart rate patterns. Two hundred term gravidas presenting in the latent phase of labor with vertex-presenting fetuses were studied. An intrapartum AFI less than or equal to 5.0 cm was associated with a significant increase in the risk of cesarean section for fetal distress and of an Apgar score of less than 7 at one minute as well as abnormal fetal heart rate patterns in late labor. The majority (71.4%) of the patients with an intrapartum AFI less than or equal to 5.0 cm had ruptured membranes on entry; however, there was no significant difference in outcome when they were compared to patients with intact membranes and oligohydramnios. Variable decelerations on entry were associated with oligohydramnios in 43.8% of the patients. An AFI less than or equal to 5.0 cm in the early intrapartum period is a risk factor for perinatal morbidity and abnormal fetal heart rate patterns in subsequent labor, and ruptured membranes in early labor are a risk factor for oligohydramnios.

Relationship of early intrapartum fetal heart rate patterns to subsequent patterns and fetal outcome.

This study evaluated subsequent fetal heart rate (FHR) patterns and fetal outcome in laboring women with normal or abnormal initial FHR patterns. Four hundred term gravidas presenting in the latent phase of labor were studied. Ninety (22.5%) exhibited abnormalities on the initial tracing, with the majority of those abnormalities (58.9%) including mild variable decelerations, either alone or in combination with other abnormalities. An analysis of the outcome for those patients revealed a significant increase in cesarean delivery for fetal distress and depressed one-minute Apgar scores when compared to patients with initially normal tracings. Analysis of subsequent FHR patterns in that group showed a significant increase in the incidence of atypical variable declerations and bradycardia. Patients with more than one abnormality on the initial FHR tracing showed a greater incidence of loss of variability, loss of reactivity and bradycardia on subsequent FHR tracings. Likewise, pregnancy outcome for this group was remarkable for an increased risk of meconium staining, cesarean delivery for fetal distress and depressed one-minute Apgar scores. An abnormal initial FHR tracing seems to be associated with the subsequent development of ominous FHR patterns and increased fetal morbidity, particularly when more than one abnormality is present on the initial tracing.

Four-quadrant assessment of amniotic fluid volume. Interobserver and intraobserver variation.

While the use of the four-quadrant technique, or the amniotic fluid index (AFI), for amniotic fluid volume assessment has been shown to correlate with perinatal outcome, one concern among clinicians is the reliability of a single AFI measurement. The purpose of this investigation was to ascertain the margin of error using this technique among 23 term and postterm women. The AFI was obtained using linear array real-time B-scan ultrasound to measure the vertical diameter of the largest amniotic fluid pocket in each of the four quadrants. The sum of these measurements was expressed as the AFI. Eight women underwent ten consecutive AFI measurements by the same sonographer to determine intraobserver variation. Interobserver variation between five sonographers was measured by assessing the AFI in 15 additional patients. With the amniotic fluid volume in the low or normal range, our results demonstrated the intraobserver and interobserver variations in AFI to average 1.0 and 2.0 cm, respectively. With an above-normal amniotic fluid volume, a 2.5- to 3-fold greater variation was observed. A relatively small margin of error appears to exist between observers using the four-quadrant technique to assess amniotic fluid volume.

Amniotic fluid index measurements during pregnancy.

Amniotic fluid volume assessment has become an important part of antepartum fetal surveillance. The amniotic fluid index (AFI), or four-quadrant technique, has been suggested for this purpose. While previous reports have outlined this technique and correlated the results with pregnancy outcome, none have reviewed the changes in AFI throughout pregnancy. We studied AFI changes from 11 through 43 weeks' gestation. As part of the entry criteria, only patients with good dates were evaluated. The AFI was determined by the summation of the vertical diameter of the largest pocket in each of the four quadrants. All amniotic fluid studies were conducted using real-time linear array B-scan. During the study period, 197 patients with good dates confirmed clinically and sonographically underwent 262 AFI assessments. From 11 to 26 weeks the AFI rose progressively. Thereafter until term, the AFI remained approximately 16.2 +/- 5.3 cm. After 38 weeks the AFI appeared to gradually decline. Data obtained from this study population corroborate previously defined normal amniotic fluid volumes. These results also suggest that serial measurements of the AFI may be an effective means of assessing fetal status throughout pregnancy.

Vaginal birth after cesarean delivery. Trial of labor in women with breech presentation.

Vaginal birth after cesarean delivery in a woman with breech presentation is a controversial issue. In this prospective study, 137 patients had a breech presentation. Of them, 27 (19.7%) met the protocol criteria for attempted vaginal delivery and desired a trial of labor. Thirteen (48%) achieved vaginal delivery, with no increase in fetal or maternal morbidity. Our data suggest that in selected patients, a trial of labor after a cesarean delivery with a breech presentation is a reasonable consideration.

Does the onset of neonatal seizures correlate with the timing of fetal neurologic injury?

The onset of seizures after birth has been considered evidence of an intrapartum asphyxial event. The present study was undertaken to determine whether the timing of neonatal seizures after birth correlated with the timing of a fetal asphyxial event. Thus, singleton term infants diagnosed with hypoxic ischemic encephalopathy and permanent brain injury had a mean birth to seizure onset interval of 9.8 +/- 17.7 (range 1-90) hours. When these infants were categorized according to their fetal heart rate (FHR) patterns, the acute group (normal FHR followed by a sudden prolonged FHR deceleration that continued until delivery) tended to have earlier seizures than infants did within the tachycardia group (normal FHR followed by tachycardia, repetitive decelerations, and diminished variability) and the preadmission group (persistent nonreactive FHR pattern intrapartum). These seizure intervals were as follows: acute, 6.6 +/- 18.0 (range 1-90) hours; tachycardia, 11.1 +/- 17.1 (range 1-61) hours; and preadmission, 11.8 +/- 17.9 (range 1-79) hours (p < 0.05). But the range varied widely and no group was categorically distinct. In conclusion, the onset of neonatal seizures after birth does not, in and of itself, appear to be a reliable indicator of the timing of fetal neurologic injury.

Perinatal observations in forty-eight neurologically impaired term infants.

OBJECTIVE: Our goal was to review the perinatal characteristics of 48 singleton term infants with central nervous system neurologic impairment. STUDY DESIGN: Medical records were retrospectively reviewed for maternal characteristics, prenatal and intrapartum care patterns, neonatal course, and long-term outcome. Those patients without evidence of an obvious acute asphyxial event, traumatic delivery, or preterm birth were excluded. The study population was then subclassified according to the admission fetal heart rate pattern. RESULTS: Of these 48 term infants the admission fetal heart rate pattern was nonreactive in 33 (69%) and reactive in 15 (31%). Maternal characteristics, prenatal care, and long-term outcome were statistically similar between the two groups. However, the nonreactive group exhibited significantly more characteristics consistent with a prior asphyxial event: thick "old" meconium, "fixed" nonreactive baseline fetal heart rate, meconium-stained skin, and meconium aspiration syndrome. In contrast, in the reactive group a fetal heart rate pattern developed that was consistent with Hon's theory for intrapartum asphyxia and manifested by a prolonged tachycardia in association with persistent nonreactivity, diminished fetal heart rate variability, and fetal heart rate decelerations. CONCLUSIONS: Among fetuses later found to be neurologically impaired, a persistent nonreactive fetal heart rate tracing obtained from admission to delivery appears to be evidence of prior neurologic injury.

The fetal admission test and intrapartum fetal death.

Our objective was to describe the admission and subsequent intrapartum fetal heart rate (FHR) patterns in 21 singleton term pregnancies with an intrapartum fetal death. Through a retrospective chart review, 21 pregnancies with a term intrapartum fetal death were divided into 2 groups based on the fetal admission test (FAT): Group I-reactive (one or more FHR accelerations of 15 bpm x 15 sec in the first 30 min of monitoring); and Group II-nonreactive (NR [the absence of accelerations]). The FAT was compared with the subsequent intrapartum FHR pattern. Of the 21 deaths, the FAT was reactive in 7 fetuses (33%) or NR in 14 fetuses (67%). While the demographic features of these groups were statistically similar, Group II had higher rates of meconium (12 out of 14 (86%) vs. 2 out of 7 [29%] p = 0.017) and admission FHR decelerations (9 out of 14 (64%) vs. 1 out of 7 [14%] p = 0.06). In Group I, a sudden catastrophic event such as a uterine rupture produced a prolonged FHR deceleration in six fetuses (86%). One (14%) fetus died after a Hon pattern. In Group II, four patients had a stair steps to death pattern. Intrapartum fetal death can occur after a reactive or NR FAT. With a reactive FAT, a catastrophic event appears necessary to cause fetal death. The higher rates of meconium, FHR decelerations, and stair steps to death patterns in the NR group suggest the underlying basis for the fetal demise was related to preadmission fetal compromise.

Predictable ultrasonographic findings of early abortion.

Early fetal growth delay and early oligohydramnios have been suspected as signs of embryonal jeopardy. However, little information is available for the prediction of early abortion. Sonographic examination of 111 early pregnancies between the sixth and ninth gestational week with regular, 28 day menstrual cycles was performed to investigate predictable sonographic findings of early abortion. Sonographic measurements of the gestational sac (G-SAC), crown-rump length (CRL) and fetal heart rate (FHR) were performed using a linear array real time transducer with Doppler. All measurements of 17 early abortions were compared to those of 94 normal pregnancies to investigate the objective rules for the screening of early abortion. Most of the early aborted pregnancies were classified correctly by discriminant analysis with G-SAC and CRL (G-SAC = 0.5222 CRL + 14.6673 = 0.5 CRL + 15, sensitivity 76.5% specificity 96.8%). With the addition of FHR, 94.1% of early abortions could be predicted. In conclusion, sonographic findings of early intrauterine growth retardation, early oligohydromnios and bradycardia can be predictable signs for the poor prognosis of early pregnancies.

Nucleated red blood cells: a marker for fetal asphyxia?

OBJECTIVE: Our purpose was to determine whether a relationship exists between the presence of nucleated red blood cells, hypoxic ischemic encephalopathy, and long-term neonatal neurologic impairment. STUDY DESIGN: Nucleated red blood cell data from 46 singleton term neurologically impaired neonates were compared with cord blood nucleated red blood cells of 83 term nonasphyxiated newborns. The neurologically impaired neonates group was also separated as follows: nonreactive, nonreactive fetal heart rate from admission to delivery; tachycardia, reactive fetal heart rate on admission followed by tachycardia with decelerations; rupture, uterine rupture. The first and highest nucleated red blood cells value and the time to nucleated red blood cells disappearance were assessed. RESULTS: The neurologically impaired neonates group exhibited a significantly higher number of nucleated red blood cells per 100 white blood cells (34.5 +/- 68) than did the control group (3.4 +/- 3.0) (p < 0.00001). When the neurologically impaired neonates are separated as to the basis for the neurologic impairment, distinct nucleated red blood cell patterns were observed. Overall, the nonreactive group exhibited the highest mean nucleated red blood cell (51.4 +/- 87.5) count and the longest clearance times (236 +/- 166 hours). CONCLUSION: In this limited population, nucleated red blood cell data appear to aid in identifying the presence of fetal asphyxia. When asphyxia was present, distinct nucleated red blood cells patterns were identified that were in keeping with the observed basis for the fetal injury. In general, the closer the birth was to the asphyxial event, the lower was the number of nucleated red blood cells. Thus our data suggest that cord blood nucleated red blood cells could assist in the timing of fetal neurologic injury.

Fetal acoustic stimulation in the early intrapartum period as a predictor of subsequent fetal condition.

Fetal acoustic stimulation has recently received much attention in the literature. This study evaluates fetal acoustic stimulation in the early intrapartum period as a predictor of subsequent fetal condition. The study group consisted of 201 patients, approximately 60% of whom had complicated pregnancies. All were in the latent phase of labor with singleton, vertex-presenting fetuses. Gestational age ranged from 37 to 43 weeks. Fourteen of the 201 fetuses (7%) showed a nonreactive response to fetal acoustic stimulation and those fetuses were at significantly greater risk of initial and subsequent abnormal fetal heart rate patterns, meconium staining, and cesarean delivery because of fetal distress and Apgar scores less than 7 at both 1 and 5 minutes. Transient fetal heart rate decelerations after a reactive response occurred in 25% of patients; however, fetal outcome was not worse in this group. A reactive response to fetal acoustic stimulation was associated with high specificity and negative predictive values. Therefore we conclude that fetal acoustic stimulation in the early intraprtum period may discriminate the compromised from the noncompromised fetus.

Antepartum fetal surveillance in the patient with decreased fetal movement.

Whenever a patient has the subjective perception of decreased fetal movement, prompt evaluation in the form of antepartum fetal surveillance has been undertaken. The purpose of this report is to describe our experience with 489 pregnant women who came between Jan. 1 and Dec. 31, 1985 to our Antepartum Fetal Surveillance Clinic with this complaint alone or in association with another indication for fetal surveillance. Overall, 838 nonstress tests were performed, and the results were reactive, 93.2%; nonreactive, 6.8%; and fetal heart rate decelerations, 6.1%. Comparison of the first nonstress test results between those with decreased fetal movement alone or in combination with another diagnosis demonstrated a similar incidence of nonreactivity and fetal heart rate decelerations. In those patients whose indication was decreased fetal movement alone, there was a 3.7 times greater likelihood of diminished amniotic fluid volume. When the last test within 7 days of delivery was analyzed, the decreased fetal movement alone group had a lower incidence of cesarean delivery, cesarean delivery for fetal distress, and Apgar scores less than 7 than patients with an additional indication for testing. In summary, decreased fetal movement continues to be an acceptable indication for fetal surveillance. Based on our retrospective experience, the most reasonable approach appears to be a combination of nonstress test and amniotic fluid volume assessment. Unless the patient has additional indications for fetal surveillance, the patient with decreased fetal movement with a reactive nonstress test and a normal amniotic fluid volume does not appear to warrant additional testing.

Vaginal birth after cesarean delivery in the twin gestation.

The pregnancy outcomes of 56 women with a twin gestation and a prior cesarean birth were analyzed to determine whether a trial of labor was a reasonable consideration. Of these patients, 31 (55%) underwent an elective repeat cesarean delivery and 25 (45%) attempted vaginal delivery. Of those who attempted vaginal delivery, 18 (72%) were vaginally delivered of both infants. The dehiscence rate among women with twin pregnancies who attempted a trial of labor was 4% compared with 2% in women with singleton pregnancies. There were no significant differences in maternal or neonatal morbidity or mortality rates in trial of labor versus no trial of labor groups. We conclude in this limited population that a trial of labor in a twin gestation after a previous cesarean delivery appears to be a reasonable consideration. The usual safeguards for attempted vaginal delivery in the twin gestation should be followed.