Uterine flora at cesarean and its relationship to postpartum endometritis.

OBJECTIVE: To evaluate the relationship between the presence of microorganisms at the time of cesarean at different sites of the genital tract and the development of postpartum endometritus. METHODS: One-hundred thirty-three healthy women who delivered by cesarean were enrolled in this prospective study. Cultures were obtained during the surgery and on days 3-5 postoperatively. Gram staining of uterine cavity fluid was done on days 3-5. Gram stains were examined under a high-power microscope for the presence of polymorphonuclear leukocytes. RESULTS: Twenty patients (15.0%) met the criteria for postpartum endometritis. Forty-five patients (33.8%) had one or more positive cultures (n = 133) at the time of surgery, resulting in 93 positive cultures and 123 bacterial isolates. Forty-four patients had positive postoperative uterine cavity cultures at days 3-5 postpartum, resulting in 65 isolates. Of 44 patients with a positive postoperative culture, 26 (59.1%) also had Gram stain positive for polymorphonuclear leukocytes in the uterine cavity fluid, whereas only six of 89 patients (6.7%) with negative postoperative culture had a positive Gram stain (P < .05). The relative risk of having a positive culture on postoperative day 3-5 if the culture at surgery was positive at any site was 15.6 (95% confidence interval [CI] 5.9, 42.2), and it was 19.5 (95% CI 6.8, 57.8) if the culture was positive at the lower uterine segment. CONCLUSION: The presence of bacteria in the lower uterine segment at the time of the surgery predicts their presence in the uterine cavity during puerperium. The Gram stain of uterine cavity fluid on postcesarean days 3-5 is another quick tool that can expedite the diagnosis of postpartum endometritis.

Triplet and quadruplet pregnancies and management.

The rate of multiple pregnancies with more than 2 fetuses has significantly increased since the introduction of ovulation induction agents. From 1970 through 1978, there were 19 triplets and 6 quadruplets in the authors' department, incidences of 1:696 and 1:5370, respectively. Eighteen (72%) of the 25 multiple pregnancies followed treatment with ovulation induction agents and 7 were spontaneous. The diagnosis of more than 2 fetuses was made earlier in the induced than in the uninduced pregnancies. Management, initiated upon diagnosis, included bed rest, high-protein diet, beta-mimetic agents, progestins, dexamethasone late in the second trimester, and selective cerclage. The mean gestational age was 34 weeks in the triplets and 35 weeks in the quadruplets. Forty-four percent of the deliveries were by cesarean section and the remainder were by vaginal delivery. The mean weight of the neonates was 1807 g in the triplets and 1950 g in the quadruplets. The mean overall Apgar score was 8.16, and the perinatal mortality was 185 per 1000, corrected (more than 28 weeks) to 137 per 1000. The main neonatal complications resulted from prematurity, and maternal complications noted were postpartum hemorrhage necessitating hysterectomy in 2 patients. The preferable mode of delivery cannot be stated dogmatically. Fetal outcome was similar in vaginal and cesarean deliveries among the various gestational age groups.

A comparison of clinical and ultrasonic estimation of fetal weight.

OBJECTIVE: To compare the accuracy of routine ultrasonic and clinical birth weight estimation. METHODS: The study sample included 1717 women with singleton pregnancies, admitted in early labor with an ultrasonic estimated fetal weight (EFW) performed during the preceding week. Clinical EFW was obtained before rupture of the membranes by the attending senior resident, who was unaware of the ultrasonic EFW. Accuracy was determined by the percentage error, the absolute percentage error, and the proportion of estimates within 10% of the actual birth weight (birth weight +/- 10%). Statistical analysis was done by the paired t test, the comparison of correlated variances, the Wilcoxon sign test, and the chi2 test. Actual birth weight in the study sample averaged 3334+/-607 g (+/- standard deviation, [SD]) and ranged between 690 and 5320 g. RESULTS: The means of all error terms of the clinical EFW were significantly smaller than those of the ultrasonic EFW. However, the rates of estimates within 10% of birth weight were not significantly different (72 and 69%, respectively). In birth weights less than 2500 g, both methods overestimated the birth weight, but the mean errors of the ultrasonic EFW were significantly smaller than those of the clinical EFW. The ultrasonic EFW had significantly higher rates of birth weight +/- 10% than the clinical EFW (63 compared to 49%, respectively). In the 2500-4000 g birth weight, only the clinical EFW had no systematic error, whereas the ultrasonic EFW underestimated the birth weight. The mean errors of the clinical EFW were significantly smaller and the rate of birth weight +/- 10% significantly higher than those of the ultrasonic EFW. In the birth weight greater than 4000 g, both methods underestimated the birth weight, and the mean errors and the rate of estimates within 10% of birth weight were similar for both methods. CONCLUSION: Clinical estimation of birth weight in early labor is as accurate as routine ultrasonic estimation obtained in the preceding week. In the lower range of birth weight (less than 2500 g), ultrasonic estimation is more accurate; in the 2500-4000 g range, clinical estimation is more accurate. In the higher range of birth weight (greater than 4000 g), both methods have similar accuracy.

Investigation of the uterine cavity in recurrent aborters.

To prospectively compare the diagnostic ability of both HSG and diagnostic hysteroscopy in recurrent aborters, an HSG followed by a diagnostic hysteroscopy was performed in 106 patients during an investigation into recurrent abortions. The uterine cavity findings on HSG and at hysteroscopy were compared. Among the 60 abnormal HSG patients, intrauterine pathology was demonstrated in 37 (34.9%). Among the 46 normal HSG patients, a normal uterine cavity was found in 33 (31.3%). The sensitivity of the HSG in revealing intrauterine abnormalities was therefore 79% and its specificity 60%. In 23 pathologic HSG, no abnormalities were seen by hysteroscopy. In 13 cases, hysteroscopy demonstrated mild intrauterine findings overlooked by HSG. The false-positive rate was 38% and the false-negative rate was 28%. Hysterosalpingography showed a high false-positive rate, especially in the intrauterine adhesions group. In view of the low specificity and high false-positive and false-negative rates, we believe that hysteroscopic evaluation of the uterine cavity is superior to HSG in recurrent abortions.

Ripening of the unfavorable cervix with extraamniotic catheter balloon: clinical experience and review.

The use of an extraamniotic catheter balloon, inflated above the internal cervical os, has been advocated as a nonpharmacological, mechanical method of cervical ripening before induction of labor. Additional measures may include applying traction on the catheter, or the infusion of normal saline (1 ml/min) via the catheter's port into the extraamniotic space. The results of catheter balloon cervical ripening are reviewed from 13 published reports and a departmental series of 190 pregnancies with unfavorable cervix, encompassing nearly 1000 patients. A mean change in cervical score of at least 3 points, was noted in most studies after balloon expulsion or removal. The present series and other studies suggest that oxytocin use for induction and/or augmentation of labor is increased after balloon ripening, compared with its use in spontaneous labor or after cervical ripening by prostaglandins. In 11 studies, catheter balloon ripening was compared with cervical ripening by other mechanical, or pharmacological (i.e., oxytocin or prostaglandins) methods. Of these, eight were prospective and randomized-controlled and three were case-controlled studies. It is suggested that ripening efficacy by catheter balloon is similar, or better, than other methods; but there is no significant difference in the mode of delivery or perinatal outcome. This review also suggests that cervical ripening with extraamniotic catheter balloon has the advantages of simplicity, low cost, reversibility, and lack of systemic or serious side effects.

Sodium potassium adenosine triphosphatase activity in preterm and term infants and its possible role in sodium homeostasis during maturation.

AIM: To investigate sodium (NA(+)) potassium (K(+)) adenosine triphosphatase (ATPase) activity in newborn infants at different gestational ages, to elucidate the mechanism underlying poor renal sodium conservation in preterm infants. METHODS: Fifty three healthy newborn infants, gestational age 30-42 weeks, were studied. Umbilical cord red blood cell Na(+) K(+)ATPase activity, plasma renin activity, and plasma aldosterone activities were measured in all of them. Red blood cell Na(+) K(+)ATPase activity was re-examined in eight preterm infants, one and two weeks after birth. Total and ouabain sensitive ATPase activity was measured spectrophotometrically using a method that couples ATP hydrolysis with NADH oxidation. RESULTS: Red blood cell Na(+) K(+)ATPase activity was significantly lower (p<0.01) in preterm babies with a gestational age below 35 weeks, compared with those with aged 35 weeks and above: 2.3 (0.8) and 6.7 (1.3) nmol NADH/minute/mg protein, respectively. There was no correlation between gestational age, Na(+) K(+)ATPase, plasma renin activity and aldosterone values either in the preterm or term babies. Two weeks after birth, irrespective of gestational age, the enzyme activity of the preterm babies increased to values similar to those observed in the term neonates at birth. CONCLUSION: The differences in sodium homeostasis between term and preterm babies are modulated via changes in Na(+) K(+)ATPase activity.

Sterilization at the time of cesarean section: tubal ligation or hysterectomy?

The operative, postoperative and subsequent course of 86 patients who underwent cesarean hysterectomy (C.H.) during the years 1970-1979 are compared to an equal number of cesarean sections with tubal ligation (C.S.L.). Both groups are similar regarding age, gravidity, parity, number of living children and indications for abdominal delivery. Operative and postpartum complications of both groups were all minor, although significantly (p less than 0.05) more frequent in the C.S.L. group. More patients of the C.H. group required blood transfusions than the C.S.L. group (p less than 0.01). The mean period of hospitalization was similar in both groups. Two pregnancies occurred after tubal sterilization, a failure rate of 1:43. During the follow-up period, 49 surgical gynecological procedures were performed in the C.S.L. group compared to 1 in the C.H. group. Ten patients of the C.S.L. group subsequently underwent abdominal hysterectomy. Hysterectomy is the procedure of choice for permanent sterilization and prevention of many subsequent gynecological problems. Consideration must be given to coexisting gynecological conditions while considering sterilization at elective C.S. and C.H. should be offered to those patients.

PIP: The operative, postoperative, and subsequent course of 89 patients who underwent cesarean hysterectomy (CH) during the period 1970-79 are compared to an equal number of cesarean sections with tubal ligation (CSL). Both groups are similar with regard to age, parity, gravidity, number of living children, and indications for abdominal delivery. Operative and postpartum complications of both groups were all minor, although significantly (p0.05) more frequent in the CSL group. More patients in the CH group required blood transfusions than the CSL group (p0.01). The mean period of hospitalization was similar in both groups. 2 pregnancies occurred after tubal sterilization, a failure rate of 1:43. During the follow-up period, 49 surgical gynecological procedures were performed in the CSL group compared to 1 in the CH group. 10 patients in the CSL group subsequently underwent abdominal hysterectomy. Hysterectomy is the procedure of choice for permanent sterilization and prevention of many subsequent gynecological problems. Consideration must be given to coexisting gynecological conditions while considering sterilization at elective CSL and CH should be offered to those patients.

Current management of ruptured corpus luteum.

The objectives of the study are to assess current management of the rather frequent event of ruptured corpus luteum. Special emphasis is made on the value of ultrasonography, laparoscopy and culdocentesis in deciding appropriate treatment. A series of 70 patients with ruptured corpus luteum diagnosed and treated during a period of 6 years in one institution in Israel is reported. Eighteen patients with concurrent ruptured corpus luteum and ectopic pregnancy are included. Abdominal pain, the most prevalent presenting symptom, has no typical characteristics. The correlation between large amount of fluid as observed by ultrasound and the finding of > 250 ml of blood at laparotomy is very high. Culdocentesis was performed in only 21 patients. Surgical intervention (laparoscopy, laparotomy following laparoscopy or direct laparotomy) was carried out in 58 patients (83%). The remaining 12 cases were handled by observation only. Forty patients required laparotomy in whom 17 underwent wedge resection. We conclude that observation is sufficient treatment in hemodynamically stable patients, without severe abdominal pain and in the presence of a small amount of pelvic fluid demonstrated by ultrasound. When a large amount of fluid is observed and/or in the presence of severe abdominal pain laparoscopy should be performed on admission. Direct laparotomy is mandatory in case of circulatory collapse.

Maternal ECG recorded by internal monitoring closely mimicking fetal heart rate in a recent fetal death.

A case of intrapartum fetal death in which the maternal heart rate was recorded by internal fetal monitoring is presented. The electrical activity of the maternal heart was transmitted via the fetal body and the recording mimicked a "normal" fetal heart rate (FHR). The patient was referred because of sudden abdominal pain and bleeding; Doppler fetal heart tones were not heard. Because internal monitoring was synchronous with the maternal pulse, ultrasonography was performed and established the diagnosis of fetal demise. Awareness and usage of simple modalities are mandatory for proper diagnosis in such cases.

Clinical and sonographic fetal weight estimates in active labor with ruptured membranes.

OBJECTIVE: To determine and compare the accuracy of clinical and sonographic estimates of fetal weight (EFW) in active labor with ruptured membranes. STUDY DESIGN: Clinical and sonographic EFWs were obtained on 107 term patients in active labor, with cervical dilatation of 4 cm or more and ruptured membranes. Accuracy of birth weight was determined by calculating percentage error, absolute percentage error and ratio of estimates within 10% of actual birth weight for all stages of labor. Statistical analysis was by paired t test, Wilcoxon sign test, chi 2 test and Mann-Whitney U test; P < .05 was considered significant. RESULTS: Absolute percentage errors were lower by the sonographic method at all stages. Except for the second stage of labor, the rates of birth weight +/- 10% were higher with the sonographic method than with the clinical method (83.17% vs. 60.75% and 84.9% vs. 63.44%, respectively). Estimations performed in the first stage were more accurate than in the second stage with both methods (absolute error of 7.82 +/- 5.5 vs. 12.38 +/- 4.9 for clinical and 5.44 +/- 5.99 vs. 9.08 +/- 3.19 for sonographic). CONCLUSION: During active labor with ruptured membranes, sonographic EFWs are more accurate than clinical estimations. The accuracy of both methods is reduced during the second stage of labor.

Cervical cerclage for the incompetent cervical Os. Improving the fetal salvage rate.

The precerclage and postcerclage term delivery rate (TDR), premature delivery rate (PDR) and late abortion rate (LAR) were evaluated in 260 parturients undergoing elective cerclage at 12-16 weeks' gestation. The TDR increased from 0.49 to 0.78, the PDR dropped from 0.35 to 0.18, and the LAR dropped from 0.16 to 0.04. The rate of early and late complications was acceptable, and the fetal survival rate was significantly improved. The fetal salvage rate increased from 0.73 to 0.92, establishing a fetal salvage ratio of 1.26. Based on this experience, cerclage placement in cases of incompetent cervical os may prolong the duration of pregnancy and improve the outcome.

Breast-feeding and smoking habits among Israeli women.

BACKGROUND: Many women stop smoking before or during pregnancy, or while breast-feeding (nursing). OBJECTIVES: To assess the relation between breast-feeding and smoking habits. METHODS: A survey was conducted among 920 women attending family health clinics (group 1) and a maternity department (group 2) on their breast-feeding and smoking habits. RESULTS: A total of 156 women (16.95%) smoked during pregnancy. A significant correlation was found between breast-feeding and not smoking after delivery (P = 0.009 in group 1, P = 0.03 in group 2). A higher tendency to nurse was found among women with an uneventful pregnancy, who vaginally delivered a singleton at term weighing 2,500-4000 g, and who received guidance on breast-feeding. CONCLUSION: Professional guidance in favor of breast-feeding is crucial to increase the rate of nursing. Encouraging breast-feeding will probably decrease the rate of cigarette smoking.

The effect of sampling technique on measurement of fetal blood pH and gases--an in vitro system.

OBJECTIVE: Fetal scalp blood for intrapartum pH monitoring is usually collected aerobically in small volumes and may therefore be affected by the mode of sampling. The effect of specimen collection and handling on measured index values of fetal blood acid-base balance was evaluated in an in vitro simulated system. STUDY DESIGN: The system consisted of an air-tight syringe filled with either arterial or venous fresh cord blood and an attached needle with a blunted tip. The rate of blood drop formation at the tip was determined by a variable-speed infusion pump. Two techniques, simulating actual scalp blood sampling, were evaluated: (1) commonly used technique--aspiration of individual drops into a glass tube, transfer into a syringe, and measurement and (2) direct technique--collection as a continuous column of blood into a capillary and subsequent measurement. RESULTS: Control acid-base values obtained before and immediately after completion of each test were not significantly different. Significant changes from control values were noted when sampling by the commonly used technique: mean arterial pH (7.21 to 7.26 and 7.24) and PO2 (19 to 25 and 23 mm Hg) increased, whereas PCO2 decreased (56 to 44 and 47 mm Hg) at slow and fast drop rates, respectively. Changes in venous blood samples were of similar direction and magnitude. Absolute changes from control during sampling by the commonly used technique averaged 21% +/- 2% and 15% +/- 1% (+/- SEM) for slow and fast drop rates, respectively (p < 0.01). On the other hand, sampling by the direct technique did not have a significant effect on measured acid-base values at slow and fast drop rates: absolute changes from control averaged 4.5% +/- 0.4% and 4.7% +/- 1.3% (+/- SEM), respectively. CONCLUSIONS: The mode of fetal scalp blood sampling and handling affects measured acid-base index values. Such changes reflect aeration of small blood volumes and may result in falsely elevated capillary scalp pH. This effect may be prominent when blood drops are slow forming or difficult to obtain.

Chromosome 20 long arm deletion in an elderly malformed man.

A 46,XY/46,XY,del(20)(q13-->q13.33) mosaicism was identified in a 68 year old man who had mild mental retardation and severe malformation of the limbs. The clinical findings of the patient are compared to those of the very few cases of 20q deletion published to date.

Metabolic effects of intravenous ritodrine infusion in pregnancy.

The effects of intravenous administration of Ritodrine on blood glucose, insulin, electrolytes, plasma and red cell potassium and venous pH were investigated. A highly significant increase in blood glucose and insulin occured. A highly significant negative correlation between serum and red cell potassium concentration was registered (r = -0.96268). No signficant changes during Ritodrine infusion were recorded in serum levels of sodium, chloride, calcium, phosphorus and magnesium. The pH did not seem to be influenced by intravenous Ritodrine administration. No cardiac arrhythmias or electrocardiographic deteriorations occurred. While intravenous Ritodrine administration seems to be safe in normal pregnancies, a risk may be present in diabetic and digitalized patients, and pregnant women being treated by diuretics.

Perinatal outcome following physicians' strike of 1983.

Organized public medical services were profoundly disturbed during the 4 months of the physicians' strike in 1983. An unknown proportion of patients were referred to private services, but only a minority of them attended the alternative centers. The findings during the strike and the following 6 months were compared with those of the year 1982. The incidence of high-risk cases and of multiple and premature deliveries were unchanged. There was a significant rise (P less than 0.01) in the rate of cesarean sections during the strike, 10.8%, compared with 7.8% in 1982. Also, a significant reduction in instrumental deliveries and labor inductions was observed during the strike and for 4 months afterwards. There was no change in the perinatal mortality (total and corrected) or in Apgar scores. This indicates that good perinatal results were achieved despite drastic disturbances in organized perinatal care.

Elective caesarean hysterectomy. Indications and outcome: a 17-year experience of 140 cases.

In an earlier report of 86 elective Caesarean hysterectomies (1970-1979) we showed that the operation was associated with few complications but a high blood transfusion rate. In this paper we report an extended series comprised of 140 cases (1970-1986), and compare results of the 1970's series with that of the 1980's. The operative and postoperative complications were minimal during the entire period. The blood transfusion rate which was 64% in 86 cases of the 1970-1979 period decreased to 17% in 54 cases of the 1980-1986. Our results show that Caesarean hysterectomy is a safe procedure with some long-term advantages; therefore this option should be discussed with women who ask for tubal sterilization at the time of Caesarean section.