Increase in fetal breech presentation in female carriers of Duchenne muscular dystrophy.

Female carriers of Duchenne muscular dystrophy (DMD) may demonstrate elevated serum creatine kinase (CK) and reduction of muscle dystrophin in all muscle types. We hypothesized that decreased dystrophin in uterine or pelvic girdle musculature might affect the obstetrical performance of females heterozygous for a dystrophin mutation. We reviewed the outcome of 34 deliveries resulting in 35 children from 13 women who were mothers of males attending a muscular dystrophy clinic. Obstetrical performance was examined retrospectively by chart review and patient contact. Of 35 children, 6 (17%) were delivered in the breech position, which is a fivefold increase above the national standards for term pregnancies. Of the six infants with breech presentation, two were males affected with DMD, one was a female heterozygote, one was a male who died perinatally, and the carrier status of the other two females is unknown. Most DMD affected males (12/14) were delivered in the vertex position. Thus, it is likely that maternal, rather than fetal, muscle weakness was the significant factor in determination of fetal position at term. We speculate that subtle changes in uterine or pelvic girdle muscle tone may contribute to a higher rate of fetal breech position in carriers of the DMD gene.

Fetomaternal bleeding as a cause of recurrent fetal morbidity and mortality.

A woman had fetomaternal bleeding of unknown cause during at least three of five pregnancies. Each event was associated with significant fetal morbidity or mortality. Although fetomaternal bleeding has been reported as a cause of unexplained fetal death, its occurrence in subsequent pregnancies has not been described previously.

Elevated maternal serum alpha-fetoprotein and hydrops fetalis in association with fetal parvovirus B-19 infection.

A woman was referred at 19 weeks' gestation for genetic counseling regarding elevated maternal serum alpha-fetoprotein levels. Sonography identified fetal hydrops and fetal death. Fetal tissue specimens showed evidence of human parvovirus infection by DNA probe analysis.

Use of breast stimulation for antepartum stress testing.

Bilateral breast stimulation was used to evoke a spontaneous contraction stress test. The success rate and incidence of abnormal uterine activity using the stimulus was compared with patients tested by the authors' standard oxytocin stress test protocol. Bilateral breast stimulation was initially used for 346 tests between 32 and 43 weeks of gestational age. A satisfactory test, or three contractions within ten minutes, was obtained in 239 (69%) patients. The testing time was reduced with successful breast stimulation. The incidence of abnormal uterine activity after breast stimulation was not statistically different from that observed with oxytocin administration alone. However, when oxytocin was administered after breast stimulation, there was a significant increase in the incidence of prolonged contractions.

Elevated maternal serum alpha-fetoprotein: association with placental sonolucencies, fetomaternal hemorrhage, vaginal bleeding, and pregnancy outcome in the absence of fetal anomalies.

Elevated maternal serum alpha-fetoprotein (MSAFP) levels have been associated with an increased incidence of both placental sonolucencies and pregnancy complications. We designed a prospective study to test the hypothesis that the presence of these sonolucencies or a positive maternal Kleihauer-Betke stain would be associated with an elevated risk of obstetric complications. We enrolled 95 women with singleton pregnancies, elevated MSAFP, and no evidence of fetal anomalies on second-trimester ultrasound evaluation. Placental sonolucencies were documented at the time of ultrasound examination, and a maternal Kleihauer-Betke stain for fetal cells was obtained on the same day. Complications of pregnancy included fetal growth retardation, preterm delivery, late vaginal bleeding (at or after the 20th week of gestation), and fetal death. Women with elevated MSAFP had an increased incidence of placental sonolucencies, positive maternal Kleihauer-Betke stains, first-trimester vaginal bleeding, late vaginal bleeding, preterm delivery, fetal growth retardation, and fetal death compared with controls. Thirty-nine of 95 women with elevated MSAFP (41.1%) had at least one complication. In women with elevated levels, neither the presence of placental sonolucencies nor a positive Kleihauer-Betke stain correlated with first-trimester vaginal bleeding, the MSAFP level, or an increased risk of pregnancy complications. First-trimester vaginal bleeding was associated with an increased risk of preterm delivery in subjects with elevated MSAFP.

Successful pregnancy outcome in association with lipoatrophic diabetes mellitus.

Lipoatrophic diabetes mellitus is a rare syndrome characterized by lipoatrophy and insulin-resistant diabetes mellitus. Partial lipodystrophy without clinical diabetes mellitus has been associated with intrauterine growth retardation and fetal death. We report successful pregnancy outcomes in two women with lipoatrophic diabetes mellitus.

Hysterotomy to effect vaginal delivery with mentum anterior head entrapment.

BACKGROUND: Entrapment of the aftercoming head after mentum anterior rotation is a life-threatening complication of vaginal breech delivery. Few options exist when rotation and flexion from this position cannot be performed successfully either transabdominally or with vaginal maneuvers. CASE: A term primigravida presented with a singleton breech in advanced labor. The fetal torso and arms delivered vaginally, but the aftercoming head became extended and was entrapped in a mentum anterior position. The fetal head could not be rotated and flexed, either vaginally or transabdominally with suprapubic pressure. Laparotomy and hysterotomy were performed, and vaginal delivery of a live fetus was accomplished after rotation and flexion of the fetal head through this incision. CONCLUSION: Hysterotomy is a safe and effective maneuver for delivery of the entrapped fetal head with mentum anterior rotation after standard procedures have failed.

Adenosine diphosphate-induced platelet activation inhibited by magnesium in a dose-dependent manner.

OBJECTIVE: To examine the hypothesis that magnesium inhibits platelet activation at concentrations equivalent to therapeutic levels. METHODS: Fifteen subjects were enrolled: five healthy, female donors with regular, spontaneous menstrual cycles; five women with uncomplicated third-trimester pregnancies; and five preeclamptic subjects before magnesium therapy. Anticoagulated whole blood was added to tubes containing 0.5 micromol/L adenosine diphosphate (to activate platelets), HP1-1D (activation-independent platelet antibody), CD62 antibody and CD63 antibody (activation-dependent platelet antibodies), and magnesium sulfate in increasing concentrations (2-100 mg/dL). The percentage of activated platelets (CD62 or CD63 positive) was determined using three-color flow cytometric analysis. Data were analyzed using the Student t test, repeated measures analysis of variance, two-way analysis of variance, and Student-Newman-Keuls for pairwise comparison in appropriate cases. P < .05 was considered significant. RESULTS: Adenosine diphosphate-induced platelet activation was inhibited with increasing magnesium concentration in all subjects (P < .001). Significant inhibition of CD62 and CD63 expression first occurred at a magnesium concentration of 4 mg/dL in the normal pregnant group (P < .05), at 6 mg/dL in the preeclamptic group (P < .05), and at 8 mg/dL in the nonpregnant group (P < .05). CONCLUSION: Magnesium inhibits adenosine diphosphate-induced platelet activation in a dose-dependent manner. This effect initially attains statistical significance at concentrations equivalent to therapeutic levels.

Pruritic urticarial papules and plaques of pregnancy and its relationship to maternal-fetal weight gain and twin pregnancy.

Thirty women who were seen at our institution between 1984 and 1988 for pruritic urticarial papules and plaques of pregnancy (PUPPP) were retrospectively evaluated and interviewed. We found a significantly increased maternal weight gain and newborn birth weight in patients with PUPPP, compared with age and parity-matched controls. The average weight gain during pregnancy was 18.1 +/- 0.9 (SEM) kg for the patients with PUPPP (excluding twin gestations) and 14.6 +/- 1.0 kg for the controls. The mean newborn birth weight was 3.6 +/- 0.09 kg for the PUPPP group and 3.3 +/- 0.08 kg for the control group. There were three twin pregnancies (10%), compared with the twin gestation rate at our institution of 1.6%. Therefore, based on our findings of an increased maternal weight gain and neonatal birth weight, an increased twin rate, and an abdominal eruption that occurs in primigravidas in their third trimester of pregnancy, we suggest that abdominal distention or a reaction to it may play a role in the development of PUPPP.

A vaginal delivery protocol for the term breech infant utilizing ball pelvimetry.

Ball pelvimetry has been utilized at the Medical Center Hospital of Vermont to evaluate infants with breech presentation for vaginal delivery. That technique provided measurements of both the fetal head volume and maternal pelvic capacity so that relative fetomaternal relationships could be established. Between January 1979 and December 1981, 107 patients in spontaneous labor with term pregnancy were evaluated with the protocol. Inadequate pelvimetry and hyperextension of the fetal head occurred in 21 patients (20%). Of the 86 patients who were allowed to labor, 51 (59%) had a vaginal delivery. The total cesarean section rate was 52%. Vaginal delivery in our highly selected patient population did not increase neonatal morbidity. There were no neonatal deaths.

Hepatitis B surface antigen screening in a nonindigent population.

The recommendation for universal screening of all pregnant women for hepatitis B surface antigen (HBsAg) is based on data from publicly funded hospitals. We retrospectively reviewed screening results of 2,696 mothers who delivered between May 1989 and April 1990. Our population was 85% privately funded. Screening for HBsAg was positive in 0.07%, negative in 80.4% and not done in 19.6%. All positive screens would have been identified by screening only patients with recognized risk factors. We conclude that the sensitivity of identifiable risk factors to detect HBsAg carriers may be high in some populations. We speculate that universal screening in these populations is not cost efficient.

Elevated maternal serum alpha-fetoprotein levels and maternal risk factors. Their association with pregnancy complications.

Maternal serum alpha-fetoprotein (MS-AFP) screening programs identify a population of pregnant women with elevated MS-AFP values. When the levels are unassociated with a fetal anomaly, those women have a high incidence of pregnancy complications. Such patients were compared to a population with normal MS-AFP values to determine the incidence of historical risk factors and to ascertain if their presence affected the rate of pregnancy complications. A total of 358 patients were followed prospectively, 23 with elevated MS-AFP levels and 335 with normal levels (control group). Historical risk factors were more frequent in the patients with elevated MS-AFP levels. There was a fourfold increase in the rate of pregnancy complications when a patient had both risk factors and elevated MS-AFP levels as compared with elevated MS-AFP levels alone. In the control group, patients with known risk factors experienced twice the incidence of pregnancy complications as did patients with no risk factors. Using multiple logistic regression analysis, elevated MS-AFP levels were shown to be an independent variable in the risk assessment. The results of this study have wide application in the counseling and follow-up of patients identified by MS-AFP screening programs.

Neonatal morphometrics after endurance exercise during pregnancy.

This study was designed to test the hypothesis that continuation of a regular running and/or aerobics program during late pregnancy at or above 50% of preconceptional levels limits fetal growth. Accordingly, detailed neonatal morphometric data were gathered in the offspring of two groups: 77 well-conditioned recreational runners and aerobic dancers who were delivered at term after continuing their exercise regimen at or above 50% of the preconceptional level throughout pregnancy and 55 matched controls. Daily exercise performance was quantitated before conception and throughout pregnancy. Significant reductions in birth weight (-310 gm), birth weight percentile (-20), ponderal index (-0.24), its percentile (-30), and the fetoplacental weight ratio (-0.7) were seen in the offspring of the exercise group whereas crown-heel length (51.4 cm) and head circumference (35.0) were similar in the two groups. Reductions in two-site skin-fold thickness (-1.5 mm), skin-fold percentile (-30), calculated percent body fat (-5.0%), and fat mass (-220 gm) in the offspring of the exercise group confirmed the asymmetric pattern of growth restriction and indicated that approximately 70% of the difference in birth weight could be explained by the difference in neonatal fat mass. In runners, the relative level of exercise performance in the last 5 months of pregnancy explained 40% of the variability in birth weight over an 1100 gm birth weight range. We conclude that continuation of a regular aerobic or running program at or above a minimal training level during late pregnancy results in an asymmetric pattern of growth restriction that primarily impacts on neonatal fat mass.

The changing glycemic response to exercise during pregnancy.

This study was designed to test the hypothesis that pregnancy reverses the nonpregnant hyperglycemic response to sustained exercise. Serial data were obtained from 75 exercising women. Before pregnancy, exercise produced an intensity-dependent increase in blood glucose that averaged 1.5 mmol/L at high intensities. By the eighth week this response was blunted and blood glucose increased only when exercise intensity exceeded 80% of maximum. At 15 weeks this progressed and was not associated with a change in either the insulin or catecholamine response. By the twenty-third week exercise produced a decrease in blood glucose that was no longer related to exercise intensity. We conclude that the hypothesis is correct and speculate that the early change in the response is related to decreased hepatic glucose release coupled with increased glucose oxidation. In late pregnancy this is probably accentuated by fetoplacental demands.

Management of preterm premature rupture of membranes: lack of a national consensus.

A questionnaire concerning the management of women with preterm premature rupture of membranes was sent to the members of the Society of Perinatal Obstetricians. Expectant management was recommended by 97% of the respondents. There was no consensus about the role and frequency of steroids, blood work, ultrasound examination, and fetal monitoring in the follow-up of these patients.

Cardiovascular changes in early phase of pregnancy.

To assess the magnitude and timing of cardiovascular changes in pregnancy, eight subjects were serially studied before conception and at 8, 16, and 24 weeks' gestation. With the use of M-mode echocardiography, cardiac output, ejection fraction, stroke volume, and end-diastolic volume were calculated from left ventricular dimensions with subjects in the left lateral position. Systemic vascular resistance was calculated with the use of cardiac output and simultaneously obtained measurements of arterial pressure. Cardiac output increased 1 L/min at 8 weeks' gestation, which represented greater than 50% of the total change seen. Cardiac output increased primarily because of stroke volume rather than heart rate. By 8 weeks' gestation, systemic vascular resistance had fallen to 70% of its preconceptional value. Thus when subjects are studied before conception and during the early phase of pregnancy, the majority of the pregnancy-induced changes in these parameters occur during the embryonic period.

When do cardiovascular parameters return to their preconception values?

To determine if the postpartum period is reflective of a woman's cardiovascular status before pregnancy, we performed serial studies of 13 women before conception and at 6 and 12 weeks post partum. All pregnancies were singleton without hypertensive complications. Cardiac output, stroke volume, and end-diastolic volume were calculated with M-mode echocardiography from the left ventricular dimensions with subjects in the left lateral position. Systemic vascular resistance was calculated from cardiac output and simultaneous measurements of blood pressure. Stroke volume and end-diastolic volume remained consistently elevated over preconception values at 6 and 12 weeks. Systemic vascular resistance remained decreased, compared with baseline, at 12 weeks. Thus cardiovascular parameters had not returned to the preconception baseline, and previous studies that have used this time period for comparison have underestimated the contribution of stroke volume to the total change in cardiac output during pregnancy.

Cesarean deliveries at a university hospital: analysis of rates and indications.

The objective of this paper is to evaluate the influence of patient risk status on the incidence of and indications for cesarean delivery. All live births > or = 23 weeks at the University of Vermont in 1995 (n = 2395) were retrospectively analyzed for delivery route, indication for cesarean, gestational age, parity, and practice group (to reflect risk status). The total cesarean rate was 14.4% (344 of 2395), and the primary rate was 11.4% (244 of 2144). Abnormal presentation was the most common indication (25.6%, 88 of 344). The "corrected" cesarean rate (maternal-fetal medicine and transported patients excluded) was 12.4% (273 of 2194), and the "corrected" primary rate was 9.6% (190 of 1975). Furthermore, when all deliveries were analyzed, regardless of risk status but limited to gestational age > or = 36 weeks, the rates did not change (12.6%, 280 of 2214; primary 9.2%, 183 of 1994). Arrest of dilation was the most common indication in both "corrected" subgroups (23.4 and 24.6%, respectively). Cesarean rates at tertiary care hospitals should be compared with rates at community hospitals only after correcting for dissimilar patient groups or gestational age.

Labor induction with a prenatal diagnosis of fetal macrosomia.

Since our institution has a low cesarean rate (14%), it was our hypothesis that the rate of cesarean delivery in patients who underwent induction for macrosomia would be similar to the cesarean rate in patients with similar birth weights who entered labor spontaneously. A retrospective analysis of cases seen from December 1993 to July 1995 revealed 53 nondiabetic patients who underwent induction for fetal macrosomia. These study patients were matched to the next nondiabetic patient delivering a child of equal or greater birth weight who entered labor spontaneously. Maternal demographics, labor characteristics, and neonatal outcome data were reviewed. There were no differences between the induction and spontaneous labor groups in maternal age, gestational age, rate of nulliparity, incidence of shoulder dystocia, Apgar scores, or vaginal birth after prior cesarean delivery. The cesarean delivery rate was higher in the induction group when compared to the spontaneous labor group (36% vs. 17%, P < 0.05) despite a lower birth weight in the induction group (4,102 +/- 374 g vs. 349 g, P < 0.05). Regional analgesia was administered more frequently in the induction group (38% vs. 53%, P < 0.05). An increased risk of cesarean delivery was observed in subjects undergoing induction for the indication of fetal macrosomia. These data support a plan of expectant management when fetal macrosomia is suspected.

Uterine artery Doppler velocimetry in the detection of adverse obstetric outcomes in women with unexplained elevated maternal serum alpha-fetoprotein levels.

OBJECTIVE: We hypothesized that in pregnancies complicated by unexplained elevations of maternal serum alpha-fetoprotein, second-trimester uterine artery Doppler findings would detect adverse obstetric outcomes. STUDY DESIGN: One hundred three subjects with unexplained elevations of maternal serum alpha-fetoprotein had uterine artery Doppler velocimetry studies performed at the time of targeted ultrasonographic examination (17 to 22 weeks). A resistance index > 95th percentile or the presence of a uterine notch was considered abnormal. Adverse outcomes included preeclampsia, preterm birth, low birth weight, intrauterine growth restriction, abruptio placentae, and fetal death. Statistical analysis was performed by Student t test, chi 2 analysis, and stepwise logistic regression analysis. RESULTS: An elevated uterine resistance index was associated with an increased relative risk for both preeclampsia (relative risk 41.82, 95% confidence interval 5.36 to 326.13) and low birth weight (relative risk 4.65, 95% confidence interval 1.90 to 11.39). A uterine artery notch was associated with an increased risk of preeclampsia (relative risk 52.22, 95% confidence interval 6.82 to 399.70), preterm birth (relative risk 3.21, 95% confidence interval 1.32 to 7.81), and low birth weight (relative risk 4.18, 95% confidence interval 1.64 to 10.66). When the presence of a uterine notch, vaginal bleeding, and level of maternal serum AFP were analyzed by stepwise logistic regression, the presence of a notch was found to be the only significant factor (odds ratio 6.95, 95% confidence interval 1.24 to 39.10) for the development of an adverse outcome. CONCLUSIONS: Abnormal uterine artery Doppler findings are associated with an increased frequency of adverse obstetric outcomes in women with unexplained elevated maternal serum AFP levels. Abnormal Doppler findings demonstrated high sensitivity for the development of preeclampsia but were less sensitive in predicting other outcomes. The presence of a uterine artery notch is a better independent predictor of adverse outcome than are early vaginal bleeding or maternal serum AFP level.