Meconium aspiration syndrome without evidence of fetal distress in early labor before elective cesarean delivery.

Seventy-seven cases of meconium aspiration were documented among 14,527 deliveries. Four cases occurred in early labor and with normal fetal heart tracings. Three cases followed repeat cesarean sections at term, and one followed an elective cesarean section for a primigravid breech presentation. Aggressive airway management was used in every case, and included intrapartum pharyngeal suctioning with a DeLee catheter and intubation of the trachea with suctioning under direct vision. These cases suggest that meconium aspiration may occur before the onset of active labor and without evidence of fetal distress.

What is the significance of the human chorionic gonadotropin value in ectopic pregnancy?

Surgical and pathology data were analyzed with the quantitative serum hCG values from 131 patients with tubal pregnancies. The hCG value correlated with both the size and contents of the eccyesis. Patients with ruptured tubal pregnancies had significantly greater serum hCG levels than did those with intact tubal gestations. Isthmic tubal pregnancies were associated with more frequent rupture and larger amounts of hemoperitoneum than were pregnancies in the ampullary segment of the tube. Tubal rupture with hCG values below 100 mIU/mL occurred in two isthmic pregnancies but in no ampullary pregnancies. With serum hCG levels below 300 mIU/mL, significant hemorrhage did not occur unless the tube was ruptured. Half of the patients had hCG levels sufficient to use a vaginal sonographic hCG discriminatory zone to assist in the diagnosis. A maximum of 15% of tubal pregnancies may be diagnosed by ultrasonographic detection of adnexal cardiac activity. A serum hCG assay sensitive to 10 mIU/mL will detect nearly all tubal pregnancies. The hCG level frequently has diagnostic value when used in conjunction with vaginal sonography. At hCG levels of 100 mIU/mL or less, tubal rupture is very unlikely for ampullary, but not for isthmic, tubal pregnancies.

Massive fetomaternal hemorrhage preceded by decreased fetal movement and a nonreactive fetal heart rate pattern.

BACKGROUND: Massive fetomaternal hemorrhage occurs in one in 1000 deliveries and has been associated with decreased fetal movements and a sinusoidal fetal heart rate (FHR) pattern. CASES: Three women presented with decreased fetal movements, nonreactive FHR patterns, and positive Kleihauer-Betke tests. All three were at a viable gestational age and were immediately delivered by cesarean. The three infants were severely anemic, with hemoglobin levels of 6.5, 5.3, and 5.1 g/dL, respectively. CONCLUSION: A patient who presents with decreased fetal movement associated with a nonreactive FHR pattern and a positive Kleihauer-Betke test of more than 140 mL should be considered for immediate delivery if the gestational age is consistent with neonatal viability.

A rapid solid-phase radioimmunoassay specific for human chorionic gonadotropin in gestational trophoblastic disease.

A rapid solid-phase radioimmunoassay (RIA) specific for human chorionic gonadotropin (hCG) has been used for the measurement of serum hCG activity in patients with molar pregnancy and gestational trophoblastic disease (GTD). Serum hCG regression as determined by the specific RIA method after evacuation of uncomplicated molar pregnancy was noted to occur over a longer duration of time than previously reported from this Center using a nonspecific RIA system which measures human luteinizing hormone (hLH) and hCG simultaneously. Therapy for proliferative trophoblastic disease was withheld after evacuation of molar pregnancy while the serum hCG level regressed normally, but was instituted when the serum hCG level rose or plateaued for more than two consecutive weeks. Serum hCG levels in patients requiring chemotherapy for GTD were also more accurately monitored with the specific RIA method than with the nonspecific technic. Therapy was based solely on the hCG titer rather than the subsidence of toxicity, as has been our practice in the past. As a result, the duration of hospitalization, total dose of drug required for remission, and toxic side effects were substantially reduced without sacrificing the effectiveness of chemotherapy.

Direct laparoscopic entry using a sharp and dull trocar technique.

For direct laparoscopic entry using a sharp and dull trocar technique, the sharp trocar is inserted with a twisting motion under constant pressure, then replaced with a dull trocar when a slight loss of resistance is felt. A slow, gradual entry into the peritoneal cavity is accomplished by twisting the dull trocar under constant pressure. Previous major abdominal or pelvic surgery is not a contraindication to this procedure, and use of these trocars, which can be resterilized for every use, may reduce surgical costs by decreasing the need for disposable trocars. This technique has been used in 1655 patients without complication or failure.

Persistent ectopic pregnancy.

From 1982-1986, 625 tubal ectopic pregnancies were treated at the University of Hawaii School of Medicine Affiliated Hospitals. The percentage of cases in which the involved tube was preserved increased from 7% in 1982 to 26% in 1986. The presence of persistent trophoblastic tissue was diagnosed by elevated serum levels of the beta subunit of human chorionic gonadotropin (beta-hCG) after conservative surgery in four patients. Three of the four patients developed intra-abdominal hemorrhage and required laparotomy. One patient remained asymptomatic despite elevated beta-hCG levels, which disappeared 60 days after surgery. Evaluation of histologic slides demonstrated persistent intraluminal trophoblastic tissue without invasion in two patients, and extraluminal invasion into the tubal wall in one patient. The use of postoperative serial beta-hCG titers might facilitate recognition of this complication in time to prevent further tubal damage and hemorrhage.

Long-term tocolysis with combined intravenous terbutaline and magnesium sulfate: a 10-year study of 1000 patients.

OBJECTIVE: To determine whether long-term intravenous (IV) tocolysis using combined terbutaline and magnesium sulfate is safe and effective. METHODS: One thousand consecutive women in preterm labor were treated with combination IV tocolytic therapy. Terbutaline was initiated with an infusion rate of 1.75 micrograms/minute and increased to a maximum of 80 micrograms/minute. Magnesium sulfate was infused at 2 g/hour without any bolus and increased to maintain a serum level of 6.5-7.5 mg/dL. Tocolysis was continued until fetal lung maturity was achieved or delivery occurred. RESULTS: Combination tocolytic therapy prolonged pregnancy by a mean (+/- standard deviation) of 61 +/- 23.6 days in 751 women with intact membranes and by 20.5 +/- 17.4 days in 249 with ruptured membranes. The longest durations of continuous IV tocolysis were 123 days in a patient with intact membranes and 77 days in one with ruptured membranes. The most common side effects were nausea and vomiting, followed by chest tightness and shortness of breath. CONCLUSION: Long-term IV tocolysis appeared to be safe and to have acceptable side effects, allowing patients to receive combined terbutaline and magnesium sulfate until delivery.

Evaluation of the cost-effectiveness of home monitoring of uterine contractions.

In 1988, the major health insurance carrier in the state of Hawaii initiated a prospective study to determine the cost-effectiveness of ambulatory uterine activity monitoring. At the end of the study, 79 patients had completed 3189 days on the monitor. Thirty-six patients (45.6%) did not have preterm labor; the daily monitoring resulted in an average loss to the insurance carrier of $3300 per patient, or $118,800. Forty-three patients (54.4%) experienced preterm labor and were found to have benefited from the monitoring system. Earlier detection of preterm labor and better management of oral tocolysis in this group resulted in earlier initiation of maternal tocolytic therapy, which ultimately decreased the preterm birth rate and hospitalization days in the neonatal intensive care unit. Cost analysis of this group demonstrated an average savings of $24,000 per patient, or an overall savings of $1,032,000. The total group of high-risk patients (79) resulted in a net savings to the insurance carrier of $913,200, or $11,500 per patient, suggesting that use of the ambulatory uterine activity monitoring system significantly reduced the cost associated with preterm labor and early delivery.

Diagnosis of a supernumerary ovary with human chorionic gonadotropin.

The preoperative diagnosis of ectopic ovarian tissue has been reported only once in the literature. In the present case, differential ovarian and adrenal testing was used to diagnose and aberrant ovarian source of persistently elevated plasma estrogen in a patient who had undergone bilateral oophorectomy and adrenalectomy for metastatic breast carcinoma. The ovarian source was diagnosed by stimulation with human chorionic gonadotropin (hCG), and treatment with human menopausal gonadotropin (hMG) prior to surgery was used to facilitate its location at laparotomy.

Rapid hCG-specific radioimmunoassay for menstrual aspiration.

Fifty-one women with missed periods ranging from 5 to 14 days who suspected a pregnancy underwent an aspiration curettage with a flexible soft-tipped cannula attached to a Karman-type syringe. Sera from these women were measured for human chorionic gonadotropin (hCG) by a rapid 2-hour solid phase radioimmunoassay using an antibody with a specificity for the beta subunit of hCG. The sensitivity and specificity of this assay insured detection of bCG with 100% accuracy at the time of the missed period. Of the 51 women, 33 (64.7%) were found to have hCG in their serum, and 29 (56.8%) had histologic evidence diagnostic of pregnancy.

PIP: Aspiration curettage was performed on 51 women who suspected pregnancy and had missed periods from 5 to 14 days. Sera obtained from the patients were analyzed for human chorionic gonadotropin (HCG) by a rapid, 2-hour solid-phase radioimmunoassay using an antibody with a specificity for the beta subunit of HCG. 33 of the women (64.7%) were found to have serum values ranging from 8 mIU/m1 to 3997 mIU/m1. 29 of the women (56.8%) showed histologic evidence of pregnancy. Generally, more women had HCG in their serum as the number of days following the missed period increased. The test can detect HCG with 100% accuracy at the time of the missed period.

Microscopic appearance of the human fallopian tube following a reanastomosis procedure.

Microscopic evaluation of a human fallopian tube following end-to-end anastomosis over a polyethylene stent was performed 10 days after the initial surgical procedure. The stent was removed on the 3rd postoperative day. Examination of the excised tube revealed a patent lumen without any evidence of mucosal compromise. The submucosa adjacent to the anastomotic site revealed a mild polymorphonuclear leukocytic infiltration, although a marked inflammatory response was observed around the 5-0 chromic sutures used in the reanastomosis. This case and recent animal studies suggest that early removal of the stent does not appear to jeopardize the patency of the tube and may be preferable to removal after 3 to 4 months.

The role of laparoscopy in the management of the infertility patient.

Laparoscopy has traditionally been used only as a diagnostic step in the evaluation of the infertility patient. With the advent of more sophisticated instrumentation including the use of laser surgery, laparoscopic procedures can now be performed instead of conventional laparotomy. Lysis of pelvic adhesions as well as treatment of endometrial implants and endometriomas are now routine laparoscopic procedures with improvement in pregnancy rates comparable to microsurgery. New advances in instrumentation will increase the pregnancy rate following laparoscopic tubal surgery as well as laparoscopic assisted in Vitro Fertilization, and will also increase the safety of this procedure.

Incidence of Chlamydia trachomatis infection related to selected signs and symptoms of lower genital tract infections in women.

Chlamydia trachomatis infections of the female reproductive tract is associated with a spectrum of clinical syndromes from simple colonization to mucopurulent cervicitis, urethritis, proctitis, and pelvic inflammatory disease. Its natural history and tendency for progression is unclear. It is said these infections are the most common of all sexually transmitted diseases.

Transient blindness in a preeclamptic patient secondary to cerebral edema.

Blindness associated with a cerebral lesion has been described as cortical blindness. This is the first reported case in which computerized tomography has documented cerebral edema to be the cause of cortical blindness in a preeclamptic patient.

Vaginal birth after cesarean section in Hawaii. Experience at Kapiolani Medical Center for Women and Children.

Medical records at Kapiolani Medical Center for Women and Children were reviewed for cases that had a trial of labor subsequent to prior cesarean section during the period January 1990 to July 1991. All cases were > or = delivered 36 weeks' gestation. During the 19-month period, 356/483 or 73.5% cases with a trial of labor had successful vaginal births after previous cesarean sections (VBAC). The majority of the others that did not were due to failure of progression in labor. The incidence of scar separation was 5/483 (1.04%). There were 5/483 neonates with Apgar scores of < or = 6 at 5 minutes, giving a perinatal morbidity rate of 1.04%. There were no maternal deaths. Oxytocin induction resulted in successful VBAC in 30/47 (63.8%) cases. This study concludes that a trial of labor for vaginal birth after cesarean section is well established at our institution. In addition, the rates of successful VBAC, its complications and outcomes, are comparable to national averages.

The incidence of meconium-aspiration in Hawaii.

Meconium in the amniotic fluid was found in 2,633 obstetrical patients and meconium-aspiration occurred in 77 cases out of 14,527 deliveries. Although the incidence of meconium in the amniotic fluid increased significantly at 39 weeks, a corresponding significant increase in meconium-aspiration did not occur until 41 weeks gestation. All deaths associated with meconium, as well as 84% of the cases of severe meconium-aspiration syndrome, occurred in infants born of patients with oligohydramnios and a gestational age of 41 weeks or greater.