The fetal heart rate W-sign.

A biphasic fetal heart rate variable deceleration pattern (W-sign) was investigated and found to be significantly associated with a greater length of umbilical cord (73.07 +/- 17.1 cm) than was found in patients without this pattern (56.47 +/- 11.4 cm) during the first stage of labor (P less than .001). The possible etiology of this variable deceleration pattern and its relative benignity are discussed.

Abnormal fetal growth patterns. Ultrasonic diagnosis and management.

Diagnostic ultrasound is a useful tool in the management of high-risk pregnancies and provides valuable information about abnormal fetal growth patterns including excessive fetal size and intrauterine growth retardation. Two patterns of growth retardation can be distinguished ultrasonically. Fetuses exhibiting "reduced growth potential" type patterns have little risk of fetal distress and are readily recognized as small for gestational age at birth. Fetuses suffering from uteroplacental insufficiency frequently exhibit a pattern of biparietal growth arrest in the third trimester. These fetuses have a high risk of fetal distress and should be closely monitored with other parameters of fetal-placental function including serial estriols and oxytocin challenge tests. Utilizing conventional pediatric growth criteria, the existence of intrauterine growth retardation is often unrecognized in this latter group.

The effects of prophylactic management and therapeutics on hypertensive disease in pregnancy: preliminary studies.

A controlled prospective evaluation of pregnancy complicated by chronic hypertension is proposed and preliminary data on population selection and pregnancy outcome are presented. Sixty-three women with evidence of underlying hypertensive disease were followed prospectively throughout pregnancy. Twenty-three patients were followed in a protocol of intensified prenatal care and randomized assignment of antihypertensive agents: placebo, hydralazine, or methyldopa. Forty patients were followed in the high-risk pregnancy clinics at Duke University. The incidence of preeclampsia in the randomized prophylactic antihypertensive group was statistically lower than that in the nonrandomized group (8.7 versus 32.5%; P less than .01). There were no other statistically significant differences between the groups. The 63 hypertensive women had a high incidence of diabetes mellitus diagnosed during pregnancy (49.2%) as compared to the authors' general obstetric population (8.1%).

Prolongation of the latency period in preterm premature rupture of the membranes using prophylactic antibiotics and tocolysis.

Mixed results have been obtained in several studies using tocolysis or antibiotics individually in the treatment of premature rupture of membranes (PROM). We compared the outcomes of a management protocol consisting of tocolysis, prophylactic antibiotic administration, and documentation of pulmonary maturity with a control group treated with passive expectant management for premature rupture of membranes. There were 55 women in the treatment group and 57 women in the control group. The mean latent phase (+/- SEM) in the treatment group was 7.34 (+/- 1.25) days compared with 1.86 (+/- .431) days in the control group (P less than .001). Eighteen of 55 patients (33%) in the treatment group were electively delivered after documentation of lung maturity, contributing to a falsely lowered mean latent phase in the treatment group. Twenty-four patients in the treatment group and 6 in the control group had a latent phase of 5 days or greater (P = .00018). There were 9 postpartum infections in the control group and 10 infections in the treatment group (P = NS). There was no difference in the length of latent phase of patients treated with ceftizoxime compared with the other antibiotics used (cefoxitin, cefazolin, ampicillin), although postpartum ceftizoxime was more effective in preventing postpartum infections (1 of 28 vs 9 of 27) (P = .005). There were fewer infected neonates in the study group, but this was not significant. It appears that treatment with this protocol significantly prolongs the latent phase in patients with preterm PROM without increasing infectious morbidity.

Disseminated blastomycosis in a pregnant woman successfully treated with amphotericin-B. A case report.

An 18-year-old woman developed disseminated blastomycosis in the 30th week of pregnancy. She was treated with amphotericin-B. Simultaneous maternal-infant blood levels at birth were 1.9 and 1.3 micrograms/mL, respectively. The amphotericin-B level in the amniotic fluid was 0.3 microgram/mL at delivery. The infant was normal and without ill effects from either the blastomycosis or the amphotericin-B. The skin lesions and pulmonary infiltrates in the mother improved rapidly, without unexpected side effects from the therapy. The limited experience with amphotericin-B indicates that it is both well tolerated and effective in this clinical situation.

Active expectant management in very early gestations complicated by premature rupture of the fetal membranes.

Premature rupture of the membranes (PROM) in the previable gestation is frequently associated with fetal or neonatal death. Passive expectant management is successful in only a small minority of cases. Women presenting with PROM at < or = 27 weeks' gestation were treated with tocolysis and prophylactic antibiotics and delivered electively for lung maturity. The corrected perinatal survival was > 92%. The mean latency phase was 21.6 days (+/- 18.12 SD). Twenty-one percent of patients presented in labor; the mean latency phase for this subgroup was 14.4 (+/- 8.54) days. Nineteen patients (79%) had a latency phase > 7 days, and 14 (58%) had a latency phase > 14 days. Thirty-nine percent of infants required < 48 hours of mechanical ventilation. Six infants were delivered with intraventricular hemorrhage; in all cases it was grade 1 or 2. There were three (12.5%) postpartum infections and three septic neonates. Active expectant management using tocolysis and prophylactic antibiotics was associated with a prolonged latency phase, low infectious morbidity and good neonatal outcome.

Concurrent hypertension and pregnancy.

Concurrent hypertension in pregnancy alters the diagnosis and prognosis of both the vascular disease and the gestation. Insight into the physiologic and pathophysiologic changes is essential to assessing the patient's status and to determining what antenatal care may yield the best outcome of the pregnancy. In this monograph we have presented (1) a classification, which correlates well with those currently in use, of the types of hypertension and their causes; (2) a brief review of current fact and theory regarding the effect of hypertension on maternal and perinatal morbidity and mortality; (3) a detailed approach to monitoring the physical and laboratory parameters of the parturient; (4) a rational approach to monitoring the fetoplacental unit; and (5) an analysis of currently available therapeutic regimens that may alter the course of hypertension in pregnancy sufficiently to increase fetal salvage and decrease maternal complications. Certainly more research into the mechanisms of CHP will be forthcoming as will newer and more precise diagnostic aids. Pharmacologic agents with varied hypotensive actions are constantly being developed, and combinations of these may yield more beneficial results.

Differential protein binding of ceftizoxime in cord versus maternal serum.

Ceftizoxime concentrations are higher in cord blood and amniotic fluid than in maternal blood. More avid binding to fetal serum proteins is a suggested mechanism. We measured ceftizoxime protein binding in fetal and maternal blood and documented significantly less protein binding to fetal proteins (21.9% vs 57.8%).

LTUA--a new and more reproducible method of estimating intrauterine size.

A system of estimating intrauterine size by adding the maximal longitudinal and transverse uterine areas (LTUA) is described. In our hands this measurement is less prone to observer variability and more sensitive in diagnosing intrauterine growth retardation (IUGR) than the total intrauterine volume (TIUV) measurement. Intraobserver variability for the LTUA was 3.7 per cent, whereas that for the TIUV was 10.0 per cent. Interobserver variability was 6.5 per cent for the LTUA and 12.9 per cent for the TIUV. Sensitivity for the LTUA and the TIUV was 70 per cent and 40 per cent, respectively, and the respective specificities were 94 per cent and 96 per cent. These results suggest that the LTUA may be a more accurate and reliable method of predicting IUGR than is the TIUV.

Isovolumetric partial exchange transfusion in the management of sickle cell disease in pregnancy.

A technique that permits isovolumetric partial exchange transfusion is presented, with experience from 10 partial exchange transfusions in five obstetric patients with sickle cell disease. The technique is performed in an outpatient setting and requires less than two hours once blood has been cross matched. A mathematical model of the blood volume is used to predict final hematocrit and final hemoglobulin (Hgb) A percentage and to compare this technique with a previously described algorithm. Once the decision to perform a partial exchange transfusion has been made, this technique affords diminished risk to the patient and economy of time and money by permitting prediction of the hematocrit and percentage normal hemoglobin (% Hgb A) resulting from various transfusion/withdrawal volumes.

Hemoglobin A1c in normal and diabetic pregnancy.

The usefulness of determining hemoglobin A1c (HbA1c) levels during pregnancy was evaluated. In contrast to previous reports, the HbA1c values did not predict abnormal maternal glucose tolerance or infant birth weight. They did, however, correlate with long-term control of the diabetes of pregnant insulin-dependent patients. The slight decrease in HbA1c values observed as pregnancy advanced was secondary to improved control of diabetes.

Steady-state cord and amniotic fluid ceftizoxime levels continuously surpass maternal levels.

As part of our management protocol for preterm premature rupture of membranes, ceftizoxime and tocolysis were used to prolong the latent period and prevent or treat concomitant infection. Ceftizoxime was selected for this protocol based on its physiochemical properties, which favor placental transfer of the drug. Patients achieving steady-state pharmacodynamics (more than three doses of the drug) were considered eligible for study. Ceftizoxime levels were determined by reverse-phase high-pressure liquid chromatography. All levels measured after the first hour of treatment were indicative of the relative concentration of ceftizoxime in the fetal and amniotic fluid compartments when compared with the maternal compartment. Mean (+/- SEM) ceftizoxime levels were 11.96 + 2.35 micrograms/ml in maternal serum, 24.54 +/- 4.78 micrograms/ml in cord serum, and 43.45 +/- 4.97 micrograms/ml in amniotic fluid. Based on its broad antibacterial activity and its high concentration in fetal blood and amniotic fluid, ceftizoxime appears to be an ideal agent for treatment of the intrauterine environment.

Bacterial colonization of amniotic fluid in the presence of ruptured membranes.

Amniotic fluid (AF) was collected from 37 selected patients by amniocentesis, aspiration through a pressure catheter, or aspiration at the time of cesarean section. The unspun AF was examined directly by Gram stain for bacteria and white blood cells (WBC) and was cultured. Thirteen AF cultures were positive, defined as growth on primary plating media which corresponded to greater than 10(2) colony-forming units (CFU) per milliliter. Almost equal numbers of aerobic and anaerobic bacteria were isolated. The presence of bacteria, but not WBC, on Gram stain of AF correlated significantly with a positive culture, which indicated that microscopic examination of AF would usually predict the culture result. Growth of greater than 10(2) CFU/ml from AF was significantly associated with clinical chorioamnionitis, but colonization also was observed in five afebrile patients, four of whom were in premature labor. In patients delivered by cesarean section, bacteria on Gram stain and a positive culture from AF each were significantly correlated with postpartum endometritis.

Vertical transmission of group B Streptococcus. Relation to intrauterine fetal monitoring.

A prospective study of 70 mother-infant pairs was designed to evaluate vertical transmission of group B Streptococcus (GBS) in relation to the use of intrauterine fetal monitors (IUFMs). Multiple-site cultures obtained from mothers during the intrapartum interval and those obtained from infants on day 1 and at discharge or day 4 were plated on a selective medium. Thirteen (27.1%) of 48 IUFM-exposed women vs seven (31.8%) of 22 non-IUFM-exposed women had GBS at one or more sites. The GBS colonization with maternally concordant serotypes occurred in eight (61.5%) of 13 infants born to GBS-colonized, IUFM-exposed women vs two (28.6%) of seven infants born to GBS-colonized, non-IUFM-exposed women. While this suggests that vertical transmission of GBS is enhanced by IUFM placement, the differences in these infant rates were not statistically significant.

Nasal colonization of infants with group B Streptococcus associated with intrauterine pressure transducers.

The rate of nasal colonization with group B Streptococcus in infants cultured at the time of discharge from the nursery rose significantly during a four-month interval. Investigation of this trend resulted in detection of group B streptococci in the domes of two intrauterine pressure transducers (IPTs). Subsequent routine sterilization of IPT domes after each maternal use was associated with a decline in infant group B streptococcal colonization to the usual endemic rate in the nursery. Retrospective evaluation demonstrated that colonization in infants born to IPT-monitored women had increased significantly during the study interval and that no increase in colonization occurred in infants born to non-IPT-monitored women. From epidemiologic evidence it appears that use of contaminated IPTs during labor was a nosocomial source of group B streptococcal colonization.

Monoclonal immunoglobulin-secreting lymphoma in a patient with severe combined immunodeficiency disease.

A 3.5 year old boy with X-linked severe combined immunodeficiency disease (SCID), who had been in laminar flow isolation throughout his life, developed a B cell tumour producing up to 3008 mg/dl of an IgM kappa paraprotein 1 month after infusion of both liver and thymus cells from a fetal donor and 6 months after the last of six fetal liver cell infusions given over a 3 year period. Pretransplant studies revealed a high percentage of circulating B lymphocytes. HLA typing suggests that the tumour was of host origin.