A double-blind randomized trial of two dose regimens of misoprostol for cervical ripening and labor induction.

OBJECTIVES: The objective of this study was to compare the efficacy and safety of two dosing regimens of misoprostol for cervical ripening and labor induction. METHODS: Patients who fulfilled the study criteria were randomized to received misoprostol 25 microg or 50 microg intravaginally every 3 h for a total of eight doses for cervical ripening or until labor was established. Endpoints for successful cervical ripening was achievement of Bishop score of nine or greater, and for labor induction reaching the active phase of labor in the first 24 h. The rates of success, duration of first and second stages of labor, type of delivery, significant side effects, and neonatal outcome were measured and compared between the two study groups. Two hundred and fifty-one patients were randomized in two groups--126 received 50 microg and 125 received 25 microg misoprostol. Demographics of the two study groups were similar. RESULTS: Patients in the 50 microg group had a shorter first stage (848 min vs. 1,122 min, P < 0.007), shorter induction-to-vaginal delivery interval (933 min vs. 1,194 min, P < 0.013), decreased incidence of oxytocin augmentation (53.9% vs. 68%, P < 0.015), and decreased total units of oxytocin (2,763 mU vs. 5,236 mU, P < 0.023), but there was a higher hyperstimulation rate (19% vs. 7.2%, P < 0.005). CONCLUSIONS: Successful induction rate, delivery types, and fetal outcome were similar in both groups. Although the rate of vaginal delivery and neonatal outcome were similar in both groups, the 50 microg regimen had shorter first and second stages of labor, and a higher hyperstimulation rate that was easily manageable, allowing for flexibility in using the higher dose in low-risk pregnancies.

Fetal pyelectasis: is it always "physiologic"?

OBJECTIVE: Our purpose was to determine the degree of fetal pyelectasis predictive of neonatal renal pathologic processes. STUDY DESIGN: Eighty-four cases of pyelectasis were identified during the study period (1989 through 1993). Fetuses with anteroposterior diameter of the renal pelvis > or = 4 mm before 33 weeks or > or = 7 mm after 33 weeks without caliectasis were included. Fetuses with an anteroposterior diameter of > 10 mm were excluded. Postnatal evaluation included renal sonogram, voiding cystourethrogram, and renal flow and function studies. RESULTS: Sixteen cases were excluded because of incomplete postnatal workup. Renal pathologic processes were found in 30 of 68 (44%) at birth; the most common were ureteropelvic junction obstruction (37%) and vesicoureteral reflux (33%). Only four cases required surgical intervention (13%), and the remaining 87% were managed conservatively. A normal urinary tract was found in 25% of the infants and the remaining 21 of 68 (31%) had regression of pyelectasis before birth. Fetuses with a dilated anteroposterior diameter > or = 8 mm after 28 weeks' gestation were found to have renal pathologic features in two of three of the cases, with sensitivity, specificity, and positive and negative predictive values of 87%, 41%, 66.7% and 70%, respectively. CONCLUSION: Fetuses with an anteroposterior diameter of the renal pelvis > or = 8 mm after 28 weeks' gestation require appropriate urologic evaluation after birth.

Elevated tissue levels of collagenase during dilation of uterine cervix in human parturition.

Seven biopsy specimens from the cervix and 17 from the lower uterine segment were obtained in 24 women at term (37 to 42 weeks). Collagenase was extracted and assayed on telopeptide-free [3H]collagen; typical collagen cleavage products were found on sodium dodecyl sulfate-gel electrophoresis. There was no significant difference between collagenase levels in the cervix and in the lower uterine segment in women not in labor and with the cervix closed. Levels of active and latent collagenase in 11 such specimens were 0.14 +/- 0.03 and 0.64 +/- 0.90 U/gm wet weight, respectively (mean +/- SEM; 1 U = 1 micrograms collagen digested per minute at 30 degrees C). Thirteen women at term in active labor with cervical dilation of 4 to 8 cm exhibited a thirteenfold increase in mean collagenase activity in the lower uterine segment. Active and latent collagenase increased to 2.06 +/- 0.92 and 8.64 +/- 2.87 U/gm, respectively. This is the first direct evidence that interstitial collagenase increases markedly during cervical dilation in human parturition.

Pregnancy outcome at greater than or equal to 20 weeks' gestation in women in their 40s. A case-control study.

The obstetric performance of 166 women in their 40s who delivered during a one-year period at greater than or equal to 20 weeks' gestation was compared to that of a cohort of controls younger than 40. Medical complications--diabetes, chronic hypertension and antepartum bleeding--occurred more frequently in the older patients. They had a threefold increase in antepartum hospital admissions over the controls (23.5% vs. 7.8%). Both groups had the same perinatal mortality rate, 18/1,000, and their newborns had similar incidences of neonatal complications except for a higher frequency of major and minor congenital anomalies in the study group (16% vs. 8.4%). The older patients had a longer second stage of labor. Older nulliparas had a higher incidence of premature deliveries and cesarean sections than did their controls. The outcome of pregnancy in this age group is affected by multiple confounding variables; medical complications, parity and age play major roles.

Premature rupture of the membranes before 28 weeks: conservative management.

The maternal and fetal outcomes of 70 consecutive singleton pregnancies with prolonged premature rupture of the membranes before 28 weeks, which were managed expectantly, were evaluated; 58.6% of the mothers developed chorioamnionitis and 13% postpartum endomyometritis. No long-term maternal sequelae were noted. None of the 22 infants born before 25 weeks survived the neonatal period. The weights of the 35 surviving infants ranged between 800 and 4100 gm. Only 29.4% of the 17 infants with long-term follow-up were both physically and developmentally normal at 6 months of age or more.

Segmental epidural analgesia in labor: a matched control study.

The effects of epidural analgesia, given during the first stage of labor, on the course of labor, mode of delivery, and fetal outcome were evaluated in 43 matched controlled patients. Both stages of labor were prolonged, more forceps were applied, and more patients needed oxytocin augmentation for a longer period in the epidural group. Cesarean section was associated also with the use of epidural analgesia, owing to failure to progress. Fetal outcome was similar in both groups as judged by Apgar scores. Patients who elect this mode of pain relief in labor should be made aware that these side effects can be expected.

Morphologic changes in the renal tract in pregnancy.

The morphology of the urinary tract is altered considerably during gestation. Changes occur as early as the first trimester and increase as pregnancy progresses. The edema and hyperemia that occur in the bladder along with its decreased tone predispose the patient to asymptomatic bacteriuria. The bacteria can then be transmitted to the ureters via the vesicoureteral reflux. The increase in urinary volume in the ureteropelvic system enhances the growth of the organisms and hence is thought to be the major cause of the increased incidence of pyelonephritis in pregnancy. The morphologic alterations regress dramatically as pregnancy is terminated and reach prepregnancy status at most by the third month post partum, a fact of which clinicians should be aware when interpreting diagnostic test results.

Physiologic and biochemical effects of ritodrine therapy on the mother and perinate.

The materno-fetal and neonatal effects of ritodrine were studied in 37 women treated for premature labor with intravenous (i.v.) ritodrine. Marked cardiovascular, respiratory, and biochemical side effects of therapy were seen in the mothers and tachycardia was noted in the fetuses. The neonates of 18 women in whom ritodrine successfully postponed delivery were delivered with good Apgar scores and their admission vital signs and nursery courses were benign. Ritodrine failed to delay delivery more than a week in 19 mothers. There were no differences between their newborns and 20 control neonates in admission vital signs, blood gases, blood chemistries, complete blood counts, platelet counts, peak bilirubin, or duration of oxygen therapy. This study revealed no deleterious effects on neonates delivered after maternal ritodrine therapy despite significant maternal and fetal effects.

Fetal supraventricular tachycardia: a case of (intermittent) atrial flutter.

Fetal tachycardia of "supraventricular" origin is uncommon. The authors present a patient with fetal ascites and atrial flutter. A review of the pertinent literature is included.

Successful pregnancy in a woman with a left ventricular cardiac aneurysm. A case report.

Ventricular cardiac aneurysms associated with pregnancy are extremely rare. The effects of one on the other are not known. The pathophysiology of cardiac aneurysms as known in the nonpregnant state combined with the physiologic cardiovascular adjustments of pregnancy can be suspected of compromising the welfare of the pregnant patient. We recently treated a 21-year-old pregnant patient with a post-myocardial-infarction left ventricular cardiac aneurysm. The outcome was successful.

Malaria in pregnancy.

Recent evidence suggests an increasing incidence of malaria among the civilian population of the United States. The effects of malaria in pregnancy can be serious to both mother and fetus. We present four patients with malaria during pregnancy and review the charts of 18 additional patients with malaria (two of whom were pregnant) in order to familiarize the reader with the general clinical picture. The currently recommended chemoprophylaxis and treatment are outlined.

Endogenous creatinine clearance during pregnancy. II. Variations in normal standards based on methodology.

A comparison of the endogenous creatinine clearance (ECC) values by using creatinine levels measured by the autoanalyzer and the modified Jaffe reaction using Lloyd's reagent was performed in 108 normal ambulatory pregnant women at various stages of gestation. The mean ECC was found to be significantly lower when the former method was employed except between 39 and 41 weeks when the values became similar. The mean ECC when calculated from the autoanalyzer results did not vary during pregnancy since serum creatinine by this method remained fairly constant. The difference in serum creatinine level between the two methods observed during pregnancy was absent in the nonpregnant state.

Endogenous creatinine clearance during pregnancy. Part I. Methodologic considerations.

The effect of noncreatinine chromogens on the endogenous creatinine clearance (ECC) during pregnancy was investigated. It was found that these chromogens measured as plasma "creatinine" cause a significant reduction in the ECC value. This fact should be considered when the ECC value is used to evaluate renal function during pregnancy.

The regulatory effect of estrogens on fetal growth. IV. Brain development in growth accelerated fetuses in rabbits.

Brain weights and DNA, RNA, and total protein concentrations were determined on 31-day-old fetuses whose growth had been accelerated incidental to estrogen deficiency following maternal oophorectomy. Compared to controls, there were no differences in the DNA, RNA, or total protein concentrations, although the mean brain weight was increased. The higher mean brain weight in the growth accelerated fetuses was related to the increased mean fetal weight, and did not represent an independent response to the estrogen deficiency. A comparison of the influence of fetal weight versus gestational age on the weight of the fetal brain shows that gestational age exerts an effect apart from that of fetal weight.