Episiotomy: risks of dehiscence and rectovaginal fistula.

The obstetric literature was reviewed to assess the risk of episiotomy dehiscence and rectovaginal fistula formation from routine episiotomy, with and without third- and fourth-degree laceration into the rectal sphincter or rectal mucosa, respectively. Strong evidence suggests that elective episiotomy predisposes to severe 3rd and 4th degree perineal lacerations and that episiotomy dehiscence with rectovaginal fistula formation is strongly related to 3rd and 4th degree perineal lacerations.

Uterus didelphys and unilateral lower limb amelia in a discordant monozygotic twin. A case report.

Uterus didelphys and unilateral lower limb amelia were diagnosed in a discordant identical twin. The discordant occurrence of these anomalies in monozygotic twins suggests a possible coincidence.

Management of severe hemorrhagic cystitis in pregnancy. A report of two cases.

Acute hemorrhagic cystitis (AHC) is gross hematuria and symptoms of cystitis. Usually a self-limiting entity, it is found mainly in children and cancer patients receiving chemotherapy or radiation. In a small number of patients, AHC can be severe and require aggressive management. We present two cases of severe acute hemorrhagic cystitis in pregnant women that led to hemorrhage, resistance to antibiotic therapy and premature labor. Continuous bladder irrigation with normal saline was attempted with success in stopping the hematuria and arresting the premature labor. Severe hemorrhagic cystitis in pregnancy may require aggressive management when associated with a significant blood loss and preterm labor.

Lamellar body concentrations and the prediction of fetal pulmonary maturity.

OBJECTIVE: Amniotic fluid lamellar body concentration was quantified in pregnancy and compared with the lecithin/sphingomyelin ratio and phosphatidylglyceryl to predict fetal lung maturity. STUDY DESIGN: Amniotic fluid was obtained from 56 patients at various gestational ages (16 to 42 weeks) and quantified on a Coulter counter set for particle size used for platelets (2 to 20 fl). The lamellar body concentration best agreeing with a mature lecithin/sphingomyelin ratio of 2 and with phosphatidylglycerol was determined. The lamellar body concentration cutoff was compared with the lecithin/sphingomyelin ratio and phosphatidylglycerol as a predicator of fetal lung maturity. RESULTS: Lamellar body concentration increased exponentially with gestation (r = 0.70, p < 0.001), as did the lecithin/sphingomyelin ratio (r = 0.78, p < 0.001). The two tests correlated with each other linearly (r = 0.67, p < 0.001). The lamellar body concentration cutoff value that best agreed with both mature lecithin/sphingomyelin ratio and phosphatidylglycerol was 30,000/microliters (kappa-test 0.66 and 0.73, respectively). In 28 patients delivered within 72 hours the lamellar body concentration correctly predicted four cases of respiratory distress syndrome (100% sensitivity and specificity). CONCLUSION: This study confirms that lamellar body concentration is a reliable and practical assay and should be evaluated further, especially for use in a community hospital setting.

Delayed birth intervals of immature fraternal triplets in preterm labor. A case report.

The preterm birth of immature triplets before 28 weeks is associated with excess morbidity and mortality risks attributable to extreme immaturity. We report a case of fraternal triplets in preterm labor in which the second and third triplet births were delayed 11 days after the first birth, at 26 4/7 weeks' gestation. The later-born sibs were heavier at birth and throughout their neonatal course in the hospital and suffered less severe complications as compared to the first-born triplet. Delayed birth intervals of triplets in preterm labor should be considered to improve perinatal salvage of immature triplets, although a successful outcome is rare and unexpected.

Insignificant blunt maternal trauma with lethal fetal outcome: a case report.

We report a case of a twenty-nine-week breech fetus with skull fracture, intracranial bleeding, and liver laceration sustained in a vehicular accident. This case describes insignificant maternal trauma with poor fetal outcome.

Obesity and vaginal hysterectomy.

A retrospective study was done of 471 consecutive vaginal hysterectomies done in a three-year period. Three groups of patients--239 normal to 9% overweight, 132 10-24% overweight and 100 greater than or equal to 25% overweight--were compared. Surgical difficulties were similar in all three groups. The more obese patient had a slightly greater incidence of febrile morbidity, stayed one day longer in the hospital and had a minimally greater loss of hemoglobin 48 hours postoperatively. However, obesity per se caused few problems during and after vaginal hysterectomy. The vaginal approach is the procedure of choice for hysterectomy in obese women.

Predictability of pregnancy outcome in preterm delivery.

Multivariate models have great potential value in enhancing the understanding of why some pregnancies have poor outcomes. Recently, such models have been advocated as a basis for predictive scoring systems that attempt to classify patients into high-risk and low-risk groups. In this report the usefulness of such an approach was assessed by studying the predictability of preterm delivery at The Johns Hopkins Hospital during 1980, using a multiple logistic model. Choosing a cutoff point (or probability of preterm delivery) of 10%, 697 of 2865 patients were placed in the high-risk group. The sensitivity, specificity, and positive predictive value of the model, as applied to this select population, were 62.2, 79.4, and 22.7%, respectively. Thus, only 23% of patients predicted to have preterm deliveries in fact delivered preterm. The predictive value could have been improved by increasing the cutoff point, but only at the expense of markedly reducing the sensitivity of the model. It was concluded that the potential value of multivariate analyses of pregnancy outcome as a predictive, risk-classification technique is limited. Nevertheless, such studies may aid the clinical evaluation of each individual patient by providing a better understanding of the etiologies of poor outcome.

Comparison of urinary estrogens, contraction stress tests and nonstress tests in the management of postterm pregnancy.

In a retrospective review of 697 postterm pregnancies we attempted to validate three tests used to identify the fetus at increased risk: the 24-hour urinary estrogen per gram creatinine (E/Cr), the nonstress test (NST) and the contraction stress test (CST). Using the corrected perinatal mortality rate (PMR) among term pregnancies (0.23%) as a standard for comparison, we found the PMRs among postterm patients with negative screening tests to be as follows: 0.23% with normal E/Crs, 0.65% with negative CSTs (not significantly different) and 2.4% with reactive NSTs (p less than 0.005). When we used intrapartum fetal distress as a standard for comparison, the E/Cr exhibited the highest sensitivity (88%) whereas those of the CST and NST were much lower (7-10%). The specificities were 63%, 98% and 92%, respectively. From this retrospective study the E/Cr appears to be of most assistance in identifying fetuses at increased risk, the CST is of intermediate assistance, and the NST is of least assistance.

Premature rupture of membranes and spontaneous preterm labor: maternal endometritis risks.

Preterm and term deliveries were analyzed at The Johns Hopkins Hospital from January 1, 1976, through December 31, 1977, to determine maternal infection risks associated with premature rupture of the membranes (PROM). Gravidas who delivered preterm infants demonstrated an increased incidence of endometritis with or without PROM. The risk of endometritis attributable solely to PROM was insignificant compared with the risk attributable to preterm delivery. These findings implicate infection in the mechanism of preterm labor, with or without PROM.

An ominous undulating fetal heart rate pattern.

Three cases of severely compromised fetuses are reported in which a similar FHR tracing was observed: an undulating pattern describing a "sinusoidal" shape, a frequency of 0.5-1 cpm, amplitude of 10-15 bpm, and flattened baseline varying between 60-120 bpm. This pattern appears to differ significantly from the sinusoidal pattern described previously and appears to identify an agonal or pre-agonal fetus that nonetheless may be salvageable and, therefore, requires maximal obstetric intervention.

Prenatal fetoscopic diagnosis of the Apert syndrome.

We report the prenatal diagnosis of the Apert syndrome by fetoscopy. The patient was a 22-year-old college student with this autosomal dominant form of acrocephalosyndactyly whose first pregnancy had resulted in a stillborn, affected infant. Fetoscopy at 17 weeks showed that she was carrying another affected fetus, and the pregnancy was terminated.

Premature rupture of membranes and preterm labor: neonatal infection and perinatal mortality risks.

The purpose of this study was to analyze neonatal infection rates and perinatal mortality in births complicated by premature rupture of membranes (PROM) and spontaneous labor before term (less than 37 weeks' gestation). Neonatal infection occurred more commonly in preterm compared with term infants. The risk of infection due solely to PROM was insignificant compared with the risk attributable to preterm birth. Perinatal mortality and cause-specific mortality varied inversely with gestational age. These rates were not significantly different between groups with or without PROM or with or without associated development of maternal endometritis. Although the mortality due to infection was higher in preterm compared with term groups, most preterm deaths were attributed to other factors, particularly anoxia and respiratory causes. The diverse fetal risks associated with PROM and the associated maternal infection risks analyzed support expectant management when PROM occurs preterm.

Premature rupture of the membranes and prolonged latency.

The aim of this retrospective study in 8320 patients with premature rupture of the membranes (PROM) was to determine the consequences of prolongation of the latent period. Among patients with pregnancies of more than 37 weeks' duration, those with PROM and latent periods of more than 1 day demonstrated an increased incidence of intrapartum fever (IPF), whereas those with latent periods of more than 3 days demonstrated a marked increase in fetal (but not neonatal) deaths. Although IPF and perinatal mortality were more common in preterm pregnancies, neither was found to increase or decrease with prolonged latency, provided differences in gestational ages and race were taken into account. In the absence of chorioamnionitis, there appears to be no benefit to delivery before 37 weeks' gestation.

The glucose tolerance test as a means of identifying intrauterine growth retardation.

The purpose of this prospective, nonconcurrent study was to determine whether maternal hypoglycemia, as measured by a 3-hour glucose tolerance test, is associated with pregnancies resulting in growth-retarded infants. Our results demonstrate that maternal hypoglycemia is significantly associated with intrauterine growth retardation other than the low birth weight type and that the 3-hour glucose tolerance test is an effective early screening test in detecting pregnancies at risk of fetal growth retardation.

The relative significance of human placental lactogen in the diagnosis of retarded fetal growth.

The purpose of this prospective study was to determine whether serial maternal venous hPL determinations could identify pregnancies resulting in growth-retarded infants from a selected population at presumed high risk for IUGR. Our results demonstrated that mean hPL levels in IUGR outcome pregnancies were significantly lower than normal after 33 weeks' gestation. Mean hPL was also lower in some pregnancies resulting in normal-weight neonates with abnormally low PI or short CHL, suggesting that these neonates, despite normal birth weight achievement, may represent previously unsuspected.

Patterns of intrauterine growth retardation.

A prospective study of 70 singleton pregnancies at high risk for intrauterine growth retardation (IUGR) was undertaken to determine 1) the differences in intrauterine growth patterns; 2) the diagnostic accuracy of obstetric techniques; and 3) the frequencies of perinatal complications. Thirty infants displayed signs of IUGR. Although only 14 infants had low birth weights, these 14, as well as the remaining 16 infants under study, displayed many other features of growth abnormalities, including a low ponderal index, short stature, and small head circumference. These data demonstrate various patterns of IUGR. Although the perinatal complications occurred primarily in the low-birth-weight group, the major growth abnormalities observed in the non-low-birth-weight group demonstrate the need for additional short- and long-term follow-up studies in both groups.