A simplified phenytoin regimen for preeclampsia.

The objective of this study was to assess the feasibility of giving phenytoin to a group of mild preeclamptic women in a universal dosing scheme comparable to that typical of magnesium sulfate administration. Serum phenytoin levels were measured at regular intervals for 32 hours following a 1 g intravenous loading dose in 14 patients. A second group of 14 women received 500 mg orally to supplement the 1 g initial dose and had serum levels similarly measured. The resultant serum levels are described, and the effect of maternal weight analyzed. The average serum phenytoin level in the first 14 women given the 1 g loading dose fell to 10 micrograms/mL approximately 12 hours after treatment. Serum levels plateaued above this threshold in the 14 women given 500 mg of additional medication orally 10 hours after treatment initiation and were maintained for an additional 14 hours before decline was observed. The serum levels resulting from the initial 1 g loading dose were analyzed 8 hours after treatment initiation in the entire group of 28 women according to body weight, and a clinically significant effect of weight on serum level was observed only at the extremes of weight. We conclude that a universal dosing scheme comparable to that typically used for magnesium sulfate is feasible for phenytoin administration to preeclamptic women.

Birth weight threshold for postponing preterm birth.

OBJECTIVE: The study was designed to determine the birth weight threshold at which obstetric efforts intended to delay delivery might potentially improve rates of neonatal morbidity and mortality among pregnancies delivered after spontaneous preterm labor or rupture of the membranes. STUDY DESIGN: We studied 1147 singleton infants with birth weights between 1000 and 2499 gm and whose only complication was spontaneous preterm labor or preterm rupture of the membranes. The Mantel-Haenszel chi 2 statistic was used to evaluate trends for neonatal mortality and several indexes of morbidity. RESULTS: The birth weight threshold for neonatal mortality was 1600 gm (p < 0.001). For neonatal morbidity the threshold was between 1600 and 1900 gm (p < 0.008). CONCLUSION: Aggressive obstetric attempts to prevent preterm birth for infants whose weights exceed 1900 gm offers few apparent potential benefits.

Prolonged pregnancy. I. Observations concerning the causes of fetal distress.

During a 2-year prospective investigation of prolonged pregnancy in 727 women, 59 (8%) were delivered by cesarean section for fetal distress. This condition was diagnosed by means of electronic fetal heart rate monitoring in 47 of the women, and the patterns were unexpectedly characteristic of umbilical cord compression rather than uteroplacental insufficiency. Blinded sonar examinations were performed in 213 women, and the incidence of cesarean section for fetal distress as now described was significantly increased in those with oligohydramnios (two or fewer 1 cm pockets of amniotic fluid). We conclude that the pathophysiology of fetal distress in prolonged pregnancy is typically oligohydramnios that leads to compromised umbilical cord perfusion, rather than uteroplacental insufficiency.

Cefotaxime sodium therapy for endomyometritis following cesarean section: dose-finding and comparative studies.

One hundred eighteen women who developed endomyometritis after cesarean section in Parkland Memorial Hospital were treated with parenteral cefotaxime sodium. The requirement for additional antimicrobial therapy was significantly higher at an initial daily dose of 3 g/day (16.4%) than when the dose was 6 g/day (4.8%) (P less than .05). The latter clinical efficacy and the observed in vitro susceptibility of 88% of isolates indicate that cefotaxime is well suited for single-agent parenteral therapy for this polymicrobial pelvic infection. Subsequently, 120 women with the same diagnosis were randomly treated with cefotaxime or clindamycin and gentamicin. Patient populations, surgical variables, in vitro microbiologic data, and side effects were similar for both groups. Clinical success observed was also similar: it was 97.5% for women given cefotaxime and 95% for women given clindamycin and gentamicin.

Perioperative antimicrobials for cesarean delivery: before or after cord clamping?

To determine neonatal risk of exposure to intrapartum antimicrobials given to reduce maternal infection following cesarean delivery, 642 mother-infant pairs were evaluated. In 464, the mother was given an initial dose of antimicrobial(s) before cord clamping, whereas in the remaining 178 administration of these drugs was not begun until after delivery. Despite the facts that all infants were at equivalent risk for infection and that none were proved to have bacteremia, 28% of those exposed to intrapartum maternal antimicrobials were evaluated for sepsis whereas only 15% of those not exposed were evaluated (P less than .001). Excess hospital charges for infants in whom sepsis workup was initiated was $127 greater than that for infants not suspected of having sepsis (P less than .025). Of 305 women given three-dose perioperative antimicrobial therapy, 255 were given the initial dose before cord clamping and 24% experienced a subsequent uterine infection. This was not significant when compared with a uterine infection rate of 22% in 50 women in whom three-dose therapy was not initiated until after cord clamping. As maternal benefits that accrue from such intrapartum therapy are equivalent regardless of the timing of three-dose treatment, and as fetal exposure to these drugs has significant clinical and economic impacts, it is concluded that antimicrobials given to these women at high risk should be withheld until after cord clamping.

Perinatal outcome in the absence of antepartum fetal heart rate acceleration.

The perinatal outcome of 27 pregnancies in which antepartum fetal activity testing revealed fetal heart rate acceleration to be either absent or less than 10 beats per minute for 80 minutes is presented. At delivery, each pregnancy was found to have one or more features consistent with uteroplacental insufficiency. These included fetal growth retardation (74%), oligohydramnios (81%), fetal acidosis (41%), meconium (30%), and placental infarction (93%). There were four fetal and seven neonatal deaths, for a perinatal mortality of 41%. Despite delivery of all live-born infants by cesarean section without labor, the infants who died during the neonatal period appeared to be in such poor condition as to preclude survival. The authors conclude that the inability of the fetus to accelerate its heart rate, when not due to maternal medications, is an ominous signal. Throughout the literature on fetal activity testing there are indications that other investigators have had similar experiences. The purpose of the present report is to direct attention to an abnormal fetal activity test result of which the significance is not widely recognized.

Continuing investigation of women at high risk for infection following cesarean delivery. Three-dose perioperative antimicrobial therapy.

At Parkland Memorial Hospital a group of women at high risk for infection following cesarean delivery was identified. These included nulliparas who underwent cesarean section for cephalopelvic disproportion 6 or more hours following membrane rupture. During the puerperium, uterine infection developed in 85 to 95% of such women, and one third of this high-risk group had associated complications. The authors have previously reported the efficacy antimicrobial agents given to these women at the time of cesarean section and continued for 4 days. The present prospective study was designed to assess the efficacy of a shorter course of perioperative antimicrobial therapy for these high-risk women. Three doses of antimicrobial agents were given perioperatively to 305 women randomly assigned to 1 of 3 treatment regimens: 115 were given penicillin plus gentamicin, 82 received 2, 1, and 1 g of cefamandole, respectively, and the remaining 108 were given 2, 2, and 2 g of cefamandole, respectively. The incidence of uterine infection in these 305 women was 24% and associated complications were identified in 7% of all women. Based upon a comparison of results with the progenitor study, the authors conclude that 3-dose perioperative antimicrobial therapy is preferred to 4 days of treatment for women at high risk for infection following cesarean delivery.

Moxalactam for obstetric and gynecologic infections. In vitro and dose-finding studies.

Moxalactam (LY 127935), a "third-generation" beta-lactam antimicrobial, has been shown to have promising in vitro activity against a wide spectrum of pathogens similar to those isolated from women with pelvic infections. Pharmacodynamic studies have shown that its serum half life is longer than 2 hours, which permits less frequent dosing. The current investigation was carried out in two parts: In the first phase, the minimal inhibitory concentration of moxalactam against 519 clinical isolates was determined and compared to antimicrobials used in infections caused by these microbes. In vitro activity of moxalactam comparable to that of clindamycin was demonstrated against B. fragilis and other Bacteroides species. There was similar activity to penicillin G and clindamycin against anaerobic gram-positive cocci and activity superior to amikacin was demonstrated against Enterobacteriaceae. The second part of this investigation was a clinical one and 100 women with pelvic infections were given treatment with moxalactam. With an initial dose of 3 gm/day, women with posthysterectomy cellulitis and pelvic inflammatory disease did well. Women with pelvic infections following cesarean section responded less readily to this dose; however, when the initial dose was increased to 6 gm/day, a 91% cure rate was effected. The results of these investigations indicate that moxalactam is useful as a single-agent antimicrobial for treatment of polymicrobial female pelvic infection.

Nonobstructive cecal dilatation and perforation after cesarean section.

A case of nonobstructive cecal dilatation and perforation after cesarean section is reported with a review of the surgical literature on the management of this entity.