Fetal bradycardia and disseminated coagulopathy: atypical presentation of amniotic fluid emboli.

We present a parturient who developed an atypical case of amniotic fluid emboli presented by sudden fetal bradycardia, followed by maternal disseminated coagulopathy. The typical feature of cardiopulmonary collapse was absent in this patient implying that in some cases of amniotic fluid emboli (AFE), fetal hypoxia or acidemia is unrelated to maternal cardiopulmonary status.

Antepartum risks of shoulder dystocia and brachial plexus injury for infants weighing 4,200 g or more.

A cohort of 236 vaginally delivered neonates weighing > or = 4,200 g was evaluated. Shoulder dystocia was encountered in 27 deliveries (11.4%) and brachial plexus injury was diagnosed in 3 infants (1.3%). The 'traditional' antepartum risk factors could not be associated with shoulder dystocia. In this cohort, primiparity was significantly more frequent among the dystocia cases (OR = 8.58, 99% CI = 1.35-54.35, p = 0.021). Shoulder dystocia could not be attributed to a particular difference between the current and the previous heaviest birth weight. A policy of cesarean section for all infants weighing > or = 4,200 g would result in at least 5- to 6-fold increase in cesarean rate in this group of patients. Our data reconfirm that shoulder dystocia and brachial plexus injury are unpredictable, even in macrosomic infants. It is a matter of policy whether to accept the expected 1:9 and 1:79 respective risks associated with vaginal births.

The threat of type IV Ehlers-Danlos syndrome on maternal well-being during pregnancy: early delivery may make the difference.

We describe a successful management of a pregnancy in a woman with type IV Ehlers-Danlos syndrome that included an elective caesarean section and tubal ligation at 32 weeks' gestation. We identified 26 women (including ours) who had been pregnant with well-documented characteristics of type IV Ehlers-Danlos syndrome in the literature. These 26 women had 50 pregnancies. Ten (38.5%) died during pregnancy or in the immediate postpartum period. The maternal mortality rate per pregnancy in type IV Ehlers-Danlos syndrome was therefore calculated to be 20.0%. Pregnancy, continuing pregnancy, or subsequent pregnancy are all contraindicated in patients with type IV Ehlers-Danlos syndrome. Termination of pregnancy before 16 weeks' gestation should be strongly advised. If the patient proceeds with pregnancy, restriction of physical activity at the beginning of third trimester, frequent evaluation of the patient, and an elective caesarean delivery at 32 weeks' gestation after an appropriate antenatal steroid therapy should be advised.

Low values on 50 gram glucose challenge test or oral 100 gram glucose tolerance test are associated with good perinatal outcome.

We set out to reevaluate the hypothesis that high normal (negative) results of 50 g oral glucose challenge test or high normal glucose level on 100 g oral glucose tolerance test are associated with complications of pregnancy and delivery. This was a prospective study involving 735 nondiabetic women. The first group (n=352) was made up of pregnant women with normal 50 g oral glucose challenge test without previous history of diabetes mellitus or gestational diabetes. The second group (n=383) was made up of pregnant women without previous history of diabetes mellitus or gestational diabetes with an abnormal 50 g oral glucose challenge test and with normal 100 g oral glucose tolerance test and not more than one previous delivery. In nondiabetic women, we demonstrated a positive correlation between high normal 50 g glucose challenge test values and the incidence of preeclampsia, caesarean section rate, macrosomia, neonatal hyperlipidaemia and minor congenital abnormalities. We failed to confirm any relationship to any pregnancy complication in pregnant women with 2-hour glucose levels in the range 6.7-9.1 mmol/l on the 100 g oral glucose tolerance test. We have demonstrated a positive relationship between the incidence of premature rupture of membranes and 1-hour glucose level, caesarean section rate and maternal 1-hour glucose level or 1-hour glucose level minus fasting glucose level of 4.2 mmol/l, instrumental delivery rate and maternal 3-hour glucose level, incidence of neonatal macrosomia and 1-hour glucose level, and incidence of neonatal hyperlipidaemia and at least one high but normal glucose level on the 100 g oral glucose tolerance test. With regard to pregnancy and delivery complications there were no significant difference if the high normal value is on the 50 g glucose challenge test or on the 100 g oral glucose tolerance test. It is concluded that one high normal 100 g oral glucose tolerance test or high normal 50 g glucose challenge test are associated with adverse pregnancy and delivery outcome. Nondiabetic women with 50 g glucose challenge test value of 6.1 mmol/l and/or 100 g oral glucose tolerance test values of 5 mmol/l have a favourable pregnancy and delivery outcome.

Infection by parvovirus B 19 during pregnancy: a review.

Fetal infection by Parvovirus B 19 is a common cause of fetal anemia and nonimmune hydrops fetalis and may result in fetal death. Recent improvements in diagnosing parvovirus infections by sensitive molecular biology techniques now allow for a new insight into its pathogenic rule, immunology, and the varied clinical manifestations. The estimated overall risk of fetal loss after maternal exposure is about 6.5 percent, which is much less than previously thought. Inasmuch as complete spontaneous reversal of fetal hydrops has been commonly described, controversy exists regarding the management of the fetus with clinical signs of infection by Parvovirus B 19. According to the experience that has accumulated, it seems that only cases with severe fetal anemia or signs of fetal compromise should be managed by intrauterine transfusion. This procedure, however, is not without risk. Although an association between fetal viral infection and structural abnormalities has been described, it has not been proved yet. However, infection by Parvovirus B 19 has been recently proposed as a causative factor for congenital red blood cell aplasia.

Parathyroid hormone levels in preterm and term labor.

This prospective study was undertaken to test the hypothesis that parathyroid hormone (PTH) might be involved in preterm or term labor. Four groups of patients were formed, 15 patients in each group. The preterm labor group were patients who were admitted to our perinatal care unit with preterm labor and unruptured membranes (< 35 weeks' gestation). The preterm or term nonlabor control groups were patients matched for gestational age, maternal age, and parity, who were not in labor. The term labor group were patients matched for maternal age and parity who were in active labor. Mean (+/-SD) level of biologically intact PTH was 18.9 +/- 10.6 pgr/mL, 7.6 +/- 4.7 pgr/mL, 20.8 +/- 10.1 pgr/mL, 13.7 +/- 5.3 pgr/mL in preterm labor group, preterm nonlabor group, term labor group, and term nonlabor group, respectively (p < 0.05). No statistically significant differences were observed in the levels of calcium, phosphorus, magnesium, or albumin. We therefore suggest that PTH may have a role in preterm or term labor. The nature of its role should be investigated in further studies.

Induction of labor at 38 to 39 weeks of gestation reduces the incidence of shoulder dystocia in gestational diabetic patients class A2.

The purpose of this study was to test the hypothesis that the incidence of shoulder dystocia could be reduced in insulin-requiring diabetic women by elective induction of labor at 38 to 39 weeks of gestation. A prospective study protocol in which labor was induced at 38 to 39 weeks of gestation in insulin-requiring diabetic women was executed between January 1, 1990, and July 31, 1994 (n = 96). The outcome was compared to the results of a previous protocol (years 1983 to 1989) in which the pregnancies were allowed to progress to spontaneous labor, unless fetal health became compromised (n = 164). The incidence of shoulder dystocia in patients in whom labor was electively induced at 38 to 39 weeks of gestation was 1.4% as compared to 10.2% in patients who delivered beyond 40 weeks' gestation (p < 0.05). No increase in cesarean section rate was demonstrated. We conclude that elective induction of labor is suggested for insulin-requiring diabetic women in order to reduce the incidence of shoulder dystocia.

Congenital cytomegalovirus infection: a long-standing problem still seeking a solution.

OBJECTIVE: The purpose of this study was to review the accuracy of current tests used for the diagnosis of in utero cytomegalovirus infection and to discuss the potential value of preconceptional and postconceptional screening programs for prevention of congenital infection. STUDY DESIGN: A computer-assisted search was performed for relevant English language publications between 1987 and 1994. We identified 119 cases of suspected intrauterine cytomegalovirus infection in which either amniotic fluid or fetal blood had been analyzed antenatally. RESULTS: Congenital cytomegalovirus infection affects 0.5% to 2.5% of all newborns. The rate of transmission to the fetus after primary infection during pregnancy ranges from 15% to 50%. Of the fetuses infected in utero, 10% exhibit congenital cytomegalovirus syndrome. Evaluation of 119 cases of suspected infection has shown that polymerase chain reaction and cultures of amniotic fluid are the most reliable tests for prenatally determining the presence of viral particles. However, efficacy of routine antenatal screening in reducing the rate of fetal disease is limited. CONCLUSION: It is concluded that at present the accuracy of tests used for the diagnosis of in utero cytomegalovirus infection is undetermined. Serologic screening of all pregnant women is of limited value and at present is not recommended.

Prenatal care: an update and future trends.

Prenatal care gained universal acceptance during this century, but its efficacy and impact has been questioned widely. Many studies have linked inadequate, or lack of, prenatal care with adverse pregnancy outcomes; however others have failed to confirm the association. This article reviews salient aspects of standard prenatal care, and presents future trends in this field.

The evaluation of accelerated fetal growth.

The timely recognition of fetal macrosomia may reduce the complications associated with vaginal delivery of a macrosomic fetus. Today, the most frequently used tool for identification of fetal macrosomia is ultrasound. Although many different calculations have been applied, the most commonly used is the estimation of fetal weight. Generally, the detection rate of fetal macrosomia is 33-82%, with a specificity of 70-100%, a positive predictive value of 40-83%, and negative predictive value of 66-92%. Adding amniotic fluid volume, cheek-to-cheek diameter or fetal subcutaneous tissue: femur length ratio may improve the accuracy of the diagnosis. Other promising diagnostic tools include the echo-planar imaging and the neural network. Despite the progress that has been achieved since the use of Nagele's rule, our ability to fetal macrosomia remains limited.

The impact of external cephalic version on the rate of vaginal and cesarean breech deliveries: a 3-year cumulative experience.

The authors have reviewed the impact of their practice of external cephalic version (ECV) at term, with respect to success rate, factors associated with successful version and the effect of this protocol on the overall breech and cesarean breech rate. Two hundred and forty-nine parturients identified as having a breech presenting fetus after the 36th gestational week over a 3-year period, after excluding contraindicated cases, were offered a trial of ECV, with the use of ritodrine tocolysis. ECV was effected by one operator, using the minimally effective force necessary. Successful ECV was achieved in 196 attempts (78.7%). No deleterious effects in fetuses or mothers were noted. Of successfully turned fetuses, 78% eventually had a vaginal vertex delivery. Parity, birthweight and amount of amniotic fluid were found to have a significant effect on the success rate of ECV, whereas gestational age at version or placental location were not found to have a significant effect on success rate. Introduction of the ECV protocol effected a significant decrease in breech presentation at term, from 3.9 to 2.4% (P < 0.01), which can be translated into a decrease of 5.5% in the overall cesarean section rate. The authors conclude that ECV is a safe and effective procedure, in properly selected cases. Institution of a screening protocol to identify breech presentation after 36 weeks, and utilizing ECV where possible, may lead to a significant reduction in the breech delivery rate, and may prevent serious infant morbidity.

Prevention of diabetes-associated embryopathy by overexpression of the free radical scavenger copper zinc superoxide dismutase in transgenic mouse embryos.

OBJECTIVES: It has recently been suggested that oxygen free radicals are involved in the high incidence of fetal dysmorphogenesis that is associated with diabetic pregnancies. The purpose of the current investigation was to study the effect of copper zinc superoxide dismutase, a free radical scavenging enzyme, on the prevention of diabetes-associated embryopathy in mice. STUDY DESIGN: Mice used in this study were either transgenic, bearing the human copper zinc superoxide dismutase gene, or nontransgenic controls. Diabetes was generated by streptozotocin administration on days 6 and 7 of gestation. Hyperglycemia developed on day 8 and was maintained through day 10 (critical period of organogenesis). On day 10 fetuses were examined for external anomalies, and their crown-rump lengths and deoxyribonucleic acid content were determined. RESULTS: Induction of maternal diabetes produced a significant reduction in mean crown-rump length of control embryos (4.48 +/- 0.7 mm vs 3.65 +/- 0.6 mm, p = 0.0001), whereas transgenic embryos were not affected (4.72 +/- 0.6 mm vs 4.45 +/- 0.8 mm, p > 0.05). After induction of diabetes fetal loss and malformation rates were significantly higher in control embryos (6.0% vs 23.8% and 8.4% vs 16.5%, respectively). Transgenic embryos were practically unaffected by diabetes and showed fetal loss and malformation rates of 5.9% and 4.4%, respectively, after induction of diabetes. CONCLUSIONS: Elevated levels of copper zinc superoxide dismutase, a key enzyme in the metabolism of free oxygen radicals, elicit a protective effect against diabetes-associated embryopathy.

Management of breech presentation: the 1993 Israeli census.

OBJECTIVES: To investigate current attitudes to management of labor and delivery in pregnancies complicated by breech presentation. STUDY DESIGN: A questionnaire was sent to the directors of 23 units of maternal-fetal medicine, all members of the Israel Society of Perinatal Obstetricians. The survey included 69,072 deliveries in the year 1993. Current world literature on the topics included in the survey was also reviewed. RESULTS: The overall response rate was 83% (19/23). The overall breech presentation rate was 3.4%, and overall caesarean section rate was 11.2%. In breech presentation, the caesarean section rate was 63.6%. CONCLUSIONS: A rational approach allows vaginal breech delivery to be practiced in almost half of carefully selected cases. These results again emphasize the longstanding need for prospective randomized studies regarding the different aspects associated with the delivery of the fetus in breech presentation.

Labor and delivery complicated by acute mitral regurgitation due to ruptured chordae tendineae.

Acute mitral regurgitation due to ruptured chordae tendineae is a dramatic and life-threatening clinical situation. Rarely does this complication occur during pregnancy. We present a case of a 30-year-old woman in week 31 of her pregnancy who developed acute mitral regurgitation, secondary to bacterial endocarditis and ruptured chordae tendineae. This acute event resulted in preterm labor a few hours later. Delivery was uneventful and successful and was followed by open heart surgery 5 days later. A review of the literature on chordae tendineae rupture and resulting mitral regurgitation during pregnancy is presented.

Development of proliferative retinopathy in a gestational diabetes patient following rapid metabolic control.

Rapid glucose control was achieved by insulin therapy in a patient diagnosed to have gestational diabetes at 8 weeks of pregnancy. A decrease of the initially high hemoglobin A1c level (16.2%) to normal values (5.9%) was achieved within 12 weeks. At 31 weeks severe bilateral proliferative diabetic retinopathy developed. To our knowledge this case is the first report of a patient with gestational diabetes who developed de novo proliferative diabetic retinopathy.

Reversal of fetal distress following intensive treatment of maternal diabetic ketoacidosis.

Diabetic ketoacidosis during pregnancy is frequently associated with fetal distress that may result in fetal death in utero. A patient at 33 weeks of pregnancy with diabetic ketoacidosis and evidence of fetal distress is presented. Following intensive medical treatment, maternal metabolic state improved along with improvement of fetal heart rate tracing. A healthy infant was delivered by cesarean section at 36 weeks of gestation.