A single physician's experience with four thousand six hundred genetic amniocenteses.

OBJECTIVE: We sought to assess changes in indications, technique, successful fluid aspiration, and pregnancy outcomes in a large cohort of genetic amniocenteses performed by a single physician. STUDY DESIGN: Records were reviewed regarding 4600 women who underwent genetic amniocentesis by a single physician between 1972 and 2000. Changes in indications, procedural technique, ease of performance, amniotic fluid reports, and pregnancy loss rates were tabulated and compared over time. RESULTS: The indications for amniocentesis changed significantly (P < .0001) over time with the increasing use of maternal serum screening studies and fetal assessment by ultrasonography. The ease with which clear amniotic fluid was aspirated increased with experience, improvements in ultrasound technology, and modifications of amniocentesis technique. Procedure-related total pregnancy loss rate was 0.95%, and loss rate within 60 days of the procedure was 0.55%. Increasing operator experience did not improve the pregnancy loss rate significantly. CONCLUSIONS: Successful aspiration of clear amniotic fluid increases with amniocentesis experience. Pregnancy outcome did not change significantly with increasing amniocentesis experience.

Pregnancy anxieties and natural recognition in baby-switching.

Recent media reports in the USA of baby-switching at birth have caused anxiety for a number of maternity patients. Although alternative precautionary procedures are being implemented by hospitals to prevent baby-switching, ways to allay the maternity patient's anxiety must also be considered. While maternity patients can be expected to recognize their neonates, it is less clear how well they perform recognition under specified conditions. An American team of researchers noted postpartum mothers' anxiety levels and their natural cues to recognize crying sounds and garment smells of their babies as preventive measures against baby-switching. An experimental study design was used to conduct this research. Participants completed a demographic form and Levin's pregnancy anxiety instrument, followed by three recognition challenges for hearing and smelling cues. Ten per cent of mothers reported anxiety about baby-switching, 65.9% recognized their babies from recorded crying, and 52.3% recognized their babies by smell. Mothers do have the natural ability to recognize the cries or smells of their babies, even when anxious about baby-switching. Educating new mothers, acknowledging their natural ability for baby recognition, and promoting the use of private rooms with same-room (couplet) care can serve as extra safeguards.

Indications for examination of spontaneous abortion specimens: a reassessment.

The clinical evaluation of recurrent pregnancy loss is assessed in light of recent technical advances in trophoblast culture, ultrasonography, and chromosome analysis. With an algorithm based on karyotype results, cost-benefit calculations confirm that an average savings of $1099.47 per patient could be achieved if a policy of karyotype analysis of recurrent abortion specimens was emphasized. It is estimated that a specific chromosomal cause could be identified in 45% to 70% of such cases. A more concerted effort should be made to culture trophoblast tissue from recurrent pregnancy losses; such a policy would result in both emotional and financial rewards.

Practice activities and career satisfaction among fellows of the South Atlantic Association of Obstetricians and Gynecologists.

OBJECTIVE: The practice activities and career satisfaction of obstetricians and gynecologists in private practice were compared with those in a teaching faculty setting. STUDY DESIGN: The 475 fellows of the South Atlantic Association of Obstetricians and Gynecologists were surveyed; 314 responses (66.1%) were received. Private practice and teaching faculty respondents were compared regarding practice description, factors influencing choice of practice type, practice activities, and career satisfaction. Data were examined by chi 2 testing and analysis of variance. RESULTS: Patient care involvement was the primary influence in practice choice by 86.0% of private practitioners; interest in teaching was the most important single factor for 58.2% of the teaching faculty. Significantly more teaching faculty than private practitioners had done research work during residency (81.2% vs 53.4%, p < 0.001). There were no differences regarding presentations at medical meetings during residency or publications from work performed during residency. The private practice group recorded more nights on call and more scheduled time off. The teaching faculty showed more publications, continuing medical education credits, hours worked per week, and medical meeting attendance. There were no differences in vacation days, malpractice charges, or expert witness appearances. The group showed no significant differences in their ratings of career satisfaction, but more of the teaching faculty group would elect again to enter obstetrics and gynecology if completing school today (82.4% vs 55.3%, p < 0.001). CONCLUSION: Professional activities of private practice physicians differ from those of teaching faculty physicians. The great majority of both groups are satisfied with their careers.

A counseling dilemma involving anencephaly, acrania and amniotic bands.

A suggested fetal anencephaly on routine office ultrasound examination resulted in a diagnosis of fetal acrania when targeted ultrasonography was performed by a consultant. Following pregnancy termination, examination of the abortus revealed partial cranial destruction secondary to an amniotic band. It is often difficult to distinguish between anencephaly, acrania, and amniotic band sequence prenatally, but postnatal differentiation is imperative for accurate risk assessment in genetic counseling.

Effectiveness of 1% lidocaine dorsal penile nerve block in infant circumcision.

A prospective, controlled, double-blinded investigation was conducted to evaluate whether infants undergoing circumcisions with 1% lidocaine dorsal penile nerve blocks experienced decreased stress as compared with those receiving saline solution injections or no injections. Stress was measured in terms of pulse rate and oxygen saturation on a pulse oximeter. A subjective grading scale was also developed to measure infant irritability. The total number in the study was 51 with 23 infants in the lidocaine group, 21 in the saline solution group, and 7 in the no injection group. The results of the study revealed an average increase of 28.8% in the pulse rate above baseline for the control infants (p less than 0.001) versus no significant change in the lidocaine group. The average oxygen saturation of the control groups decreased by 5.6% from baseline (p less than 0.001), and that of the lidocaine group decreased by 1.0%, which was not a significant change. The subjective data were gained by using a grading scale of 1 to 6 with 1 being the least irritable infant and 6 being the most irritable infant. The physician evaluation gave an average rating of 4.2 to the control group versus 2.4 for the lidocaine group (p less than 0.001). The nursing evaluation during the procedure gave an average rating of 4.2 to the control group versus 2.3 to the anesthetized group (p less than 0.001). The subjective evaluation of infants before and after the procedure was not significantly different. There were no major complications in any of the groups.

Ultrasound and the prenatal diagnosis of congenital anomalies: a medicolegal perspective.

A survey was conducted to determine the frequency of obstetric ultrasonography use, its value in detecting fetal anomalies, and the frequency with which ultrasound errors lead to malpractice allegations. Questionnaires were sent to one-fifth of The American College of Obstetricians and Gynecologists Fellows in District IV and were returned by 68%. Ultrasound equipment is housed in the offices of nearly 64% of the responding obstetricians, and ultrasound scanning is used in 69% of pregnancies in the district. Over 67% of obstetricians have detected one or more fetal anomalies by ultrasonography, and over 51% have overlooked anomalies. Ultrasound-related lawsuits were reported by 4.7% of the respondents.

Incidental detection of premature centromere separation in amniocytes associated with a mild form of Roberts syndrome.

Premature centromere separation (PCS) was detected in amniocytes after an amniocentesis was done because of markedly elevated maternal serum alpha-fetoprotein values in a healthy primiparous young woman. PCS has been associated with the Roberts-SC phocomelia syndrome (RS). By 23 weeks' gestation, ultrasonic evaluations did not reveal abnormal fetal development. The pregnancy continued and a male infant was born with mild manifestations of RS. PCS was confirmed in cord blood lymphocytes. This case illustrates that PCS, when detected in amniotic fluid cell cultures, requires a thorough evaluation.

Low serum alpha-fetoprotein level and sex chromosome monosomy.

A case of 45,X karyotype in association with low maternal serum alpha-fetoprotein levels is reported. Previous cases of trisomy have been linked to low alpha-fetoprotein levels. Cases of sex chromosome aneuploidy may be included in the group of aneuploidies with low levels of maternal serum alpha-fetoprotein.

Schistocytosis, aminotransferase elevation and thrombocytopenia in preeclampsia/eclampsia.

Some preeclamptic patients have schistocytosis, abnormal liver function tests and thrombocytopenia. To determine how strongly these three abnormalities cluster with each other, a sequential series of 49 preeclamptic or eclamptic patients was analyzed for the presence of schistocytosis, serum aminotransferase elevation and thrombocytopenia. These three abnormalities were found less often together (the HELLP syndrome) than singly or in pairs. These data do not clearly separate HELLP patients from other preeclamptic patients.

Sonographic findings in abdominal pregnancy.

The sonograms of 20 proven cases of abdominal pregnancy were evaluated to determine the frequency of specific abnormalities associated with this condition. The most frequent and reliable finding was separation of the uterus from the fetus (90%). Extrauterine placenta (75%) and oligohydramnios (45%) were next in frequency. Other features such as fetal parts close to the maternal abdominal wall (25%), failure to visualize myometrium between the fetus or placenta and maternal bladder (15%), abnormal fetal lie (25%), poor visualization of the placenta (25%), and maternal bowel gas impeding fetal visualization (25%) were noted.

Pseudoepidural reverberation artifact: a common ultrasound artifact in fetal cranium.

High-intensity reverberation artifacts frequently occur within the fetal cranium during obstetric ultrasound examinations. One hundred ninety-six static ultrasonograms obtained from 100 consecutive obstetric patients were reviewed to determine the incidence, shape, and location of high-intensity reverberation artifacts within the fetal head. Such artifacts occurred in one-third of the fetuses examined. The most common appearance was an arc-shaped artifact that occurred most frequently in the fetal hemicranium farthest from the maternal skin surface. Such an artifact can mimic epidural fluid collections and cause confusion for examiners not familiar with this finding. A discussion of this "pseudoepidural" artifact, its cause, and ways of excluding underlying intracranial pathology is presented.

Preterm rupture of the membranes: combination therapy.

Preterm rupture of the membranes poses perhaps the greatest threat to perinatal survival. Unfortunately, the literature leaves us in a quandry as to the management of the problem. At the Medical University of South Carolina for the past 3 years, aspects of both active and passive management have been used. Vaginal pool phospholipid analysis, the use of corticosteroids whenever appropriate, and tocolysis (in an attempt to gain 48 hours) were used in 96 consecutive patients with premature rupture of the membranes between 26 and 36 weeks' gestation. Decisions about delivery were dictated by spontaneous onset of labor and/or evidence of chorioamnionitis. This regimen prolonged gestation an average of 4.6 days. Maternal and neonatal infectious morbidity was uncommon. Clinical chorioamnionitis was diagnosed in 5.2% of mothers, and only 8.5% of all neonates had evidence of serious infection. Respiratory distress syndrome was seen in 12.8% of neonates. There were only three perinatal deaths, and most babies (92.5%) were discharged without residual problems (average hospital stay, 18.1 days). A detailed analysis of the group by gestational age categories will be presented.

Antepartum heart rate testing in diabetic pregnancy.

Fetal death in utero remains a significant contributor to diabetics' perinatal mortality despite the reassuring results of antepartum heart rate testing. We retrospectively reviewed 48 pregnancies (one set of twins) of class B-F diabetic women with a reactive nonstress test (NST) or a negative contraction stress test (CST) within one week of delivery. Four fetal deaths occurred four to seven days after the test; no fetal deaths occurred within three days of it. We advocate initial screening with the NST, followed by a CST if the NST is nonreactive. Testing should be done more often than weekly.