Optimal gestational age for twin delivery.

OBJECTIVE: We evaluated the timing of twin delivery associated with perinatal outcome in gestations of at least 36 completed weeks. STUDY DESIGN: This was a retrospective analysis of infant and maternal hospital records for a consecutive series of twin deliveries at New York Hospital-Cornell Medical Center. The inclusion criteria were delivery after 36 weeks' gestation during a 7-year period (1987 to 1993), without congenital anomalies or early fetal demise. Adverse perinatal outcomes were compared between deliveries before 38 weeks' gestational age and those at or after 38 weeks' gestation. RESULTS: Of 776 twin deliveries during the study period, 329 met the inclusion criteria. Adverse perinatal outcome was significantly higher among the twin pregnancies that delivered before 38 weeks' gestation compared with those that delivered at or after 38 weeks' gestation. Twin pregnancies that delivered between 36 and 37 weeks' gestation were 13 times more likely to require neonatal intensive care compared with those who delivered at or after 38 weeks' gestation (95% confidence interval 1.8 to 95.9; p < 0.001). CONCLUSION: In uncomplicated twin gestations, delivery at between 36 and 37 weeks' gestation was not associated with a reduction in neonatal complications compared with deliveries at or after 38 weeks' gestation.

Detection of endocervical anti-Chlamydia trachomatis immunoglobulin A in pregnant women by a rapid, 6-minute enzyme-linked immunosorbent assay: comparison with PCR and chlamydial antigen detection methods.

There is a need for a rapid, uncomplicated, and inexpensive test for Chlamydia trachomatis infection in women. We evaluated the ability of a 6-min enzyme-linked immunosorbent assay (ELISA) that requires no laboratory equipment (IgA Rapid SeroTest; Savyon Diagnostics) to detect C. trachomatis immunoglobulin A (IgA) in the endocervices of 167 inner-city pregnant women and compared the results with DNA amplification (Amplicor PCR; Roche Diagnostics) and antigen detection (Chlamydiazyme; Abbott Laboratories) performed on the same women. Anti-C. trachomatis IgA was detected in the cervices of 32 women (19.2%). Samples from 23 women (13.8%) were PCR positive, while chlamydial antigen was present in 20 women (12.0%). There was only 1 sample (4.3%) that was positive by PCR but negative by ELISA; 10 samples were ELISA positive and PCR negative. In contrast, seven samples (30.4%) were PCR positive but Chlamydiazyme negative and four were Chlamydiazyme positive and PCR negative. Compared to PCR, the IgA ELISA had a sensitivity of 95.7%, a specificity of 93.1%, a positive predictive value of 68.8%, and a negative predictive value of 99.3%. The antigen assay had a sensitivity of only 69.6%, a specificity of 97.2%, a positive predictive value of 80.0%, and a negative predictive value of 95.2%. In high-risk groups where laboratory testing is not available, or where the patient might not return to obtain her testing result and be treated, the Rapid IgA SeroTest is a viable alternative for detection of cervical C. trachomatis in pregnant women.

Role of amniotic fluid in newborn acceptance and bonding in canines.

Maternal behavior, such as licking and cleaning of the newborn, and oral consumption of the placenta and membranes is characteristic of nearly all mammals. They are the first step toward maternal acceptance and bonding in canines. Factors affecting these initial behaviors are unclear. Also the impact of these initial behaviors in regard to establishing long-term newborn acceptance and bonding is unclear. We undertook this study to determine the role of the amniotic fluid on newborns and oral consumption of the placenta and membranes on the initial development of the maternal-newborn relationship. Thirty litters were studied, nine serving as controls in which the maternal and neonatal behaviors were simply observed for 36 h after delivery. Twenty-one litters underwent three different manipulations and served as the study groups. The first study group consisted of nine litters where the pups, placenta, and membranes were immediately separated from the mother at birth. Pups were washed three times and returned to the mother, and observation began. The second group of nine litters had the pups, placentas, and membranes immediately removed from the mother at birth. These pups were washed three times and returned to their mother. After 2.5 h of observations, pups were bathed in their amniotic fluid and the placenta and membranes returned to mother. In the third study group, three litters had the pups immediately separated from their mother, washed only once, and returned to their mother. The placenta and membranes were removed permanently in this case. In the control group, acceptance of pups was universal. In the first study group, all pups were rejected for the entire 36 h of observation. In the second study group, all pups were rejected until they were bathed in amniotic fluid and the placentas returned to the mother. At this point, the mother accepted all pups. In the third study group, all pups were accepted by the mother during the entire observation period. It appears that having the amniotic fluid on pups is an important signal for the mother to begin licking, accepting, and establishing maternal bonding with the newborn in canines. In the absence of amniotic fluid on the pups, rejection for the first 36 h was universally present.

Biochemical markers predictive of preterm delivery.

Preterm delivery is the leading cause of perinatal morbidity and mortality worldwide. Despite a great deal of research into this disease, we still do not understand its pathophysiology. Our treatments for this disease are only marginally effective. Biochemical markers were developed with the hope of giving us new tools to prevent preterm deliveries. Specifically the hope was that they could predict which patients were destined to have a preterm delivery. At the present time these markers perform only satisfactorily at predicting preterm labor. They are expensive and not convenient to use at present. Perhaps more importantly, though, these markers have given us insight into the complexities of preterm delivery. Preterm delivery can arise from many different etiologies. This will lead to research into new treatments as knowledge about preterm delivery is amassed. We know that any number of pathological processes may be involved in any given patient with preterm labor. Biochemical markers have the distinct advantage of being able to determine the specific pathophysiology in a given patient and may allow us to tailor therapy according to the specific problem. In the future it is likely that a careful search for specific pathophysiology will be the only way we can treat this disease effectively. For the present time the biochemical markers will be used only to predict preterm delivery. Ultrasound measurements of the cervix during the pregnancy are likely a faster and less expensive way to accomplish that goal.

Detection of Chlamydia trachomatis and Trichomonas vaginalis by polymerase chain reaction in introital specimens from pregnant women.

OBJECTIVE: We analyzed whether specimens obtained from the vaginal introitus were comparable to endocervical and posterior vaginal vault specimens for detection of Chlamydia trachomatis and Trichomonas vaginalis by polymerase chain reaction. STUDY DESIGN: Introital and endocervical specimens were obtained from 300 women at the first prenatal visit. Specimens from the posterior vaginal vault were also obtained from 219 of these patients. All samples were tested for C. trachomatis and T. vaginalis by polymerase chain reaction. RESULTS: C. trachomatis was identified in the endocervices of 36 women (12.0%); all but one of these women and none of the endocervical-negative women were positive for this organism in the introitus. T. vaginalis was detected in 22 women (10.0%); all but one were also introitus positive for this organism. Compared with endocervical and vaginal polymerase chain reaction, introital testing had a 100% specificity and a 97.2% and 95.5% sensitivity for detecting C. trachomatis and T. vaginalis, respectively. CONCLUSION: Polymerase chain reaction analysis of vaginal introital specimens is highly sensitive and specific in detecting C. trachomatis and T. vaginalis in pregnant women and thus provides an alternative to speculum examination in screening for these pathogens.

Conflicts between physicians and patients in non-elective cesarean delivery: incidence and the adequacy of informed consent.

A study was undertaken in 372 consecutive patients undergoing non-elective cesarean delivery to explore the incidence and nature of conflicts between physician and patient surrounding the decision to undergo non-elective cesarean delivery; to examine the adequacy of informed consent at the time of non-elective cesarean delivery; and to describe the importance of a preventive ethics approach to non-elective cesarean delivery. During a 6-month interval, all patients who underwent non-elective cesarean delivery and their physicians were asked to take part in a survey in the early postpartum period concerning their response to recommendations for cesarean delivery. The survey included demographics as well as questions pertaining to informed consent and the presence and nature of patient-physician conflict. Of the 326 patients who were interviewed, 319 (98%) agreed to the recommendation for non-elective cesarean delivery and 7 patients (2%) initially disagreed. Reasons for disagreeing included: feared surgery (4 of 7), needed husband's approval (1 of 7), and questioned the medical necessity of surgery (2 of 7). In all 7 cases of initial disagreement, cesarean delivery was eventually performed with the patient's consent. The mean age of patients who initially disagreed was younger (24.7 +/- 6) than that of those who agreed (31.0 +/- 4 [p < 0.05]). Conflicts were present in 7 of 113 clinic patients and 0 of 213 private patients (p < 0.05). Of those surveyed, 26 (8.7%) indicated that they did not have adequate input in the decision for non-elective cesarean delivery. Patients with inadequate input expressed significantly more concerns with regard to the effect of surgery on their own health (p < 0.05) as well as its effect on the baby (p < 0.05). Our findings suggest that even though the incidence of physician-patient conflict about non-elective cesarean delivery was quite low, a significant number of patients (1 in 12) may have reservations concerning the informed consent process at the time of non-elective cesarean delivery. Patients with reservations are more likely to have greater concerns with regard to maternal and fetal risks, suggesting that a more detailed risk disclosure prior to the procedure is warranted for all pregnant patients. Perhaps by incorporating the preventive strategies discussed, the adequacy of informed consent and therefore the patient's autonomy could be enhanced, thus diminishing patient reservations and preventing physician-patient conflict in the intrapartum period.

Advantages of larger volume, less frequent intrauterine red blood cell transfusions for maternal red cell alloimmunization.

Larger volume intravascular transfusions to manage severe maternal red cell alloimmunization in pregnancy may prolong the interval between procedures without increasing maternal, fetal, or neonatal complications. A retrospective cohort study compared the management and outcome of 19 patients with severe red cell alloimmunization managed at two facilities with different intravascular transfusion protocols. The volume of blood transfused, pre- and post-transfusion fetal hematocrit, and interval (days) between intravascular transfusions were compared. The respective maternal, fetal, and neonatal results were compared. The red blood cell volume transfused per procedure and the post- but not pre-transfusion fetal hematocrits were higher at New York Hospital than at Westchester County Medical Center. The interval between transfusions at New York Hospital (25.2 +/- 8.65 days) was longer than at Westchester County Medical Center (13.5 +/- 6.0 days, p < 0.0001). Although larger volume transfusion was occasionally associated with transient fetal bradycardia, all red blood cell transfusions were completed without complication. The adverse outcomes, complication rates, and neonatal outcomes were otherwise similar in both management protocols. It is possible to significantly increase the interval between intravascular transfusions with larger transfusion volumes for the management of severe maternal red cell alloimmunization without undue risk. The overall risk for the fetus and mother may be reduced by performing fewer transfusions and avoiding additional blood product exposures.

Detection of tumor necrosis factor-alpha, interleukin-6, and fetal fibronectin in the lower genital tract during pregnancy: relation to outcome.

OBJECTIVE: Our purpose was to determine whether tumor necrosis factor-alpha, interleukin-6, and fetal fibronectin could be identified in the lower genital tract during pregnancy and whether their occurrence was associated with preterm delivery. STUDY DESIGN: A prospective cohort study was undertaken of 111 pregnant women in which cervicovaginal swabs were obtained at < 37 weeks' gestation. Seventy-three specimens were obtained from women during routine prenatal examination, whereas 38 specimens were obtained from women undergoing evaluation of preterm labor. Interleukin-6 and fetal fibronectin levels were determined by enzyme-linked immunosorbent assays, whereas tumor necrosis factor-alpha determinations were by bioassay. Urinary tract and lower genital tract samples were cultured for evidence of infection. The rates of maternal and neonatal complications were assessed. RESULTS: In patients undergoing evaluation for preterm labor the presence of tumor necrosis factor-alpha or fetal fibronectin was associated with an increased prevalence of preterm delivery. Women with tumor necrosis factor-alpha had a 6.19 greater risk (p < 0.005), whereas the presence of fetal fibronectin was associated with a 4.81 greater risk (p < 0.05), of preterm birth. This association was not evident in women who were sampled during routine prenatal examinations. In all women the presence of cytokines in the lower genital tract correlated with detection of fetal fibronectin. CONCLUSION: Localized inflammatory responses may lead to microscopic disruption in the amniotic membranes, leading to leakage of fibronectin. In patients being evaluated for preterm labor, the presence of tumor necrosis factor-alpha or fetal fibronectin in the lower genital tract is predictive of subsequent preterm delivery.

The use of vibroacoustic stimulation during the abnormal or equivocal biophysical profile.

OBJECTIVE: To determine whether vibroacoustic stimulation during the biophysical profile can change the fetal behavioral state and thus improve the score without increasing the false-negative rate of the test. METHODS: Eighty-one patients whose biophysical profile scores were 6 or lower after 15 minutes of observation had an electronic artificial larynx applied to the maternal abdomen in the region of the fetal head for 3 seconds, followed by continued observation for fetal movement, tone, and breathing for 15 minutes. We compared the obstetric and neonatal outcomes of 41 patients whose biophysical profile scores improved to normal after vibroacoustic stimulation with those of 283 patients whose scores were normal without vibroacoustic stimulation. RESULTS: Vibroacoustic stimulation did improve an abnormal or equivocal biophysical profile score to normal in 67 of 81 cases (82%). No antepartum stillbirths or perinatal deaths occurred. There was no increase in the obstetric and neonatal complication rates of cesarean delivery for fetal distress, meconium staining of the amniotic fluid, and the incidence of small for gestational age infants. CONCLUSION: Vibroacoustic stimulation improved the biophysical profile scores in most cases, an effect seen throughout the third trimester. Vibroacoustic stimulation did not appear to increase the false-negative rate of the biophysical profile and may reduce the incidence of unnecessary obstetric intervention.