Disposition of sperm donors with resultant abnormal pregnancies.

We wished to determine how clinicians manage sperm donors whose offspring have chromosomal or structural abnormalities. A directed, multiple-choice survey was given to reproductive endocrinologists and obstetrical geneticists to assess management of sperm donors whose offspring have chromosomal or structural abnormalities. The questionnaire was completed by 66 reproductive endocrinologists and obstetrical geneticists. Abnormalities and the most common inheritance modes included: Trisomy 21 (aneuploidy, maternal origin), Turner syndrome (aneuploidy, paternal origin), cleft lip/palate (multifactorial), VATER sequence (vertebral defects, imperforate anus, tracheo-esophageal fistula, radial and renal dysplasia, sporadic inheritance), and Hurler syndrome (autosomal recessive). Response choices were: (i) remove donor from programme, (ii) inform potential recipients of prior pregnancy outcomes and continue to use donor, or (iii) further study donor to assess karyotype/mutations. Inheritance mode appeared to influence decisions to remove donors from sperm banks; however, no clear consensus was noted. Guidelines exist for screening potential gamete donors, but not for managing donors whose offspring has a chromosomal or structural abnormality. Guidelines must be developed to manage sperm donors with untoward pregnancy outcomes.

Renal biopsy and pregnancy.

OBJECTIVE: Our aim was to review our experience with renal biopsy in pregnancy. STUDY DESIGN: We reviewed 18 renal biopsies performed during pregnancy or in the immediate postpartum period at the University of North Carolina. Indications, histopathologic findings, complications, and neonatal outcome were reviewed for each case. RESULTS: Fifteen patients underwent biopsy during the antepartum period and 3 in the postpartum period. Only 5 patients had the classic histopathologic preeclamptic lesion glomeruloendotheliosis confirmed. There were 7 identifiable renal hematomas after biopsy; 2 patients required blood transfusion. There were 4 intrauterine fetal deaths in this series; it is presumed that none were a result of the biopsy. CONCLUSION: Renal biopsy in pregnancy is a morbid procedure and should be considered only if it offers the opportunity to make a diagnosis other than severe preeclampsia in a patient remote from term.

Pregnancy in transplant recipients.

A growing number of transplant recipients are women of reproductive age or children who will reach reproductive age. Thus, menstrual function and pregnancy increasingly are important issues because fertility is restored to women who were previously unable to conceive. To date, successful pregnancies have been reported in female recipients of kidney, liver, heart, pancreas-liver, bone marrow, and lung transplants. Women often become pregnant while being maintained on numerous medications, including immunosuppressive agents, and their care providers must be able to counsel and care for them. Information to date suggests that immunosuppressive medications are safe for use during pregnancy and are important in preventing maternal and fetal complications secondary to graft rejection. Although no formal guidelines have been established due to limited clinical experience, there are a few criteria that are commonly agreed on to improve the probability of a successful pregnancy outcome and the maintenance of graft function in transplant patients. Successful management of the pregnant transplant patient requires a cooperative effort between the obstetrician and transplant team.

Neonatal skin care: evaluation of the AWHONN/NANN research-based practice project on knowledge and skin care practices. Association of Women's Health, Obstetric and Neonatal Nurses/National Association of Neonatal Nurses.

OBJECTIVE: To develop and evaluate an evidence-based clinical practice guideline for assessment and routine care of neonatal skin, educate nurses about the scientific basis for practices recommended in the guideline, and design procedures that facilitate implementation of the project guideline into clinical practice. DESIGN: Descriptive report of the collaborative neonatal skin care research-based practice project of the Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. SETTING: Neonatal intensive-care unit (NICU) and special-care nurseries and well-baby nurseries in 51 hospitals located throughout the United States. PARTICIPANTS: Member site coordinators (N = 51), nurses who work at the selected sites, and the neonates observed during both the pre- and postimplementation phases of the project (N = 2,820). METHOD: An evidence-based clinical practice guideline was developed, sites were selected from all respondents of the call for sites, site coordinator training was provided, data collection was facilitated by project-specific data collection tools, and the project was evaluated by the science team. MAIN OUTCOME MEASURES: Diversity and numbers of sites represented, patient representation, site coordinator knowledge of neonatal skin care pre- and postimplementation, use of project-designed implementation tools, satisfaction with project guideline and the data collection process, changes in practices and product use, and site coordinators' experiences during guideline implementation. RESULTS: Fifty-one sites completed the project, representing NICU, special-care, and well-baby nurseries in both academic and community hospital settings in 27 states. Registered nurses working in these sites totaled 4,754 full-time equivalent positions (FTEs) (in NICU/special-care and well-baby nurseries). Site coordinators demonstrated increased knowledge of research-based neonatal skin care and satisfaction with the implementation tools and data collection process. Product use changed, reflecting acquisition of new knowledge. Barriers to implementation of the guideline were identified. CONCLUSIONS: The AWHONN/NANN Neonatal Skin Care Research-Based Practice Project demonstrated increased knowledge among site coordinators who received training, facilitated changes in neonatal skin care as defined by the practice guideline, and thus advanced evidence-based clinical practice.

Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses.

OBJECTIVE: To test the effectiveness of an evidence-based clinical practice guideline for neonatal skin care on selected clinical outcomes for newborns in neonatal intensive-care units (NICU), special-care units (SCU), and well-baby nurseries. DESIGN: Prospective evaluation of the collaborative neonatal skin care research-based practice project of the Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. SETTING: NICU and well-baby units in 51 hospitals located throughout the United States. PARTICIPANTS: Member site coordinators (N = 51) and the neonates (N= 2,820) observed during both the pre- and postimplementation phases of the project. METHOD: Site coordinators received specialized education in neonatal skin care and implemented an evidence-based clinical practice guideline addressing 10 aspects of neonatal skin care. Baseline observations of skin condition, care practices, and environment of newly admitted neonates were collected by site coordinators. Postimplementation observations were then completed. MAIN OUTCOME MEASURES: Skin condition was assessed with the Neonatal Skin Condition Score (NSCS), which ranges from a score of three (best condition) to a score of nine (worst condition), based on dryness, erythema, and skin breakdown. Changes in frequency of selected skin care practices were used to assess the effectiveness and feasibility of using the practice guideline in everyday clinical practice. Aspects of the care environment with potential effect on skin integrity were monitored to determine risk factors. RESULTS: Fifty-one site coordinators made 11,468 systematic assessments of 2,464 NICU and SCU newborns and 356 well newborns. Baseline skin scores were better in well newborns compared with premature newborns. After implementation of the guideline, skin condition was improved, as reflected by less visible dryness, redness, and skin breakdown in both the NICU/SCU and well newborns. The guideline was integrated into care, as evidenced by increased use of emollients, particularly with premature infants, and decreased frequency of bathing. A relationship was shown between selected aspects of the environment and alterations in skin integrity. CONCLUSIONS: Use of the AWHONN/NANN Neonatal Skin Care Research-Based Clinical Practice Guideline was successfully implemented at 51 sites, and effectiveness was demonstrated by changed care practices and improved skin condition in premature and full-term newborns. The results of this project support a wider dissemination of the project's practice guideline for neonatal skin care.

Preeclampsia into eclampsia: toward a new paradigm.

OBJECTIVE: This study was undertaken to characterize aspects of the natural history of eclampsia. STUDY DESIGN: A retrospective analysis was performed on the records of patients with eclampsia who were delivered at two tertiary care hospitals. RESULTS: Fifty-three pregnancies complicated by eclampsia were identified. Thirty-seven of the women were nulliparous. The mean age was 22 years (range, 15-38 years). Mean gestational age at the time of seizures was 34.2 weeks' gestation (range, 22-43 weeks' gestation). Twenty-eight women had antepartum seizures (53%); 23 of the 28 had seizures at home. Nineteen women had intrapartum seizures (36%). Eight of these women had seizures while receiving magnesium sulfate, and 7 had therapeutic magnesium levels. Six women had postpartum seizures (11%), 4 >24 hours after delivery. Headache preceded seizures in 34 cases. Visual disturbance preceded seizures in 16 cases. The uric acid level was elevated to >6 mg/dL in 43 women. There were no maternal deaths or permanent morbidities. There were 4 perinatal deaths. Two patients had intrauterine fetal deaths at 28 and 36 weeks' gestation. These mothers had seizures at home. One infant died of complications of prematurity at 22 weeks' gestation and one died of respiratory complications at 26 weeks' gestation. There were 4 cases of abruptio placentae, 1 of which resulted in fetal death. Of the 53 cases of eclampsia, only 9 were potentially preventable. One of these was that of a woman who was being observed at home. The other 8 women were hospitalized and had hypertension and proteinuria. Only 7 women could be considered to have severe preeclampsia before seizure (13%), and 4 of these 7 women were receiving magnesium sulfate. CONCLUSIONS: Eclampsia was not found to be a progression from severe preeclampsia. In 32 of 53 cases (60%) seizures were the first signs of preeclampsia. In this series eclampsia appeared to be more of a subset of preeclampsia. Only 9 cases of eclampsia were potentially preventable with current standards of practice. Our paradigm for this disease, as well as our approach to seizure prophylaxis, should be reevaluated.

Central hemodynamic effects of an oxytocin receptor antagonist (atosiban) in the isolated, perfused rat heart.

OBJECTIVE: Atosiban is a selective oxytocin receptor antagonist capable of inhibiting oxytocin-induced contractility of the uterus. Trials of this agent in intact animals and women as a tocolytic agent for preterm labor have shown atosiban to be devoid of cardiac effects. This is in contrast to other tocolytic agents, which have profound hemodynamic effects. We conducted this study to determine the cardiac effect of atosiban in the isolated, perfused rat heart model. METHODS: Hearts were excised from 60 female Sprague-Dawley rats and attached to a Langendorff apparatus. Left ventricular systolic pressure, heart rate, and contractility were measured. Hearts from half of the animals were exposed serially to 300 micrograms/min, 600 micrograms/min, and 1200 micrograms/min of atosiban. The remaining hearts formed the control group and were exposed to aerated Krebs solution. RESULTS: There were no significant differences between hearts exposed to atosiban and hearts within the control group for heart rate, left ventricular systolic pressure, and contractility. P values ranged from .12 to .73. CONCLUSIONS: Using a classic physiologic model to study cardiac performance and drug effects, we were unable to detect any central hemodynamic effects of atosiban. This is in contrast to oxytocin, which we previously studied and found negative chronotropic and positive ionotropic effects.

Peripartum cardiomyopathy: a review of the literature.

UNLABELLED: Peripartum cardiomyopathy (PPCM) is a poorly characterized, rare form of cardiomyopathy. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The presentation is similar to other forms of congestive heart failure; the diagnosis of PPCM should not be considered until other causes of cardiac dysfunction are ruled out. Echocardiography is central to diagnosis. Early diagnosis and initiation of treatment are essential to optimize pregnancy outcome. Intensivists and anesthesiologists should be consulted to assist with management in complicated cases. Management of PPCM is essentially supportive. Prognosis is poor, although cardiac transplant is improving prognosis and should be considered when conventional therapy fails. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to understand the typical presentation of peripartum cardiomyopathy including adverse outcome predictors, to understand how to make the diagnosis of PPCM and how to manage it, and to understand the natural history of the disease.

Urinary incontinence in pregnancy and the puerperium: a prospective study.

OBJECTIVE: Pregnancy and childbirth are commonly thought to be associated with the development of urinary incontinence and lower urinary tract symptoms. The purpose of this study was to assess the relationship, if any, between pregnancy and the development of lower urinary tract symptoms. STUDY DESIGN: A prospective study of lower urinary tract symptoms was carried out in a cohort of pregnant women who answered a series of symptom questionnaires and kept a 24-hour bladder chart on which frequency of urination and volumes voided were recorded throughout pregnancy and for 8 weeks after birth. RESULTS: A total of 123 women participated in the study. Mean daily urine output (P =.01) and the mean number of voids per day (P =.01) increased with gestational age and declined after delivery. Episodes of urinary incontinence peaked in the third trimester and improved after birth (P =.001). White women had higher mean voided volumes and fewer voiding episodes than did black women. Ingestion of caffeine was associated with smaller voided volumes and greater frequency of urination. CONCLUSION: Pregnancy is associated with an increase in urinary incontinence. This phenomenon decreases in the puerperium. Pregnancy and childbirth trauma are important factors in the development of urinary incontinence among women. These findings warrant further investigation.

Management of cervical cerclage after preterm premature rupture of membranes.

The optimal management of preterm premature rupture of membranes (PPROM) in a patient with a cerclage is controversial. The issues are whether the latency period between rupture of membranes and delivery is decreased if the cerclage is removed and whether there is an increased rate of maternal or neonatal infection if the cerclage is kept in place. The data are sparse in directing management of women with prophylactic cerclages placed earlier in their pregnancies who rupture membranes. Latency seems to be increased if the cerclage is kept in place, but maternal and neonatal infectious morbidity is increased also. In women at early gestational ages, keeping the cerclage in place may be warranted until labor ensues. In more advanced gestations, it seems preferable to immediately remove the cerclage upon diagnosis of PPROM.

Prenatal diagnosis and perinatal management of fetal sacrococcygeal teratoma.

Sacrococcygeal teratoma is the most common fetal neoplasm, with an incidence of 1 in 40,000 births. Fetuses with this malformation are at risk for significant perinatal morbidity and mortality. We identified nine fetuses with sacrococcygeal teratomas that were diagnosed antenatally and managed at the University of North Carolina Hospitals over a 7-year period. We retrospectively reviewed the charts of mothers and infants and recorded data concerning perinatal and surgical management. Six infants survived the neonatal period. All infants diagnosed after 20 weeks' gestation survived. Fetal hydrops developed in three fetuses, all of whom died. Inadequate ventilation secondary to prematurity was a contributing factor in each lethal case. Diagnosis at an early gestational age, development of fetal hydrops, and premature delivery predicted a poor prognosis. When possible, we recommend that delivery be delayed to allow for fetal development. Stabilization of the infant should be attempted before resection of the teratoma.

Prenatal diagnosis and perinatal management of fetal sacrococcygeal teratoma.

Sacrococcygeal teratoma is the most common fetal neoplasm, with an incidence of 1 in 40,000 births. Fetuses with this malformation are at risk for significant perinatal morbidity and mortality. We identified nine fetuses with sacrococcygeal teratomas that were diagnosed antenatally and managed at the University of North Carolina Hospitals over a 7-year period. We retrospectively reviewed the charts of mothers and infants and recorded data concerning perinatal and surgical management. Six infants survived the neonatal period. All infants diagnosed after 20 weeks' gestation survived. Fetal hydrops developed in three fetuses, all of whom died. Inadequate ventilation secondary to prematurity was a contributing factor in each lethal case. Diagnosis at an early gestational age, development of fetal hydrops, and premature delivery predicted a poor prognosis. When possible, we recommend that delivery be delayed to allow for fetal development. Stabilization of the infant should be attempted before resection of the teratoma.

Neonatal skin care: the scientific basis for practice.

OBJECTIVE: To review the literature addressing the care of neonatal skin. DATA SOURCES: Computerized searches in MEDLINE and CINAHL, as well as references cited in articles reviewed. Key concepts in the searches included neonatal skin differences; neonatal skin and care practices for skin integrity; neonatal skin and toxicity; permeability; and contact irritant sensitization. STUDY SELECTION: Articles and comprehensive works relevant to key concepts and published after 1963, with an emphasis on new findings from 1993 to 1999. One hundred two citations were identified as useful to this review. DATA EXTRACTION: Data were extracted and organized under the following headings: anatomy and physiology of the skin; physiologic and anatomic differences in neonatal skin; nutritional deficiencies; skin care practices; and care of skin breakdown. DATA SYNTHESIS: Newborns' skin is at risk for disruption of normal barrier function because of trauma. In light of available evidence about differences in neonatal skin development, clinical practice guidelines are suggested for baths, lubrication, antimicrobial skin disinfection, and adhesive removal. In addition, basic care practices are suggested for maintaining skin integrity, reducing exposure to potentially toxic substances, and promoting skin health beyond the neonatal period. Preventive care recommendations are made for reducing trauma, protecting the skin's immature barrier function, and promoting skin integrity. CONCLUSIONS: This review generated evidence with which to create a new and comprehensive practice guideline for clinicians. Evaluation of the guideline is under way at 58 U.S. sites.

Cystic fibrosis and the National Institutes of Health consensus statement: are obstetrician-gynecologists ready to comply?

OBJECTIVE: To determine if obstetrician-gynecologists are ready to comply with the April 1997 National Institutes of Health (NIH) consensus statement regarding carrier screening for cystic fibrosis. METHODS: A multiple-choice questionnaire was mailed to all active North Carolina nonfederal physicians with a primary specialty of obstetrics and gynecology. Ten questions surveyed the participants' knowledge about cystic fibrosis. RESULTS: Two hundred eighty-six surveys were returned for a response rate of 30.4%. The respondents differed in their knowledge base depending on their specialty, age, and number of years of experience as a physician. The youngest physicians and the least experienced yielded the highest percentage correct. The questions most frequently answered correctly dealt primarily with clinical information about cystic fibrosis, whereas the questions most often answered incorrectly dealt with carrier frequency and testing information. CONCLUSION: The obstetrics-gynecology community is not yet prepared to comply with the NIH Consensus Statement to offer cystic fibrosis carrier screening to couples preconceptionally or prenatally. Further education is necessary before obstetrician-gynecologists can counsel patients adequately.

Neonatal skin care: the scientific basis for practice.

OBJECTIVE: To review the literature addressing the care of neonatal skin. DATA SOURCES: Computerized searches in MEDLINE and CINAHL, as well as references cited in articles reviewed. Key concepts in the searches included neonatal skin differences; neonatal skin and care practices for skin integrity; neonatal skin and toxicity; permeability; and contact irritant sensitization. STUDY SELECTION: Articles and comprehensive works relevant to key concepts and published after 1963, with an emphasis on new findings from 1993 to 1999. One hundred two citations were identified as useful to this review. DATA EXTRACTION: Data were extracted and organized under the following headings: anatomy and physiology of the skin; physiologic and anatomic differences in neonatal skin; nutritional deficiencies; skin care practices; and care of skin breakdown. DATA SYNTHESIS: Newborns' skin is at risk for disruption of normal barrier function because of trauma. In light of available evidence about differences in neonatal skin development, clinical practice guidelines are suggested for baths, lubrication, antimicrobial skin disinfection, and adhesive removal. In addition, basic care practices are suggested for maintaining skin integrity, reducing exposure to potentially toxic substances, and promoting skin health beyond the neonatal period. Preventive care recommendations are made for reducing trauma, protecting the skin's immature barrier function, and promoting skin integrity. CONCLUSIONS: This review generated evidence with which to create a new and comprehensive practice guideline for clinicians. Evaluation of the guideline is under way at 58 U.S. sites.

Prenatal diagnosis of mosaic trisomy 13: a case report.

While the clinical features associated with full trisomy 13 have been well characterized, the clinical outcome associated with mosaic trisomy 13 is much less clear. The medical literature reports a broad range of possible clinical outcomes from severe mental retardation and birth defects to normal intelligence. There is no consensus about the typical phenotype in these cases. This makes genetic counselling after prenatal diagnosis of mosaic trisomy 13 particularly difficult. Some of the medical literature attempts to correlate the percentage of trisomic cells in peripheral blood leukocytes or skin fibroblasts with clinical outcome. There have not been case reports correlating the percentage of trisomic amniocytes and clinical outcome. We report the prenatal diagnosis of mosaic trisomy 13 by amniocentesis in which no prenatal ultrasound abnormalities were noted, and autopsy was normal with the exception of the presence of a small ventricular septal defect.

Prenatal diagnosis and perinatal management of fetal sacrococcygeal teratoma.

Sacrococcygeal teratoma is the most common fetal neoplasm, with an incidence of 1 in 40,000 births. Fetuses with this malformation are at risk for significant perinatal morbidity and mortality. We identified nine fetuses with sacrococcygeal teratomas that were diagnosed antenatally and managed at the University of North Carolina Hospitals over a 7-year period. We reviewed retrospectively the charts of mothers and infants and recorded data concerning perinatal and surgical management. Six infants survived the neonatal period. All infants diagnosed after 20 weeks' gestation survived. Fetal hydrops developed in three fetuses, all of whom died. Inadequate ventilation secondary to prematurity was a contributing factor in each lethal case. Diagnosis at an early gestational age, development of fetal hydrops, and premature delivery predicted a poor prognosis. When possible, we recommend that delivery be delayed to allow for fetal development. Stabilization of the infant should be attempted before resection of the teratoma.

Perinatal outcomes in women with systemic lupus erythematosus.

OBJECTIVE: Pregnancies of women with systemic lupus erythematosus (SLE) were studied to assess the effects interaction of this disease and pregnancy. STUDY DESIGN: Charts of pregnant women with a discharge diagnosis of lupus were reviewed. Inclusion criterion was SLE diagnosed by the criteria of the American College of Rheumatology. All patients were cared for at the University of North Carolina Hospitals, a tertiary level university center. RESULTS: Between January 1988 and June 1995, we participated in the care of 21 women with the diagnosis of SLE. Their obstetric histories included a total of 56 pregnancies spanning 19 years. Obstetric histories were divided into pregnancies occurring before the patient was diagnosed with lupus and those pregnancies occurring after she had been given the diagnosis. The diagnosis of lupus was made during the course of five pregnancies; those five were categorized as occurring after diagnosis. Of the pregnancies that occurred before a woman's diagnosis of SLE, 46% resulted in live births, 36% ended in spontaneous abortion, and 18% ended in an intrauterine fetal demise. Among pregnancies occurring after the diagnosis of SLE, 85% resulted in live birth, 10% in spontaneous abortion, 3.3% in intrauterine fetal demise, and 3.3% in neonatal death. Of all live births, 53% were delivered before 37 weeks' gestation. The most common causes of maternal morbidity were joint involvement (n = 8) and dermatologic disorders (n = 6). Other clinical manifestations of SLE included nephritis (n = 5), hypertension (n = 4), pleuritis (n = 3), and thrombocytopenia (n = 3). One maternal death occurred as a result of pulmonary disease. Four pregnancies were complicated by preeclampsia. Seven patients were hospitalized during their pregnancies for lupus-related complications. CONCLUSIONS: Substantial fetal, neonatal, and maternal risks still exist for pregnant women with lupus.

Does epidural analgesia cause dystocia?

STUDY OBJECTIVE: To analyze the effects of epidural analgesia for labor when dystocia occurs. DESIGN: Retrospective cohort study. SETTING: Academic health center. PATIENTS: 641 low risk, nulliparous women in spontaneous labor. INTERVENTIONS: 406 (63%) women received epidurals analgesia and 253 (37%) did not. Sixty women (9.4%) required an abdominal delivery for dystocia. MEASUREMENTS AND MAIN RESULTS: Women receiving epidural analgesia were more likely to be white, receive care from an attending physician, need labor augmentation, and deliver a heavier infant. Multivariate analysis identified five variables predictive of dystocia and abdominal delivery: pitocin augmentation odds ratio (O.R.) = 3.9 (2.0 to 7.6), duration of labor more than 20 hours O.R. = 2.4 (1.3 to 4.4), high epidural dose O.R. = 2.2 (1.2 to 4.1), birthweight over 4,000 grams O.R. = 2.0 (1.0 to 4.2), and early placement of epidural O.R. = 1. 9 (1.0 to 3.5). Repeating the regression after excluding the 20 women who developed abnormal labor prior to epidural placement (18 of 20 women had protracted dilatation) demonstrated that pitocin augmentation O.R. = 4.0 (1.8 to 4.), high epidural dose O.R. = 3.0 (1.9 to 6.2), duration of labor greater than 20 hours O.R. = 2.7 (1.3 to 5.7), and birthweight over 4,000 grams O.R. = 2.1 (0. 9 to 4.8) were associated with dystocia. CONCLUSION: Epidural analgesia appears to be a marker of abnormal labor rather than a cause of dystocia. High concentration anesthetics and epinephrine should be avoided, as they may influence labor. Randomized, controlled trials of this technique will be difficult to do; our work should reassure patients and their clinicians that epidural analgesia does not adversely affect labor.