Antenatal testing among 1001 patients at high risk: the role of ultrasonographic estimate of amniotic fluid volume.

OBJECTIVE: Our goal was to compare the accuracy of the amniotic fluid index and the 2-diameter pocket technique with respect to accuracy in predicting an adverse pregnancy outcome among patients at high risk undergoing antenatal testing. STUDY DESIGN: All women with high-risk pregnancies and intact membranes who underwent antenatal testing during an 18-month period were prospectively enrolled. Ultrasonographic estimates of amniotic fluid volume were performed by means of the amniotic fluid index and the 2-diameter pocket technique. Relative risks with 95% confidence intervals and receiver operator characteristic curves were calculated for patients with an ultrasonographic estimate of oligohydramnios (amniotic fluid index of 5 cm or 2-diameter pocket of >15 cm2). Outcome variables studied were intrapartum and neonatal complications. RESULTS: Among 1001 patients the mean (+/-SD) amniotic fluid index was 10.5 +/- 5 cm and the mean (+/-SD) 2-diameter pocket was 18.7 +/- 13.6 cm2. Significantly more patients (46%) were considered to have oligohydramnios according to the 2-diameter pocket criteria than according to the amniotic fluid index (21%, P <.0001, relative risk 1.7, 95% confidence interval 1.5-1.8). No significant differences in the incidences of nonreactive nonstress test results, meconium-stained amniotic fluid, cesarean delivery for fetal distress, low Apgar scores, or infants with cord pH of <7.10 were observed between the oligohydramnios and normal amniotic fluid groups (P >.05) when assessed by relative risk with confidence interval and by receiver operator characteristic curves. CONCLUSIONS: Current ultrasonographic measurements with the amniotic fluid index and the 2-diameter pocket technique are poor diagnostic tests to determine whether a patient is at high risk for an adverse perinatal outcome.

Does an amniotic fluid index of

OBJECTIVE: This study was undertaken to determine whether women with high-risk pregnancies and an amniotic fluid index of /=34 weeks' gestation with an amniotic fluid index of 5 cm and the same pregnancy complication. Case patients were also matched with control subjects for maternal race, age, parity, and gestational age. RESULTS: Prospectively, 79 women at high risk with an amniotic fluid index of 5.

Membrane sweeping versus dinoprostone vaginal insert in the management of pregnancies beyond 41 weeks with an unfavorable cervix.

OBJECTIVE: To determine the best method of cervical ripening to prevent postdate inductions in women with an unfavorable cervix at 41 weeks' gestation. STUDY DESIGN: Women presenting at 41 weeks' gestation with a Bishop score of < or = 4 received daily dinoprostone (Cervidil) vaginal inserts (group I) or daily membrane sweeping (group II). RESULTS: One-hundred and eighty-two women were prospectively randomized with 91 women in each arm. The women in group II, membrane sweeping, had Bishop scores significantly greater on admission for delivery (p < 0.001), had less time elapsed from admission to delivery (p = 0.018), and had fewer labor inductions at 42 weeks (p = 0.04) than the women in group I, the dinoprostone group. In addition, a greater number of women in group II were admitted in spontaneous labor (p = 0.006) than in group I. Total antenatal costs for the membrane sweeping group was $15,120 versus $59,540 for the dinoprostone group. CONCLUSION: Daily membrane sweeping was more effective than dinoprostone administration with fewer postdate inductions at one-fourth the cost.

Can we decrease postdatism in women with an unfavorable cervix and a negative fetal fibronectin test result at term by serial membrane sweeping?

OBJECTIVE: Our purpose was to determine whether the risk for postdatism can be reduced by serial membrane sweeping in women with an unfavorable cervix at 39 weeks' gestation and a negative fetal fibronectin test result. STUDY DESIGN: Women with uncomplicated pregnancies, who were candidates for a vaginal delivery with an unfavorable cervix at 39 weeks' gestation and a negative fetal fibronectin test result were asked to participate in this investigation. Patients were chosen at random and assigned to a group for membrane sweeping every 3 days or to a control group who received gentle examinations every 3 days. RESULTS: Sixty-five women were selected at random for serial membrane sweeping (n = 33) or for the control group (n = 32). Although gestational age and Bishop score at study entry were similar, the gestational age on admission for delivery was earlier in the membrane sweeping group (39.9 +/- 0.3) versus the control group (41.5 +/- 0.6, P < .0001). The Bishop score on admission to labor and delivery was greater (8.8 +/- 2.1) in the membrane sweeping group than in the control group (6.2 +/- 2.7, P < .0001). The number of women admitted for labor inductions at 42 weeks' gestation was 18 of 32 (56%) in the control group versus none (0 of 24) in the membrane-sweeping group (P < .0001). CONCLUSIONS: Women with an unfavorable cervix at 39 weeks' gestation and a negative fetal fibronectin test result are at risk for not being delivered by 41 completed weeks and thus may require postdates induction or antenatal testing. Serial membrane sweeping significantly reduces the risk of postdatism and induction of labor.

Management of pregnancies beyond forty-one weeks' gestation with an unfavorable cervix.

OBJECTIVE: Our purpose was to determine the optimal management of pregnancies beyond 41 weeks' gestation with a cervix unfavorable for induction. STUDY DESIGN: All uncomplicated pregnancies that reached 41 weeks' gestation with a Bishop score of < or = 4 were randomly assigned to one of three groups: (1) daily cervical examinations, (2) daily membrane stripping, or (3) daily placement of prostaglandin gel until 42 weeks. RESULTS: In 105 pregnancies the Bishop score on admission to labor and delivery was significantly greater in the groups receiving prostaglandin or stripping of the membranes versus the control group, whereas the converse was time of gestational age at delivery (p = 0.0001). Fewer patients required induction in the two treatment groups (20%, 17%) versus the control (69%) patients (p < 0.0001). CONCLUSIONS: Daily membrane stripping or daily placement of prostaglandin gel is successful in reducing the number of inductions at 42 weeks for postdatism.

The incidence of respiratory distress syndrome does not increase when preterm delivery occurs greater than 7 days after steroid administration.

We sought to determine if the risk of the respiratory distress syndrome (RDS) is increased when preterm delivery occurs greater than 7 days from the last steroid administration. At our hospital, steroids were repeated weekly only on inpatients. Linking pharmacy and delivery records, we analyzed the risk of RDS with preterm delivery by interval since last steroid administration. Discriminant function analysis revealed that adjusted for gestational age, there was a negative correlation between interval since last steroids administration and risk for RDS (p<0.05, n=254). Using analysis of variance to control more precisely for gestational age (28-32 weeks, n=19) we found no difference in the risk for RDS with longer intervals since the last steroid administration. We then used multiway contingency analysis to consider intervals as zero to 7 versus greater than 7 days and similar results were obtained. Our findings suggest that the process of pulmonary maturation induced by steroid administration is permanent rather than transient. Repetitive steroid administration does not appear to be beneficial. Only a large, prospective randomized trial could definitively address the issue of repeat steroid administration. However, on the basis of our findings and review of available literature, we believe there is insufficient data to recommend weekly repeat steroid administration to women at risk for preterm delivery.

Determining the maternal and fetal cellular immunologic contributions in preterm deliveries with clinical or subclinical chorioamnionitis.

OBJECTIVE: Our purpose was to determine the maternal and fetal polymorphonuclear contributions to preterm histologic chorioamnionitis and whether this response differs in clinical chorioamnionitis when compared to cases without clinical chorioamnionitis. METHODS: Paraffin placenta blocks from 19 preterm deliveries with histologic chorioamnionitis, 9 with clinical chorioamnionitis and 10 without clinical chorioamnionitis, were identified. Only placentas from male fetuses were used. Cytospin slides were generated from tissue specimens for fluorescent in situ hybridization (FISH) and labeled with X and Y chromosome probes. Under fluorescent microscopy, polymorphonuclear cells (PMNs) were identified as having two XX signals (maternal) or a single X and Y pair (fetal). RESULTS: Maternal PMNs comprised 89% and 91% of the cellular response in the groups with and without clinical chorioaminionitis, respectively. This difference in the two groups was not statistically significant. CONCLUSIONS: The dominant contribution of PMNs seen in preterm severe histologic chorioamnionitis is maternal in origin. This response is similar in the presence or absence of clinical chorioamnionitis.

Postoperative rupture of a hepatic artery aneurysm. A case report.

BACKGROUND: Hepatic artery aneurysm is a rare finding, and its unsuspected rupture in the postoperative period can present a confusing clinical picture. CASE: A patient underwent vaginal surgery for complete procidentia and on postoperative day 1 developed hemorrhagic shock. Emergency exploratory laparotomy revealed a ruptured left hepatic artery aneurysm. CONCLUSION: Hepatic artery aneurysms are rare, and when they rupture, prompt diagnosis and therapy are essential to survival.

The relation between pulmonary hypoplasia and amniotic fluid volume: lessons learned from discordant urinary tract anomalies in monoamniotic twins.

BACKGROUND: Adequate amniotic fluid (AF) volume is one of several factors felt to be essential for normal lung development. Renal agenesis and urinary tract obstruction usually result in oligohydramnios and pulmonary hypoplasia. CASE: Two sets of monoamiotic twins with discordant urinary tract anomalies were seen. One twin in each set had anomalies that in a singleton or diamiotic pregnancy would likely have resulted in fetal pulmonary hypoplasia and subsequent death. However, neither of these infants had pulmonary hypoplasia. One infant is unique in being the first case reported of normal pulmonary function and survival despite the anomaly. CONCLUSION: Adequate AF provided by a monoamniotic twin environment may prevent pulmonary hypoplasia, which usually results from oligohydramnios due to certain fetal urinary tract anomalies.

Simultaneous carotid-vertebral reconstruction.

Vertebral atherosclerotic lesions frequently coexist with lesions in the carotid arteries. The most common cause of vertebrobasilar symptoms is hypoperfusion which may be relieved by correction of a critical carotid stenosis. A safe record with direct vertebral revascularization has led us to do simultaneous correction of lesions in the carotid and vertebral arteries through a single cervical incision. To evaluate combined carotid and vertebral reconstruction, procedures performed in a five-year period (1982 to 1987) were retrospectively studied. Thirty-six patients had combined carotid-vertebral reconstruction. In 10 patients, the primary indication was critical carotid disease; 26 patients had vertebrobasilar symptoms. The procedures performed were carotid endarterectomy with either vertebral reimplantation (22) or distal vertebral bypass (7), or external carotid angioplasty with either vertebral reimplantation (3) or distal vertebral bypass (4). Combined carotid-vertebral procedures are effective in relieving symptoms of hypoperfusion in the vertebrobasilar system. A specific lesson learned is that a distal vertebral bypass must not be done in conjunction with an external carotid angioplasty.

The carotid web: a developmental anomaly of the brachiocephalic system.

A case of a congenital carotid web is reported. This lesion is believed to be a very rare anomaly of carotid development. The embryologic development of the brachiocephalic arteries is discussed. Anomalies of the brachiocephalic arteries including anomalies of origin from the aortic arch, atresia, and persistent communications between the carotid and vertebral system are reviewed.

Gram-negative bacterial infection of aortic aneurysms.

Widespread use of antibiotics and change in pathogenesis altered the bacteriology of infected aortic aneurysms. In the past, bacterial endocarditis was the major source of emboli infecting the aorta. Now, gram-negative sepsis in elderly patients is often the initiating event of infection in atherosclerotic aneurysms. Four cases of gram-negative infection in aortic aneurysms were treated. The etiology, presentation, and surgical management are reviewed. Three abdominal aortic aneurysms were infected during urinary tract sepsis and one infection occurred with Salmonella septicemia. The clinical triad of fever, abdominal pain, and a pulsatile abdominal mass led to a preoperative diagnosis in three of four patients. Debridement of infected tissue and bypass through non-infected tissue planes remain the cornerstones of modern surgical management. Despite prompt diagnosis and proper surgical management, the mortality of gram-negative aortic infection remains high because of early rupture and extensive atherosclerotic disease.

Abdominal aortic aneurysms infected by Escherichia coli.

Three cases of atherosclerotic abdominal aneurysms infected by Escherichia coli urinary tract sepsis are presented together with a review of four additional cases of E. coli-infected aneurysms. Pathophysiology and a current system of classification of aortic infection are discussed. Important clinical features of gram-negative aortic infection include a diagnostic triad and the tendency to early rupture. Resection of infected tissue and extra-anatomic bypass for revascularization are the cornerstones of operative management. The mortality rate of E. coli aortic infection is high, with one known survivor. Death is contributed to by the high frequency of preoperative rupture, the age of the patient, and the extent of atherosclerotic disease.

Superior mesenteric artery branch aneurysms.

An example of a large, jejunal branch aneurysm is presented along with a review of 39 other cases of superior mesenteric artery branch aneurysms. current theories of etiology, including atherosclerosis, arterial dysplasia, necrotizing arteritis, and infections, are discussed. Common modes of presentation-pain, intraabdominal hemorrhage, and gastrointestinal bleeding-are reviewed. Emphasis is placed on the role of arteriography in diagnosis and management of branch aneurysms.

Eye pain due to carotid stenosis.

A 63-year-old woman presented with the acute onset of right eye pain. Ophthalmic and neurologic examinations were normal except for a loud right carotid bruit. Directional Doppler examination suggested a critical stenosis of the internal carotid artery. Subsequent arteriography revealed a 95% stenosis. The eye pain ceased following carotid endarterectomy.

A systematic approach to severe hand ischemia.

Because severely symptomatic hand ischemia is not common and because there are a wide variety of clinical conditions which can cause arterial insufficiency of the upper extremity, a retrospective study has been done to determine the efficacy of various diagnostic manipulations used in managing 65 patients with severe hand ischemia at the Northwestern University McGaw Medical Center, Traumatic, thermal, and iatrogenic causes of hand ischemia were diagnosed by simple history taking, as was advanced uremic arteritis. Doppler ultrasound and digital arterial pressure recording were confirmative, rather than diagnostic. These aided in defining precise degrees of ischemia and identifying proximal arterial occlusions. Invasive total extremity angiography clarified atherosclerotic, atheroembolic, and other chronic occlusive lesions while serum electrophoresis and immunoelectrophoresis defined the polyclonal and monoclonal gammopathies. When digital necrosis was present, organic arterial occlusions usually were found. These responded best to direct arterial reconstruction down to the mid-palm level. Transpleural, transthoracic sympathectomy was useful as an adjuvant or as definitive treatment for distal digital arterial occlusions. Selective vasodilator therapy was used as dictated by the cause of ischemia and its eventual outcome.