Novel heterozygous ABCB4 gene mutation causing recurrent first-trimester intrahepatic cholestasis of pregnancy.

Intrahepatic cholestasis of pregnancy (ICP) typically presents in the late second or third trimester and carries an increased risk of fetal demise and neonatal morbidity and mortality. First trimester onset is rare and should alert the physician to explore a possible genetic basis for the disease. We present a 26-year-old Hispanic gravida 3, para 0202 with recurrent first-trimester onset ICP. Given her atypical history and presentation, a genetic cause was considered. She was found to have a novel heterozygous missense mutation in the ABCB4 canalicular membrane transport gene. First or early second trimester presentation of ICP should prompt investigation into genetic causes of the disease. Individualized family counseling and neonatal evaluation should be addressed if a disease-causing genetic mutation is diagnosed.

Fatal fetal outcome with the combined use of valsartan and atenolol.

OBJECTIVE: To report a case of anhydramnios, pulmonary hypoplasia, very small placenta, and fetal death in a pregnancy complicated by chronic hypertension and diabetes mellitus that had been treated through the first 24 weeks of gestation with valsartan and atenolol. CASE SUMMARY: A 40-year-old Hispanic woman with well-controlled chronic hypertension and diet-controlled type 2 diabetes mellitus was treated with valsartan and atenolol until pregnancy was diagnosed at 24 weeks' gestation. An ultrasound examination revealed normal fetal growth and anatomy but anhydramnios (amniotic fluid index 0). Valsartan was discontinued, and amniotic fluid volume normalized within two weeks. Intrauterine fetal death was documented at 33 weeks' gestation. Labor was induced, with the delivery of a stillbom female fetus with small, hypoplastic lungs (weight 41% of expected) and an extremely small, 148-g placenta (weight 48% of the 10th percentile for gestational age). DISCUSSION: The use of valsartan, a selective angiotensin II receptor antagonist (ARA), in human pregnancy has not been reported, but this class of agents would be expected to cause fetal toxicity similar to that observed with angiotensin-converting enzyme inhibitors. This toxicity includes reduced perfusion of the fetal kidneys, resulting in anuria, oligohydramnios, and subsequent pulmonary hypoplasia. The small hypoplastic lungs and very small placenta were probably a consequence of valsartan and atenolol combination therapy. CONCLUSIONS: Resolution of anhydramnios after discontinuing valsartan is evidence for ARA-induced fetal toxicity. The pulmonary hypoplasia observed in the stillbom infant was a direct result of the severe oligohydramnios. The cause of fetal death nine weeks later is uncertain, but because the woman's chronic hypertension and diabetes were well controlled, we believe the primary cause was chronic placental insufficiency resulting from the previous combination of valsartan and atenolol.

A multicenter controlled trial of fetal pulse oximetry in the intrapartum management of nonreassuring fetal heart rate patterns.

OBJECTIVE: Recent developments permit the use of pulse oximetry to evaluate fetal oxygenation in labor. We tested the hypothesis that the addition of fetal pulse oximetry in the evaluation of abnormal fetal heart rate patterns in labor improves the accuracy of fetal assessment and allows safe reduction of cesarean deliveries performed because of nonreassuring fetal status. STUDY DESIGN: A randomized, controlled trial was conducted concurrently in 9 centers. The patients had term pregnancies and were in active labor when abnormal fetal heart rate patterns developed. The patients were randomized to electronic fetal heart rate monitoring alone (control group) or to the combination of electronic fetal monitoring and continuous fetal pulse oximetry (study group). The primary outcome was a reduction in cesarean deliveries for nonreassuring fetal status as a measure of improved accuracy of assessment of fetal oxygenation. RESULTS: A total of 1010 patients were randomized, 502 to the control group and 508 to the study group. There was a reduction of >50% in the number of cesarean deliveries performed because of nonreassuring fetal status in the study group (study, 4. 5%; vs. control, 10.2%; P =.007). However, there was no net difference in overall cesarean delivery rates (study, n = 147 [29%]; vs. control, 130 [26%]; P = .49) because of an increase in cesarean deliveries performed because of dystocia in the study group. In a blinded partogram analysis 89% of the study patients and 91% of the control patients who had a cesarean delivery because of dystocia met defined criteria for actual dystocia. There was no difference between the 2 groups in adverse maternal or neonatal outcomes. In terms of the operative intervention for nonreassuring fetal status, there was an improvement in both the sensitivity and the specificity for the study group compared with the control group for the end points of metabolic acidosis and need for resuscitation. CONCLUSION: The study confirmed its primary hypothesis of a safe reduction in cesarean deliveries performed because of nonreassuring fetal status. However, the addition of fetal pulse oximetry did not result in an overall reduction in cesarean deliveries. The increase in cesarean deliveries because of dystocia in the study group did appear to result from a well-documented arrest of labor. Fetal pulse oximetry improved the obstetrician's ability to more appropriately intervene by cesarean or operative vaginal delivery for fetuses who were actually depressed and acidotic. The unexpected increase in operative delivery for dystocia in the study group is of concern and remains to be explained.

The evolution of Linitis plastica as a consequence of advanced gastric carcinoma in pregnancy.

A 40-year-old multigravid woman was examined on multiple occasions during pregnancy because of persistent gastrointestinal symptoms. A metastatic, unresectable gastric carcinoma that had evolved to linitis plastica was diagnosed at 26 weeks' gestation. The patient was delivered of a viable infant at 27 weeks' gestation, and she died of disease 1.5 months after the diagnosis was made.

A "bloodless cesarean section" and perinatal transmission of the human immunodeficiency virus.

OBJECTIVE: Perinatal transmission of the human immunodeficiency virus is the main pathway for children to become infected with this virus; however, the relative contribution and timing of this transmission, whether transplacental or by exposure through the birth process, have not yet been elucidated. An obvious question is whether the mode of delivery has an impact on this transmission rate. However, a routine cesarean section will primarily diminish the duration of exposure of maternal bodily fluids to the neonate but does not prevent the baby from being exposed to maternal blood coming from the uterine incision. The purpose of this study was to determine whether the rate of perinatal transmission of human immunodeficiency virus could be significantly lowered by delivering the baby with minimal to no exposure to maternal blood or bodily fluids by the use of a surgical technique termed a "bloodless cesarean section." STUDY DESIGN: We performed a prospective cohort study in a group of pregnant women infected with human immunodeficiency virus and evaluated the rate of transmission of this virus to the neonate on the basis of the mode of delivery. One group of patients was delivered by means of a "bloodless cesarean section," in which the baby was delivered and not exposed to any maternal blood or bodily fluid. The control group gave birth either by vaginal delivery or by routine cesarean section. All of the newborns were followed up for a minimum of 15 months or until negative findings were confirmed. Multiple antenatal, intrapartum, and postdelivery variables were collected and analyzed. RESULTS: A total of 108 patients were included in this study and 14 neonates became infected with human immunodeficiency virus (13%). Three of 53 infants delivered by a bloodless cesarean section (5.7%) became infected compared with 11 of 55 control patients (20.0%). This was significant at P = .02 and represented an absolute difference in percentage between the 2 groups of 14.3%, which corresponds to a 71.5% relative reduction in transmission risk (z = 2.27, P = .012). Since the use of zidovudine greatly influences the perinatal transmission rate of human immunodeficiency virus, the study data were reanalyzed with the exclusion of patients who used antenatal or intrapartum zidovudine. Two of 32 infants in the bloodless cesarean section group (6.3%) were infected compared with 9 of 38 in the control group (23.7%). This was significant at P = .04 and revealed an absolute difference in percentage of 17.4%, which corresponds to a 73.4% relative reduction in transmission risk (z = 2.15, P = .016). There was no difference in the transmission rate between the bloodless cesarean section patients who did not use zidovudine (2/32, 6.3%) and the patients who did use zidovudine from the entire study population (3/38, 7.9%). CONCLUSION: In the absence of zidovudine usage, these data show that 70% to 75% of the perinatal transmission of human immunodeficiency virus to a newborn occurs from exposure to maternal blood and bodily fluids at the time of birth. This information is important for patients unable to take zidovudine or other antiretroviral agents, but more important, it introduces the concept of other treatment options for the future.

Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women.

BACKGROUND: Among nulliparous women, there appears to be an association between the use of epidural analgesia during labor and an increased risk of dystocia. We tested the hypothesis that combined spinal-epidural analgesia, which permits ambulation during labor, is associated with a lower incidence of dystocia than continuous lumbar epidural analgesia. METHODS: Between July 1995 and September 1996, we randomly assigned 761 nulliparous women in spontaneous labor at term who requested epidural analgesia to receive either continuous lumbar epidural analgesia or a combination of spinal and epidural analgesia. Among the women who received combined spinal-epidural analgesia, some were discouraged from walking and others were encouraged to walk. Maternal and neonatal outcomes, the incidence of dystocia necessitating cesarean section, and measures of patients' satisfaction were compared in the two groups. RESULTS: There were no significant differences in the overall rate of cesarean section, the incidence of dystocia, the frequency of maternal or fetal complications, the patients' or nursing staff's assessment of the adequacy of analgesia, or the degree of overall satisfaction between the two groups. Significantly more women receiving combined spinal-epidural analgesia had pruritus (P<0.001) and requested additional epidural bolus doses of local anesthetic (P=0.01). For all the women, dystocia necessitating cesarean section was significantly more likely when analgesia was administered with the fetal vertex at a negative station (odds ratio, 2.5; P<0.001) or at less than 4 cm of cervical dilatation (odds ratio, 2.2; P<0.001). CONCLUSIONS: As compared with continuous lumbar epidural analgesia, the combination of spinal and epidural analgesia is not associated with an overall decrease in the incidence of cesarean delivery.

Birth trauma. A five-year review of incidence and associated perinatal factors.

OBJECTIVE: To determine the current incidence of clavicular fracture (CF), facial nerve injury (FNI) and brachial plexus injury (BPI) and identify the existence, if any, of associated perinatal factors with each injury. STUDY DESIGN: A case-controlled study design was selected and the study conducted for births between January 1, 1985 and January 1, 1990, at Christ Hospital and Medical Center, a tertiary care center with level III perinatal services in suburban Chicago. Among a population of 19,370 consecutive deliveries, we identified the occurrences of CP, FNI and BPI by database search, and maternal and neonatal chart reviews. A control group was randomly selected. Maternal, labor, delivery and neonatal variables were then compared between the birth trauma and control groups for each specific injury. RESULTS: The incidence per 1,000 live births and per 1,000 live-born cephalic singletons delivered vaginally for CF was 4.5 and 5.7; for FNI, 0.6 and 0.7; and for BPI, 0.9 and 1.1, respectively. To varying degrees, the data demonstrate that the occurrences of these injuries are associated significantly more often with prolonged gestation, epidural anesthesia, prolonged second stage of labor, oxytocin use, forceps delivery, shoulder dystocia, macrosomia, low Apgar scores and a previous maternal obstetric history of macrosomia when compared to controls. Other significantly associated variables include the presence of meconium in labor and neonatal hyperbilirubinemia. Despite the presence of multiple perinatal factors that are individually associated statistically with the injured groups, multiple logistic regression analysis predicted 44.2% of CF's, none of the FNIs and only 19% of the BPIs. CONCLUSION: While multiple perinatal variables are statistically associated with the specific birth injuries studied, the use of multiple logistic regression analysis shows that the ability to predict these injuries is markedly limited.

Droperidol and diphenhydramine in the management of hyperemesis gravidarum.

OBJECTIVE: Hyperemesis gravidarum is a common pregnancy complication requiring hospitalization. Continuous droperidol infusion and bolus intravenous diphenhydramine were instituted as treatment. We compared the number and length of hospitalizations for hyperemesis gravidarum, readmissions for this diagnosis, and pregnancy outcome in patients receiving this treatment protocol with a historic group of patients receiving other forms of parenteral therapy for hyperemesis gravidarum. STUDY DESIGN: All patients hospitalized with a diagnosis of hyperemesis gravidarum between January 1992 and January 1994 were offered the droperidol-diphenhydramine protocol. These patients were compared with patients admitted between January 1990 and January 1992 with a diagnosis of hyperemesis gravidarum but who were not treated with droperidol at any time or with diphenhydramine as primary therapy for the control of severe nausea and vomiting. Data regarding the number and length of hospitalizations and readmissions for hyperemesis gravidarum were compared, as were maternal and perinatal outcomes. RESULTS: Patients treated with the droperidol-diphenhydramine protocol had significantly shorter hospitalizations (3.1 +/- 1.9 vs 3.8 +/- 2.4 days, p = 0.028), fewer days per pregnancy hospitalized for hyperemesis (3.5 +/- 2.3 days vs 4.8 +/- 4.3 days, p = 0.018), and fewer readmissions with this diagnosis (15.0% vs 31.5%, p = 0.015). There were no significant differences in maternal or perinatal outcomes. CONCLUSION: Droperidol and diphenhydramine infusion is a beneficial, cost-effective therapy for the treatment of hyperemesis gravidarum.

Evaluation of the nonreactive positive contraction stress test prior to 32 weeks: the role of the biophysical profile.

A nonreactive positive contraction stress test in a pregnancy near term is an indication for delivery. Such nonreassuring antepartum testing combined with severe prematurity presents a management dilemma. Ideally, prolongation of selected pregnancies would allow time for corticosteroid therapy and fetal maturation. Prior to 32 weeks' gestation, we utilized the biophysical profile to select patients for continued intrauterine management as an alternative to immediate delivery. Continued surveillance was undertaken if the fetus had a reassuring biophysical profile score; immediate delivery by cesarean section was undertaken if the biophysical profile score was nonreassuring. This approach allowed a mean gain of 13 days in utero for the continued surveillance group. There was no evidence of further fetal compromise in this group based on umbilical cord pH or 5-minute Apgar scores. These data suggest that the biophysical profile can be safely used to prolong selected preterm pregnancies with nonreactive positive contraction stress tests without adversely affecting the initial neonatal metabolic status.

The value of a negative antepartum test: contraction stress test and modified biophysical profile.

OBJECTIVE: To examine the outcome of pregnancies in high-risk patients whose last antepartum fetal assessment was a negative contraction stress test (CST) or a negative modified biophysical profile. METHODS: Twenty-nine hundred ninety-four women who received modified biophysical profiles were compared with 2450 who had CSTs during the preceding 3 years. Pregnancy outcomes were evaluated in patients whose last test was negative. RESULTS: Seventeen hundred fifty-three patients had negative modified biophysical profiles as the last test before delivery, and 1337 had negative CSTs as the last test before delivery. Adverse perinatal outcomes included perinatal death or death before nursery discharge, cesarean delivery for fetal distress within the first 2 hours of labor, 5-minute Apgar score less than 7, neonatal seizures, or grade III or grade IV central nervous system hemorrhage. Adverse outcomes occurred in 90 patients (5.1%) whose last test before delivery was a negative modified biophysical profile and in 93 patients (7.0%) whose last test was a negative CST (P = .04, odds ratio 1.38, 95% confidence interval 1.01-1.88). Overall, there were 11 perinatal deaths, nine of which resulted from lethal congenital abnormalities. CONCLUSIONS: In this population, the frequency of adverse perinatal outcome following a negative modified biophysical profile was no greater than that following a negative CST. Further, the incidence of potentially preventable perinatal death following a negative modified biophysical profile or CST was less than one per 1000 tested high-risk pregnancies.

Perinatal outcome with the modified biophysical profile.

OBJECTIVE: Our purpose was to evaluate perinatal outcomes in high-risk pregnancies monitored with a modified biophysical profile. STUDY DESIGN: All non-insulin-dependent patients referred for antepartum fetal surveillance received a modified biophysical profile biweekly. A modified biophysical profile is a combination of a nonstress test and an amniotic fluid index. Patients with a singleton gestation and intact membranes were entered into a protocol of randomized backup testing for an abnormal modified biophysical profile. Those patients having a nonreactive fetal heart rate, significant variable decelerations, late decelerations, or an amniotic fluid index < or = 5.0 cm received either a contraction stress test or a biophysical profile immediately. Once randomized, a patient received the same backup test, when indicated, with subsequent testing. RESULTS: A total of 2774 patients had 17,429 tests with an uncorrected perinatal mortality rate of 2.9 per 1000. The overall incidence of an adverse perinatal outcome (i.e., perinatal death or nursery death before infant hospital discharge, cesarean delivery for fetal distress within the first 2 hours of labor, 5-minute Apgar score < 7, neonatal seizures or grade III or IV central nervous system hemorrhage) was 7.0%. When compared with patients having persistently normal modified biophysical profile, patients requiring a backup test had a significantly greater incidence of adverse perinatal outcome (9.3% vs 4.9%, p < 0.001, odds ratio 2.0, 95% confidence interval 1.5 to 2.7) and small-for-gestational-age infants (5.2% vs 2.4%, p < 0.001, odds ratio 2.2, 95% confidence interval 1.5 to 3.5). No differences in outcomes between patients randomized to a contraction stress test versus a biophysical profile could be identified either overall or in limiting the analysis to outcome after a negative last test. However, patients having contraction stress test as a backup test had a significantly higher rate of intervention for an abnormal test result than did those having a biophysical profile backup test (23.7% vs 16.6%, p < 0.002, odds ratio 1.6, 95% confidence interval 1.2 to 2.1). CONCLUSION: The modified biophysical profile is an excellent means of fetal surveillance and identifies a group of patients at increased risk for adverse perinatal outcome and small-for-gestational-age infants. There does not appear to be a significant benefit with the contraction stress test compared with the biophysical profile as a backup test. Further, the contraction stress test is associated with a higher rate of intervention for an abnormal test than is the biophysical profile.

Fetal fibronectin in patients at increased risk for premature birth.

OBJECTIVE: The objective of this study was to evaluate fetal fibronectin as a screening test for subsequent preterm birth in asymptomatic pregnant women. STUDY DESIGN: Eighty-seven pregnant women at increased risk for preterm birth underwent weekly sampling of cervicovaginal secretions beginning in the middle of the second trimester and continuing until delivery or until 34 weeks of gestation, with quantitative measurement for fetal fibronectin. In addition, assessment of cervical dilatation, uterine activity, and tocolytic therapy was performed with each sampling. Preterm birth was the specific outcome measured, and the correlation of fetal fibronectin with this outcome was determined. RESULTS: Overall, 31% of the patients experienced a spontaneous preterm birth. As a predictor for delivery before 37 completed weeks of gestation, the presence of fetal fibronectin had a sensitivity of 92.6%, a specificity of 51.7%, a positive predictive value of 46.3%, and a negative predictive value of 93.9%. For delivery before 34 weeks, fetal fibronectin had a sensitivity of 92.3% and a negative predictive value of 97.8%. By means of logistic regression analysis a positive fetal fibronectin result was highly significantly correlated with preterm birth (odds ratio 3.8, p < 0.001) and more so than the presence of four or more uterine contractions per hour, tocolytic therapy, or cervical dilatation of > or = 2 cm. The addition of contractions, tocolytic therapy, or cervical dilatation to a positive fetal fibronectin result did not increase the predictive capacity of a positive fetal fibronectin alone. CONCLUSION: Fetal fibronectin in the cervicovaginal secretions of asymptomatic patients has potential value as a screening test in the identification of patients at risk for preterm birth. This test had equally high sensitivity and negative predictive value for birth before 37 weeks.

Acute maternal renal insufficiency in premature labor treated with indomethacin.

Three cases of acute renal insufficiency in pregnant women who were treated with indomethacin for premature labor are reported. At the time of presentation, all three women had normal renal function but within 30 hours of indomethacin therapy they were noted to have significant decreases in urine output and rising serum creatinines. The average time to recovery of renal function was 5 days. A consistent feature in all three women was the development of dyspnea associated with hypoxemia.

Use of Amniostat-FLM in detecting the presence of phosphatidylglycerol in vaginal pool samples in preterm premature rupture of membranes.

OBJECTIVE: The presence of phosphatidylglycerol in amniotic fluid from the vaginal pool has been established as a reliable marker of pulmonary maturity in pregnancies complicated by preterm premature rupture of membranes because its presence is not affected by contaminants. This study was undertaken to determine the distribution of positive phosphatidylglycerol relative to gestational age from vaginal pool amniotic fluid samples and to assess the efficacy and accuracy of the Amniostat-FLM (Hana Biologics; Irvine Scientific after Sept. 14, 1989), an antibody agglutination method for rapidly detecting phosphatidylglycerol. STUDY DESIGN: All singleton nondiabetic pregnancies between 26 and 36 weeks with premature rupture of membranes from whom a vaginal pool sample was obtained were studied. The percent positive by gestational age was analyzed. The neonates that were delivered with a positive phosphatidylglycerol were evaluated for the presence of hyaline membrane disease and other immediate sequelae of prematurity. RESULTS: Of the 201 vaginal pool amniotic fluid samples assayed for phosphatidylglycerol with the Amniostat-FLM procedure, 18% (36/201) were positive for phosphatidylglycerol and none of the delivered infants developed hyaline membrane disease. CONCLUSION: The Amniostat-FLM seems to be accurate in predicting pulmonary maturity from vaginal pool samples.

Cocaine intoxication presenting as preeclampsia and eclampsia.

OBJECTIVE: To relate the clinical presentation of acute cocaine intoxication in the third trimester to preeclampsia and eclampsia. METHODS: Eleven women presented to Long Beach Memorial Women's Hospital and the University of California, Irvine Medical Center with hypertension and clinical symptoms of headache, blurred vision, abdominal pain, or seizures in the third trimester of pregnancy. Each had a positive urine drug screen for cocaine. The laboratory evaluation for preeclampsia included a complete blood count, platelet count, uric acid, aspartate aminotransferase, alanine aminotransferase, creatinine, and urine for protein content. RESULTS: All women had a diastolic blood pressure of at least 90 mmHg, which returned to the normal range 45-90 minutes after admission. Each presented with one or more symptoms associated with preeclampsia, which ultimately improved as the drug wore off. In addition, all laboratory evaluations for preeclampsia were negative. CONCLUSION: If a patient presents in the third trimester with hypertension and clinical symptoms of preeclampsia that rapidly improve shortly after admission, cocaine intoxication should be considered as the possible source.

The acardiac twin: a case report using color Doppler ultrasonography.

The use of color Doppler sonography has expanded our understanding of the normal and abnormal pregnancy. A case is presented here in which color Doppler imaging was utilized to confirm a long-held theory concerning the strikingly abnormal dynamics of arterial flow to an acardiac twin and observations are also presented concerning the possible route of venous return contrary to presumed theories established within the literature.

A randomized, placebo-controlled trial of betamethasone for the prevention of respiratory distress syndrome at 24 to 28 weeks' gestation.

Previous randomized controlled studies of corticosteroids for the reduction of respiratory distress syndrome have failed to demonstrate benefit in very early premature gestational age groups. A randomized, double-blind, placebo-controlled clinical trial of betamethasone given to mothers with intact membranes and threatened premature delivery between 24 and 28 weeks of pregnancy was conducted. Thirty-six patients were randomized to receive betamethasone, two doses of 12 mg, 24 hours apart, and 41 received placebo. No difference was found in the overall incidence of respiratory distress syndrome between the two groups (betamethasone vs placebo 0.55 vs 0.66) or in the incidence of respiratory distress syndrome in babies delivered between 1 and 7 days after the first dose of drug (betamethasone vs placebo 0.78 vs 0.88). Nor were there any differences observed in any measure of severity of respiratory distress syndrome between the groups. The neonatal death rates were also similar (betamethasone vs placebo 0.25 vs 0.24). The only difference seen was an unexpected reduction in the betamethasone group in the incidence of grades 3 and 4 intraventricular hemorrhage (betamethasone vs placebo 1/31 vs 9/36, p = 0.01). Therefore this study was unable to demonstrate any beneficial effect of corticosteroids in reducing respiratory distress syndrome at less than 28 weeks' gestation in spite of a sample size that had an 80% likelihood of detecting a 50% reduction in the incidence of respiratory distress syndrome with p = 0.05, which is the minimum reduction seen in virtually all randomized trials in other gestational age groups.

Correlation of amniotic fluid index and nonstress test in patients with preterm premature rupture of membranes.

The amniotic fluid index and the nonstress test are commonly used in the expectant management of preterm premature rupture of membranes. This study was designed to investigate the interrelationship of the nonstress test and the amniotic fluid index during the preterm rupture of membranes latency period. Fifty patients with preterm premature rupture of membranes for greater than 48 hours were prospectively followed with daily 1-hour nonstress tests and blinded, daily amniotic fluid index examinations (totaling 422 evaluations). The overall average daily amniotic fluid index was statistically lower in the earlier gestations and nulliparous patients but was not influenced by the fetal position or nonlaboring uterine activity. An increased incidence of variable decelerations and nonreactive nonstress tests was associated with a significantly lower overall average daily amniotic fluid index, but these differences were beyond the standard precision of the amniotic fluid index examination. The daily nonstress test appears to identify clinically significant lower fluid volumes during the latency period and should remain the mainstay in the management of preterm premature rupture of membranes.

Rate of recurrence of preterm premature rupture of membranes in consecutive pregnancies.

The reported incidence of preterm premature rupture of membranes ranges between 1% and 2% of all pregnancies. The rate of recurrence is poorly defined. The goal of this study was to establish the frequency of recurrence in a high-risk referral practice. Over a 5-year period we identified 121 patients with preterm premature rupture of membranes who had a minimum of two consecutive pregnancies under our care, resulting in a total of 255 pregnancies for analysis. Recurrent preterm premature rupture of membranes occurred in 39 of 121 patients, for a rate of 32.2% (95% confidence interval, 23.9 +/- 40.5). We were unable to demonstrate an association between the estimated gestational age at the time of rupture in the index pregnancy, latency period, interval between pregnancies, and the probability of repeat preterm premature rupture of membranes in the next pregnancy. We conclude that patients with preterm premature rupture of membranes should be counseled regarding the significant risk of recurrence and need to have close follow-up in their subsequent pregnancies.