Requiem for a heavyweight: the demise of scalp blood pH sampling.

Fetal scalp blood pH sampling has played a valuable role in the development of our understanding of fetal welfare in labor and in the interpretation of electronic fetal heart rate patterns. There is question as to the feasibility of retaining this practice in modern obstetric care because of the advance of science, the general reliance on fetal monitoring criteria for ascertaining fetal well-being, the logistic difficulties involved in obtaining accurate and timely samples, the economic consequences of having to maintain analytic equipment in working order in times of very infrequent use, and the poor correlation between pH alterations and predictable neurologic consequences in the child. As it has all but vanished from use in most clinical care centers, and the principal argument for retaining it ultimately references the physician as the beneficiary, the author proposes that it should be removed from any possible association with purported "standards of care."

Exclusion of monoamniotic twinning by contrast-enhanced computed tomography.

Monoamniotic twinning, through relatively rare, imposes a constant threat of adverse outcome upon twin pregnancy, at least until the third trimester. This report describes the use of contrast-enhanced computed tomography as one way to define or rule out the condition and proposes an optimal technique and timing for its utilization.

How to live with statistics (without having to marry them).

In the ever more complex world of medical research and data analysis, it becomes necessary, no matter the reluctance to do so or the asthenia of spirit or capacity, for the reader to have a working familiarity with the nature of modern statistical tests. Armed with this insight, he or she can, without fail, ascertain any bias of the author or, in other cases, of the reviewer's statistical consultant. The following is in the nature of a user's manual of modern methods. Caveat emptor.

Histologic chorioamnionitis in pregnancies of various gestational ages. II: Implications in preterm labor.

A retrospective review of placental materials (membranes, chorionic plate, umbilical cord) derived from preterm birth is reported. All those studied had intact membranes on admission and did not have spontaneous rupture. Those with preterm labor unresponsive to tocolysis, including those with brief and more prolonged labors, were compared with those delivered preterm because of maternal or fetal indications without labor. Those with labor had inflammatory changes in all three sites of greater frequency than those without labor. Those with longer labors had significantly higher rates of inflammation than those without labor. In this population, removing the influence of spontaneous rupture and labor over 6 hours long greatly diminished the likelihood of inferring that inflammation of the choriamniotic environment is a cause of preterm labor unresponsive to tocolysis.

The prognosis of Rh-affected pregnancies: an exception to the usual rule.

A patient with a homozygous marital partner had three progressively less seriously involved RH-positive babies after a fetal demise due to erythroblastosis. Only the first of the three required fetal transfusions. All were Rh genotypically identical. The case is presented for interest and to illustrate an exception to the usual rule.

Histologic chorioamnionitis in pregnancies of various gestational ages: implications in preterm rupture of membranes.

A retrospective review of placental material derived primarily from preterm deliveries was conducted and inflammatory changes graded on a scale of 0-3. Reviewers were blind as to the clinical outcomes. Other reviewers, unaware of the pathologic results, surveyed the clinical data, and results were combined for analysis. The findings suggest that placental and membrane inflammation probably precedes preterm spontaneous rupture of membranes in 8-30% of cases without labor. The duration of ruptured membranes and labor enhance the frequency of inflammation. Inflammation is not associated with significant puerperal infection unless cesarean delivery occurs. Perinatal morbidity and mortality were not significantly enhanced nor associated with conservative management of spontaneous preterm rupture of membranes in this population beyond the influence of fetal weight and gestational age.

The influence of intravenous solution content on ritodrine-induced metabolic changes.

To examine the influence of intravenous (IV) solution content on ritodrine-induced metabolic changes, 25 patients treated with various IV solutions were studied before and after a bolus of fluid, and during IV drug therapy, for the effect of hematocrit, pH, lactate, glucose, and electrolyte concentrations. Results were viewed on a mg/kg/minute ritodrine dosage basis. Dextrose-containing fluids caused a significant elevation of glucose after bolus therapy, and 5% dextrose in water also significantly altered lactate and potassium levels. Dextrose enhanced drug-mediated changes in potassium, sodium, chloride, pH, and lactate. The CO2 content dropped in all patients, regardless of IV content. The best IV solution would appear to be plain lactated Ringer's, and the least desirable, 5% dextrose in water.

Perspectives on perinatal brain damage.

The author presents a perspective on perinatal brain injury from the point of brain development, and discusses subsequent adverse outcomes. It is stressed that injury is frequently attributed to perinatal causes and avoidable circumstances when in fact the obstetrician could not possibly foresee or circumvent it. Evidence of the dramatic recuperative powers of many infants, even when dying and being resuscitated, are compared with the minimal provocations frequently associated with handicap, underscoring the concept of prior injury or unique fragility. The review is presented to provoke new insights and perspectives.

Fetal dystocia.

Fetal dystocia is the result of an unfortunate relationship between fetal anatomy and maternal pelvic capacity. Most commonly, arrest of labor progress occurs at a point at which the problem is solved without significant risk to maternal-fetal welfare by abdominal delivery. This article has, in part, focused upon some rare exceptions and on how to anticipate and deal with them as well as possible.

New approaches to the management of acute puerperal uterine inversion.

Six cases of acute puerperal inversion of the uterus are reported. In four of these, tocolytic agents were used to facilitate replacement of the inverted uterus; and in five, Prostin-15M was given after replacement. The use of tocolytics may obviate the need for general anesthesia for uterine replacement in some patients with uterine inversion. Prostin-15M serves to minimize bleeding and to maintain uterine position after replacement.

Significance of endometrial cultures performed at cesarean section.

To determine the bacterial pathogenesis of postcesarean endomyometritis, swab endometrial cultures of the lower uterine segment were taken intraoperatively in 160 cases. Both aerobic and anaerobic cultures were obtained. Of all patients, 16.8% developed endomyometritis. There was a statistically significant relationship between positive cultures and the development of endomyometritis. The organisms isolated were those commonly found in other types of pelvic infection: pathogenic aerobes and anaerobes as well as commensals. An average of 1.3 organisms were recovered per patient with positive cultures. An analysis is provided for findings depending on the status of membranes and the influence of labor. The following risk factors were identified for the development of endomyometritis: primary cesarean section, labor, ruptured membranes, and postoperative hematocrit. Implications of these findings and a review of similar studies is provided.