Specialized care for twin gestations: improving newborn outcomes and reducing costs.

OBJECTIVE: To compare newborn outcomes and costs of hospital stays for twins born to mothers receiving care in a specialized twin clinic with a research-based care protocol and one consistent caregiver versus twins whose mothers received standard prenatal care. DESIGN AND SETTING: A retrospective, historical cohort study conducted in a high-risk obstetric clinic in central Texas. PATIENTS: Thirty women pregnant with twins received specialized care. The comparison group consisted of 41 women pregnant with twins who received standard care. INTERVENTIONS: An advanced practice nurse provided prenatal care, which included weekly clinic visits, home visits, and 24-hour availability for phone support. OUTCOME MEASURES: Gestational age at birth, birth weight, length of stay in the neonatal intensive-care unit (NICU), and hospital charges for the newborns. RESULTS: No newborns of less than 30 weeks gestation were born to women in the specialized care group, the mean birth weight was 249 g (SD +/- 77) higher, days in the NICU were reduced from a mean of 17 to 7, and hospital charges were $30,000 less per infant. CONCLUSIONS: Newborn outcomes were improved and length of stay and hospital charges were significantly reduced for newborns whose mothers had received care in the specialized twin clinic.

Risk factors and opportunities for prevention of early-onset neonatal sepsis: a multicenter case-control study.

BACKGROUND: Early-onset group B streptococcal (GBS) prevention efforts are based on targeted use of intrapartum antibiotic prophylaxis (IAP); applicability of these prevention efforts to infections caused by other organisms is not clear. METHODS: Multicenter surveillance during 1995 to 1996 for culture-confirmed, early-onset sepsis in an aggregate of 52 406 births; matched case-control study of risk factors for GBS and other sepsis. RESULTS: Early-onset disease occurred in 188 infants (3.5 cases per 1000 live births). GBS (1.4 cases per 1000 births) and Escherichia coli (0.6 cases per 1000 births) caused most infections. GBS sepsis less often occurred in preterm deliveries compared with other sepsis. Compared with gestation-matched controls without documented sepsis, GBS disease was associated with intrapartum fever (matched OR, 4.1; CI, 1.2-13.4) and frequent vaginal exams (matched OR, 2.9; CI, 1.1-8. 0). An obstetric risk factor-preterm delivery, intrapartum fever, or membrane rupture >/=18 hours-was found in 49% of GBS cases and 79% of other sepsis. IAP had an adjusted efficacy of 68.2% against any early-onset sepsis. Ampicillin resistance was evident in 69% of E coli infections. No deaths occurred among susceptible E coli infections, whereas 41% of ampicillin-resistant E coli infections were fatal. Ninety-one percent of infants who developed ampicillin-resistant E coli infections were preterm, and 59% of these infants were born to mothers who had received IAP. CONCLUSIONS: Either prenatal GBS screening or a risk-based strategy could potentially prevent a substantial portion of GBS cases. Sepsis caused by other organisms is more often a disease of prematurity. IAP seemed efficacious against early-onset sepsis. However, the severity of ampicillin-resistant E coli sepsis and its occurrence after maternal antibiotics suggest caution regarding use of ampicillin instead of penicillin for GBS prophylaxis.

Optimization of cationic liposome-mediated gene transfer to human bronchial epithelial cells expressing wild-type or abnormal cystic fibrosis transmembrane conductance regulator (CFTR).

We determined optimum conditions for delivering DNA to transformed human bronchial epithelial cells expressing wild-type (BEAS) or abnormal (2CF) cystic fibrosis transmembrane conductance regulator (CFTR) using cationic liposomes (Lipofectin, [N-(N,N-dimethylaminoethane)carbamyl] cholesterol[DC-Chol]/dioleoylphosphatidylethanolamine[DOPE], or LipofectAMINE) and reporter genes which measured overall transgene expression (luciferase) or the fraction of cells transfected (heat-stable alkaline phosphatase). All liposomes showed dose-related toxicity. Optimal liposome and lipid: DNA ratios were different for BEAS than for 2CF cells. For all 3 liposome preparations, small particle size and net cationic charge related to transfection efficiency. Both LipofectAMINE and DC-Chol/DOPE transfected a maximum of 3% of BEAS cells, but luciferase expression could be increased without increasing the fraction of cells transfected. LipofectAMINE transfected a maximum of 6% of 2CF cells, and luciferase expression could be increased with no further increase in fraction of transfected cells. DC-Chol/DOPE transfected over 12% of 2CF cells with relatively small increases in luciferase expression. We conclude that an optimal cationic liposome and lipid: DNA ratio for transfecting bronchial epithelial cells depends on: (1) small particle size and net cationic charge, (2) whether the cells have the cystic fibrosis defect, and (3) whether the desired outcome is transfection of the maximum fraction of the cells or maximum total expression of the transgene.

Prenatal diagnosis of congenital cytomegalovirus infection with abnormal triple-screen results and hyperechoic fetal bowel.

A 14-year-old primigravid adolescent with abnormal triple-marker screen results at 18 weeks' gestation was found to have hyperechoic fetal bowel. Amniotic fluid culture was positive for cytomegalovirus. Serial ultrasonography demonstrated progressive lateral ventriculomegaly, intrauterine growth retardation, and hydrops fetalis; fetal death occurred at 32 weeks' gestation.

Randomized, double-blinded, placebo-controlled trial of amoxicillin/clavulanic acid to prevent preterm delivery in twin gestation.

OBJECTIVE: The objective of this study was to determine whether prophylactic treatment with oral broad-spectrum antimicrobial therapy improves pregnancy outcomes in twin gestations. METHODS: Patients with twin gestations between 24 and 32 weeks were randomized to receive amoxicillin/clavulanic acid or placebo. Those patients randomized before 24 weeks received a 1-week course at 24 and at 28 weeks gestation. Those patients entered later than 24 weeks received a 1-week course either at 28 weeks or at enrollment (up to 32 weeks). Other than antibiotic use, the management of the groups was identical and unchanged from the routine care of twin gestations. RESULTS: Of 149 twin pregnancies enrolled, 76 were randomized to the drug group and 73 to the placebo group. There was no significant difference in mean gestational age at delivery (35.9 vs. 35.7 weeks), birth weight (2,358 vs. 2,344 g), mean neonatal nursery stay (9.9 vs. 11.7 days), or respiratory distress syndrome (6/76 vs. 4/73) in the drug vs. placebo group, respectively. CONCLUSIONS: The addition of prophylactic oral broad-spectrum antimicrobial therapy to the standard antepartum management of twin gestations had no demonstrable effect on the gestational age at delivery, birth weight, or neonatal complications. There did not appear to be any beneficial effect of the prophylactic use of amoxicillin/clavulanic acid in this clinical setting.

Arteriovenous malformation of the upper extremity complicating pregnancy. A case report.

A 23-year-old, pregnant woman with an arteriovenous malformation of the left brachial artery developed worsening symptomatology that demanded early delivery. The puerperium was significant for persistent debilitating symptoms that resolved partially four months following delivery.

A simplified phenytoin regimen for preeclampsia.

The objective of this study was to assess the feasibility of giving phenytoin to a group of mild preeclamptic women in a universal dosing scheme comparable to that typical of magnesium sulfate administration. Serum phenytoin levels were measured at regular intervals for 32 hours following a 1 g intravenous loading dose in 14 patients. A second group of 14 women received 500 mg orally to supplement the 1 g initial dose and had serum levels similarly measured. The resultant serum levels are described, and the effect of maternal weight analyzed. The average serum phenytoin level in the first 14 women given the 1 g loading dose fell to 10 micrograms/mL approximately 12 hours after treatment. Serum levels plateaued above this threshold in the 14 women given 500 mg of additional medication orally 10 hours after treatment initiation and were maintained for an additional 14 hours before decline was observed. The serum levels resulting from the initial 1 g loading dose were analyzed 8 hours after treatment initiation in the entire group of 28 women according to body weight, and a clinically significant effect of weight on serum level was observed only at the extremes of weight. We conclude that a universal dosing scheme comparable to that typically used for magnesium sulfate is feasible for phenytoin administration to preeclamptic women.

The return of life-threatening puerperal sepsis caused by group A streptococci.

A dramatic decline in the prevalence of serious puerperal infection caused by group A beta-hemolytic streptococci has been observed throughout most of the twentieth century, and it is currently a very uncommon cause of maternal morbidity and mortality. We report on two term pregnancies complicated by profound multisystem organ failure caused by group A streptococcal puerperal sepsis. This report serves to highlight the apparent return of serious group A streptococcal puerperal sepsis and to emphasize the clinical implications and sequelae attributable to an old yet virulent enemy.

Fetal syphilis: correlation of sonographic findings and rabbit infectivity testing of amniotic fluid.

Fetal syphilis is the presumed diagnosis when the sonographic findings of fetal hydrops are found in the presence of maternal syphilis. In the absence of fetal hydrops, the diagnosis of fetal infection is difficult. We hypothesized that intra-amniotic infection would be accompanied by anatomic placental and fetal abnormalities that could be detected by ultrasonography. Rabbit infectivity testing (RIT), intratesticular inoculation of rabbits with amniotic fluid, can be used to confirm intra-amniotic infection with Treponema pallidum. Twenty-one gravidas with untreated early (primary, secondary, and early latent) syphilis underwent sonography and amniocentesis for RIT at 24 weeks of gestation or later. Antenatal sonographic findings were compared to their amniotic fluid RIT results. Hepatomegaly was significantly (P < 0.01) associated with amniotic fluid infection detected by RIT. Antenatal detection of hepatomegaly, which is probably the initial sonographic manifestation of hydrops fetalis, may ultimately identify the fetus affected with congenital syphilis.

Identification of Treponema pallidum in amniotic fluid and fetal blood from pregnancies complicated by congenital syphilis.

Two pregnant women with secondary syphilis underwent amniocentesis and evaluation for fetal syphilis. In both cases, motile spirochetes, typical of Treponema pallidum, were observed during dark-field microscopic examination of the amniotic fluid. The presence of T pallidum was confirmed by antitreponemal monoclonal antibody immunofluorescence assays and by rabbit infectivity tests using the amniotic fluid. In the first case, an infant at 35 weeks' gestation delivered within 24 hours of amniocentesis had hepatosplenomegaly, osteochondritis, and neurosyphilis. In the second case, a fetus at 24 weeks' gestation was hydropic and a fetal blood sample showed anemia, thrombocytopenia, and elevated liver enzymes. Fetal syphilis was confirmed by rabbit infectivity testing using fetal blood obtained by funipuncture. This is the first report of the diagnosis of fetal syphilis by funipuncture and confirmation of the presence of virulent T pallidum in the blood of a human fetus. The mother was treated for secondary syphilis, but the infant had residual signs of congenital infection at birth 14 weeks later. Neonatal serum from the first case and fetal serum from the second case showed specific immunoglobulin M reactivity with the 47-kd antigen of T pallidum by Western blot assays. A new wild-type strain of T pallidum, designated DAL-1, was isolated from the amniotic fluid of the first case and is available for future studies. We conclude that the presence of T pallidum in amniotic fluid or fetal blood indicates fetal-placental infection. Further investigation is necessary to determine the pathogenesis of amniotic fluid infection and its role in the prenatal diagnosis of congenital syphilis.

Observations on the cause of oligohydramnios in prolonged pregnancy.

There is increasing evidence that implicates reduced amnionic fluid volume as a major determinant of fetal risk in prolonged pregnancy. We sought to determine whether reduced fetal urine production might be associated with oligohydramnios in pregnancies that reach 42 weeks or more. Ultrasonographic measurements of the fetal bladder were obtained every 2 to 5 minutes for 1 hour in 38 gestations verified to be at least 42 weeks. Oligohydramnios was present in eight of the prolonged pregnancies. Similar measurements were performed in 15 normal pregnancies delivered by elective repeat cesarean section between 38 and 40 weeks' gestation. Hourly fetal urine production rates were calculated with sequential bladder volume measurements. The result of this investigation suggest that diminished fetal urine production is associated with oligohydramnios in prolonged pregnancy. The mechanism by which fetal urine production is reduced in prolonged pregnancy remains unknown. A likely possibility is reduced fetal swallowing because of already diminished amnionic fluid volume, the latter a result of placental senescence.

Cordocentesis for the diagnosis and treatment of human fetal parvovirus infection.

Human parvovirus B-19 infection was diagnosed by DNA hybridization in blood obtained by cordocentesis from two hydropic fetuses at 22 and 26 weeks' gestation; B-19-specific immunoglobulin M (IgM) in fetal blood was negative in both cases. Hematologic studies demonstrated severe anemia, which was treated by intravascular fetal blood transfusions. The hydrops resolved and healthy infants were delivered at term. The pathophysiology of hydrops in fetal parvovirus infection is discussed.

Relation of rate of urine production to oxygen tension in small-for-gestational-age fetuses.

Hourly fetal urine production rate was determined by real-time ultrasonography immediately before cordocentesis for blood gas analysis in 27 small-for-gestational-age fetuses at 20 to 37 weeks' gestation; in 14 cases there was associated oligohydramnios. The values were compared with those of 101 appropriate-for-gestational-age fetuses. The hourly fetal urine production rate was significantly lower in the small-for-gestational-age fetuses than in the appropriate-for-gestational-age fetuses. Furthermore, there was a significant correlation between the degree of decrease in urine production and both the degree of fetal hypoxemia and the degree of fetal smallness. There was no significant difference between the oligohydramnios and nonoligohydramnios groups in either the degree of decrease in urine production or the degree of fetal hypoxemia.

Measurement of fetal urine production in normal pregnancy by real-time ultrasonography.

Serial measurements of fetal bladder volume were obtained by real-time ultrasonography at 2- to 5-minute intervals, and the hourly fetal urine production rate was calculated. The mean hourly fetal urine production rate increased from 5 ml/hr at 20 weeks' gestation to 51 ml/hr at 40 weeks. These values are double those reported in previous studies that measured fetal bladder volumes at 15- to 30-minute intervals because the cycle length is shorter than previously thought.

The efficacy of fetal sonographic biometry in Down syndrome screening.

Sonographic biometry has been proposed as a second-trimester Down syndrome screening modality. Approaches have relied on the apparent "shortened" femur length of fetuses with Down syndrome. Unfortunately, significant intercenter variation has been reported in the magnitude of this femur length reduction. In an effort to overcome many of these potential biases and better estimate the magnitude of femur length shortening in fetuses with Down syndrome, a retrospective review of femur length differences between 16 Down syndrome and 194 control fetuses was carried out. All scans were performed by one examiner who used the same equipment and measurement technique. A significant reduction in the observed to expected femur length ratio for a given biparietal diameter was identified in the Down versus control fetuses (0.9574 95% confidence interval 0.9197, 0.9952 versus 0.9999 95% confidence interval 0.9913, 1.0086) (p less than 0.008). However, the magnitude of this reduction was not sufficient to permit the use of this sonographic approach as an isolated marker for fetal Down syndrome.