An ex utero intrapartum treatment procedure in a patient with a family history of malignant hyperthermia.

In the EXIT (ex utero intrapartum treatment) procedure, after uterine incision, uterine relaxation is maintained to prevent placental separation and the fetus is supported via the placenta until the airway is successfully established. The traditional method to maintain uterine relaxation is with the use of high-dose potent inhaled anesthetics during general anesthesia. A patient with a family history of malignant hyperthermia required an EXIT procedure. The history of malignant hyperthermia precluded the use of potent inhaled anesthetics and an alternate plan using propofol and remifentanil infusions for anesthesia and nitroglycerin 16 µg/kg/min for uterine relaxation allowed for good surgical conditions. The presence of malignant hyperthermia required an alternate plan and close collaboration in order to ensure good patient outcome.

Rescue corticosteroids in twin pregnancies and short-term neonatal outcomes.

OBJECTIVE: To estimate the efficacy of a rescue course of antenatal corticosteroids in twin pregnancies. DESIGN: Retrospective cohort study. SETTING: Tertiary-care centre. POPULATION: Twins born from 24 to <34 weeks of gestation in a single maternal and fetal medicine practice from 2006 to 2011. METHODS: We compared neonatal outcomes in 88 twins exposed to a single course of corticosteroids with outcomes in 42 twins exposed to two courses of corticosteroids: the initial course and a single rescue course. Analyses were adjusted to control for correlation between twins born to the same mother. MAIN OUTCOME MEASURE: Short-term neonatal respiratory morbidity. RESULTS: Rescue corticosteroids were associated with fewer days of mechanical ventilation (7.3 ± 3.3 versus 33.9 ± 25.3 days, P = 0.003), fewer days with a fraction of inspired oxygen of >21% (6.3 ± 4.3 versus 33.3 ± 25.8 days, P = 0.003), a lower incidence of mechanical ventilation >14 days or death while on mechanical ventilation (0 versus 12.5%, P = 0.016), and a lower incidence of retinopathy of prematurity (0 versus 12.5%, P = 0.016). The proportion of neonates with respiratory distress syndrome did not differ between the groups (adjusted odds ratio 1.28, 95% confidence interval 0.50-3.26). There were no differences found for birthweight, head circumference and length. CONCLUSIONS: In twins born before 34 weeks of gestation, exposure to rescue corticosteroids may be associated with improved neonatal outcomes. Further studies are warranted to assess the effect of rescue corticosteroids in twin pregnancies.

Cervical length at 30-32 weeks and the risk of Cesarean delivery in twin pregnancies.

OBJECTIVES: To estimate the association between the cervical length (CL) measurement at 30-32 weeks and the mode of delivery in twin pregnancies. METHODS: This was a retrospective study of a cohort, from 2005-2010, of 265 twin pregnancies with a CL measurement at 30-32 weeks. We compared the CL measurement at 30-32 weeks based on mode of delivery. We then analyzed our data across four subgroups, based on the CL measurement quartiles at 30-32 weeks. We performed this analysis in all patients, and also performed a planned subgroup analysis of 130 patients who attempted a vaginal delivery. RESULTS: In all patients, including those who attempted a vaginal delivery, the mean CL at 30-32 weeks was significantly shorter in women who delivered vaginally compared with women who had a Cesarean section. The likelihood of Cesarean delivery increased significantly with increasing CL measurement across the groups defined by measurement quartiles. On adjusted analysis controlling for maternal age, race, in-vitro fertilization, chorionicity, induction of labor and prior vaginal delivery, the CL measurement at 30-32 weeks was independently associated with mode of delivery. CONCLUSIONS: In twin pregnancies, the CL at 30-32 weeks is significantly associated with the likelihood of Cesarean delivery. A longer CL may represent underdevelopment of the uterus, leading to a higher risk of Cesarean delivery in labor at term.

Intravaginal misoprostol versus Foley catheter for labour induction: a meta-analysis.

BACKGROUND: There are a number of agents used for cervical ripening prior to the induction of labour. Two commonly used agents are intravaginal misoprostol and a transcervical Foley catheter. OBJECTIVE: To review the evidence comparing misoprostol and transcervical Foley catheter placement for induction of labour, and perform a meta-analysis comparing these two induction agents. SEARCH STRATEGY: We conducted database searches of PubMed, Embase, the Cochrane Library Database, and the ClinicalTrials.gov website. Bibliographies of all relevant articles were reviewed. SELECTION CRITERIA: Prospective, randomised trials comparing the use of intravaginal misoprostol and transcervical Foley catheter for the purpose of cervical ripening and induction of labour were included. We excluded studies in which the patients in these two intervention groups also received other induction agents concurrently, such as oral misoprostol, oxytocin, or other prostaglandins. DATA COLLECTION AND ANALYSIS: The primary outcomes selected were time to delivery, and the rates of caesarean section, uterine tachysystole, and chorioamnionitis. Random-effects generalised linear models with a poisson distribution and log link function were used to compare the two induction agents across the studies. MAIN RESULTS: Nine studies (1603 patients) were identified as eligible to be included in this meta-analysis. There were no significant differences in the mean time to delivery (mean difference 1.08 ± 2.19 hours shorter for misoprostol, P = 0.2348), the rate of caesarean delivery (RR 0.991; 95% CI 0.768, 1.278), or in the rate of chorioamnionitis (RR 1.130; 95% CI 0.611, 2.089) between women who received misoprostol compared with transcervical Foley catheter. Patients who received misoprostol had significantly higher rates of tachysystole compared with women who received a transcervical Foley catheter (RR 2.844; 95% CI 1.392, 5.812). CONCLUSIONS: Intravaginal misoprostol and transcervical Foley catheter have similar effectiveness as induction agents. Transcervical Foley catheter is associated with a lower incidence of tachysystole.

Soft forceps.

OBJECTIVE: The risk of maternal and fetal trauma and, chiefly, the fear of law suits, have contributed to a significant decline in rates of forceps-assisted deliveries and an increase in rates of cesarean sections, especially in the United States. Our experience with gas-sterilized forceps blades covered with a soft rubber coating--the "soft" forceps--is described. METHOD: Ninety-six women who required a forceps-assisted delivery for standard indications were randomly allocated to 2 groups. There were 51 women in the regular forceps group and 45 women in the soft forceps group. Low forceps delivery with a Simpson instrument was used in all cases. The groups were compared for fetal injury. RESULTS: The rates of severe facial abrasion and minimal marking were 4.1% and 61%, respectively, in the regular forceps group and 1.9% and 34% in the soft forceps group. CONCLUSION: The soft forceps may reduce the rates of neonatal facial abrasion and skin bruises. The forceps should be further perfected, as well as vacuum extractors; they should both continue to be part of the obstetrician's armamentarium.

Endoscopic closure of fetal membrane defects: comparing iatrogenic versus spontaneous rupture cases.

OBJECTIVE: Currently, physicians manage preterm premature rupture of membranes (PPROM) by expectant management or termination of the gestation. A therapy aimed at sealing membranes would be optimal to maintain the pregnancy and achieve a normal neonate. Our objective was to compare an endoscopic technique for intrauterine closure of fetal membrane defects after both iatrogenic and spontaneous rupture of membranes. METHODS: Our technique was performed on four patients experiencing PPROM spontaneously and four patients after genetic amniocentesis. Intrauterine endoscopy allowed direct visualization of membrane defects. Rapid sequential injections of platelets, fibrin glue and powdered collagen slurry were administered at the site of the defect and of trocar placement. Sonography for amniotic fluid index, nitrazine and fern testing and pad count were performed after each procedure at three intervals: immediately post-procedure, and after 24 and 48 h. RESULTS: Eight patients underwent endoscopic intrauterine sealing of ruptured membranes between 16 and 24 weeks of gestation: four were spontaneous ruptures and four were ruptures post-amniocentesis. In the post-amniocentesis group, three patients delivered viable infants at 26, 32 and 34 weeks. In one patient, the membranes ruptured again 12 h after the sealing procedure and she decided to undergo termination of pregnancy. Of the four spontaneous rupture patients, two experienced preterm labor and delivery within 2 days of the procedure. One patient was diagnosed with fetal demise 12 h post-procedure, and one patient delivered a neonate at 31 weeks of gestation with severe respiratory distress syndrome. CONCLUSIONS: This technique for sealing ruptured membranes is effective after amniocentesis, but may not be of benefit with spontaneous rupture.

First-trimester diagnosis of sacrococcygeal teratoma: the role of three-dimensional ultrasound.

A fetus was suspected of having a sacrococcygeal teratoma (SCT) on routine nuchal translucency evaluation by sonography at 12+3 weeks. The patient was referred for three-dimensional (3D) sonography to further delineate the extent of the mass. In this case, real-time scanning of the mass in 3D mode assisted the diagnosis of the mass and patient counseling. We present what we believe to be the first case of SCT imaged in the first trimester using 3D ultrasound.

Transrectal scanning: an alternative when transvaginal scanning is not feasible.

OBJECTIVE: In scanning the female pelvis the clear images of transvaginal sonography (TVS) result from placing the transducer close to the region of interest. The advantages of TVS over transabdominal sonography (TAS) and transperineal sonography are well documented. Transrectal scanning is proposed mostly for ultrasound guidance in draining a pelvic abscess. Our aim was to investigate the applicability of transrectal scanning (TRS) for cases in which TVS is impossible. METHODS: Forty-two patients with an absolute or a relative contraindication to TVS were scanned transabdominally and transrectally. The TRS was performed using a transvaginal probe, which was lubricated and slowly advanced into the rectum. The technique used was similar to that of TVS. Images were compared for resolution and quality. RESULTS: All scans were completed without significant patient discomfort or complaints. TRS was clearly superior to TAS in 31 cases. In nine cases TAS furnished some clinical information but TRS yielded better images. Only in one such case was TAS similar in quality to TRS. In four obese patients TAS did not reveal sufficient pelvic anatomy to generate a clinical diagnosis, whereas TRS revealed two sets of normal ovaries and two patients with ovarian cysts. In the two cases with vaginal agenesis TRS revealed the diagnosis of Rokitansky-Küster syndrome. In three of the four patients with ruptured membranes the cervix could be measured precisely. CONCLUSION: Transrectal scanning should be used liberally after proper patient selection and counseling. The images obtained are superior to TAS and comparable to those obtained by TVS.

Cervical length after multifetal pregnancy reduction in remaining twin gestations.

OBJECTIVE: Multifetal pregnancy reduction is associated with an increased risk of prematurity. Because cervical length correlates with preterm delivery risk, we sought to determine whether multifetal pregnancy reduction twin gestations are associated with shorter cervical lengths compared with non-multifetal pregnancy reduction twins. STUDY DESIGN: We compared an historic cohort of patients who underwent multifetal pregnancy reduction to twins (n = 35) to a control group of twin gestations without multifetal pregnancy reduction (n = 83) from July 1996 to January 2000. Both groups of patients were treated with identical protocols. Cervical lengths across gestation and pregnancy outcomes were compared. RESULTS: Study and control groups did not differ significantly in mean maternal age (37.8 +/- 4.9 years vs 35.5 +/- 6.2 years; P =.06), median parity (0 [range, 0-1] vs 0 [range, 0-2]; P =.56), or mean gestational age at delivery (36.2 +/- 2.6 weeks vs 35.8 +/- 3.8 weeks; P =.50). The proportion delivering before 35 weeks of gestation was not significantly different (14.3% vs 30.1%; P =.10) nor was delivery before 32 weeks of gestation (8.6% vs 8.4%; P =.98). Cervical length did not differ significantly between the 2 groups. At 14 to 19 weeks the median was 3.9 cm (range, 2.4-6.0 cm) in the multifetal pregnancy reduction group versus 3.7 cm (range, 3.1-4.7 cm) in the control subjects (P =.15); at 20 to 25 weeks, the medians were 3.2 cm (range, 2.2-5.4 cm) and 3.7 cm (range, 1.5-5.7 cm), respectively (P =.43); and at 26 to 31 weeks the medians were 3.5 cm (range, 1.2-5.9 cm) versus 3.8 cm (range, 1.2-5.3 cm), respectively (P =.56). CONCLUSION: Cervical length across gestation in twin pregnancies is not affected by multifetal pregnancy reduction, despite the likely inflammatory response expected to accompany this procedure.

Endoscopic ligation of umbilical cord at 19 week's gestation in monoamniotic monochorionic twins discordant for hypoplastic left heart syndrome.

We report the first attempt of reduction of monoamniotic twins, discordant for hypoplastic left heart syndrome, using a new fetoscopic technique. Employing sonographic guidance and endoscopic visualization, cord ligation was accomplished, but significant cord entanglement, not previously appreciated, resulted in the ligation of the umbilical cord of the normal fetus. Cord entanglement may frustrate endoscopic techniques in monoamniotic twins.

Change in cervical length after cerclage as a predictor of preterm delivery.

OBJECTIVE: To determine whether the degree of cervical lengthening after cerclage and whether serial follow-up measurements of cervical length after cerclage are predictive of pregnancy outcome. METHODS: Eighty women whose primary physician determined that a prophylactic (n = 50) or urgent cerclage (n = 30) was indicated had transvaginal ultrasonographic evaluation before and after cerclage. Thereafter, most women had three additional transvaginal ultrasound examinations until 32 weeks' gestation. At each examination, the mean of three measurements was calculated. Statistical analyses were done by t test, analysis of variance, and logistic regression, with significance set at P <.05. RESULTS: The mean +/- standard deviation precerclage cervical length was 27.2 +/- 10.3 mm and after cerclage was 34.1 +/- 9.9 mm (n = 80, P <.001, paired t test). No significant association was found (r = -0.26) between the difference in cervical length (postcerclage - precerclage lengths) and pregnancy outcome. Patients with a prophylactic cerclage had a mean cervical length that was consistently longer in patients delivering at term compared with those who delivered preterm at 20 to 32 weeks' gestation. In the urgent cerclage group a significant difference in cervical length between those who delivered at term compared with preterm was evident only at 28 to 32 weeks. CONCLUSION: The increase in cervical length after cerclage is not predictive of term delivery. Serial cervical length measurements in the late second or early third trimester predict preterm birth but could provide earlier warning in patients with a prophylactic cerclage than in patients with urgent cerclage.

Neopterin concentrations in fetal and maternal blood: a marker of cell-mediated immune activation.

OBJECTIVE: Neopterin is generated by macrophages and monocytes in response to cytokine and endotoxin stimulation and is a sensitive marker of the severity of infectious-, autoimmune-, and alloimmune-mediated inflammatory disorders. This study was designed to evaluate fetal and maternal neopterin concentrations during the second half of pregnancy. STUDY DESIGN: We conducted a cross-sectional analysis of serum neopterin values with a sensitive radioimmunoassay in 35 paired fetal and maternal and 8 neonatal samples. The fetal and maternal samples were obtained between 20 and 38 weeks' gestation at the time of diagnostic cordocentesis. All maternal, fetal, and neonatal samples were derived from uncomplicated pregnancies resulting in term delivery of appropriately grown fetuses. RESULTS: Fetal neopterin concentrations increased across gestation (r = 0.64, P <.001), and mean values were significantly higher than paired maternal values (6.28 [+/-2.44] ng/mL vs 2.05 [+/-0.87] ng/mL, P <.001]. In contrast, maternal neopterin concentrations did not correlate with gestational age (r = 0.22, P =.24). No significant correlation was found between fetal and maternal values (r = 0.34, P =.07). CONCLUSION: Fetal neopterin values rise significantly across gestation. They are substantially greater than maternal levels and are not correlated significantly with paired maternal levels. These findings are the first report of a physiologically normal range for fetal neopterin concentrations in a sample of uncomplicated pregnancies. The values suggest progressive increases in fetal cell-mediated immunity and macrophage-monocyte activation as gestation progresses.

Change in cervical length after prophylactic cerclage.

OBJECTIVE: To determine changes in length of incompetent cervices after cerclage, using transvaginal ultrasound. METHODS: Patients were enrolled in a prospective, observational study under an Institutional Review Board-approved protocol. McDonald or Shirodkar sutures were placed according to physician preference. Pre- and postcerclage cervical lengths were measured within 72 hours of the procedure. At each examination, the first measurement was discarded, and a mean of the subsequent three measurements was calculated. RESULTS: Twenty-one Shirodkar and ten McDonald operations were done. The mean (+/- standard deviation) precerclage cervical length was 2.7+/-0.9 cm and the postcerclage cervical length was 3.6+/-0.9 cm (P<.001, paired t test). CONCLUSION: Prophylactic cerclage results in measurable increases in cervical length, which might contribute to the success of the procedure. Further study is needed to determine whether the degree of cervical lengthening after cerclage predicts term delivery.

The safety of intraoperative autologous blood collection and autotransfusion during cesarean section.

OBJECTIVE: We evaluated the safety of intraoperative autologous blood collection and autotransfusion during cesarean section. STUDY DESIGN: A multicenter historical cohort study identified 139 patients in whom autologous blood collection autotransfusion during cesarean section was performed. We also identified 87 control patients who underwent similar surgical procedures at the same centers without autotransfusion. The outcome variables we compared were acute respiratory distress syndrome, amniotic fluid embolism, disseminated intravascular coagulation, need for ventilatory support, infectious morbidity, and the length of postpartum hospitalization. RESULTS: Demographic and obstetric characteristics were similar in both groups. The ranges of autotransfused volumes were 200 to 11,250 mL at Yale, 225 to 1160 mL at Good Samaritan, and 125 to 4750 mL at Hinsdale. No statistically significant differences existed between the two groups in any of the outcome variables analyzed. No case of acute respiratory distress syndrome or amniotic fluid embolism was identified in either group. CONCLUSIONS: Our multicenter experience reveals no demonstrably increased risk of complications in patients receiving autologous blood collection autotransfusion during cesarean section.

The effect of fetal intravascular blood transfusion on plasma endothelin levels in fetuses with rhesus alloimmunization.

OBJECTIVE: To determine if intrauterine intravascular fetal transfusion affects fetal umbilical venous endothelin levels. METHODS: Endothelin concentrations were measured by radioimmunoassay in fetal umbilical venous blood obtained immediately before and after 36 fetal transfusions performed for Rh alloimmune hemolytic anemia. Umbilical venous pressures also were recorded before and after transfusion. RESULTS: The mean (+/- standard deviation [SD]) gestational age at transfusion was 27.0 +/- 4.6 weeks, whereas the initial and post-transfusion hematocrits were 23.3 +/- 8.5% and 41.8 +/- 6.3%, respectively. Post-transfusion endothelin levels correlated significantly with the volume of transfused blood (r = .41; P = .03) and with post-transfusion increases in umbilical vein pressure (r = .86; P < .001). Among fetuses undergoing initial transfusion, there were significant differences between mean (+/- SD) pre- and post-transfusion endothelin levels [3.6 (+/- 2.2) pg/mL versus 6.3 (+/- 4.0) pg/mL, respectively; P = .02]. In contrast, among fetuses undergoing a repeat fetal transfusion, no differences in mean (+/- SD) pre- versus post-transfusion endothelin levels were observed [3.8 (+/- 1.8) pg/mL versus 2.2 (+/- 1.77) pg/mL, respectively; P = .3)]. Step-wise multiple regression analysis identified order of transfusion as a significant predictor of change in endothelin levels from pre- to post-transfusion measurements (adjusted r2 = .26; P = .003). CONCLUSION: Rapid expansion of fetal intravascular volume by intravenous transfusion of packed red blood cells with a high hematocrit enhances fetal endothelin levels in those fetuses undergoing initial but not subsequent transfusions.

Methadone maintenance treatment and the nonstress test.

The objective of this study was to determine whether long-term in utero exposure to methadone affects fetal performance on nonstress tests (NSTs). We retrospectively reviewed our experience with 28 women who were enrolled in an outpatient methadone maintenance program and received prenatal care at our institution. The median daily methadone dosage was 60 mg. NSTs (N = 106) were done during the third trimester in conjunction with prenatal visits. Reactivity was present in 79% of the NSTs. The proportion of NST results that were reactive in our population differed from the 86% overall reactivity rate reported in the literature (p < 0.05). This finding suggests that long-term in utero methadone exposure can affect fetal performance on the NST.