Severe maternal and perinatal outcomes from uterine rupture among women at term with a trial of labor.

OBJECTIVE: To describe maternal and perinatal morbidity and mortality associated with uterine rupture (UR) among women with prior cesarean/s, singleton term pregnancies and a trial of labor after cesarean (TOLAC). STUDY DESIGN: Linked hospital discharge files and birth/fetal death certificates identified potential cases of UR in Massachusetts from 1990 to 1998 with definitive identification by medical record abstraction. RESULT: Among the 347 identified URs, severe outcomes occurred in 86 cases (25%), in 49 (14%) of mothers and 49 (14%) of infants. Of the infants, 25 were discharged with a good prognosis. Maternal age and interdelivery interval <18 months (relative risk (RR)=1.55; 95% confidence interval (CI): 1.05, 2.31) were associated with a severe outcome. The type of hospital and labor were not associated with the increased risk of a severe outcome. CONCLUSION: Assuming a 0.7% UR rate among women at term with a TOLAC, the increased rate of severe outcomes related to UR above the baseline risk of elective cesarean is estimated to be 1.3 per 1000 TOLACs.

Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion.

OBJECTIVE: Presentation of outcomes of pelvic arterial embolization for hemorrhage after spontaneous or induced abortion. STUDY DESIGN: We collected case reports of embolization after spontaneous or induced abortion from oral presentations and from members of the National Abortion Federation. RESULTS: Pelvic arterial embolization was performed for 11 women who had hemorrhage after spontaneous or induced abortion, and it was initially successful for all women. One woman ultimately required a hysterectomy after unsuccessful repeated embolization. Prophylactic embolization was done for 8 women who were at risk for hemorrhage from placenta accreta; 4 of these women had subsequent hysterectomies. CONCLUSIONS: Selective pelvic arterial embolization may be a successful treatment for hemorrhage associated with spontaneous and induced abortion. Embolization can be considered before hysterectomy is undertaken for control of hemorrhage. There may be a role for prophylactic catheterization or embolization when there is a risk of severe hemorrhage.

Brain perfusion monitoring with frequency-domain and continuous-wave near-infrared spectroscopy: a cross-correlation study in newborn piglets.

The newborn piglet brain model was used to correlate continuous-wave (CW) and frequency-domain (FD) near-infrared spectroscopy. Six ventilated and instrumented newborn piglets were subjected to a series of manipulations in blood oxygenation with the effects on brain perfusion known to be associated with brain hypoxia-ischaemia. An excellent agreement between the CW and FD was demonstrated. This agreement improved when the scattering properties (determined by the FD device) were employed to calculate the differential pathlength factor, an important step in CW data processing.

Role of frequency domain optical spectroscopy in the detection of neonatal brain hemorrhage--a newborn piglet study.

OBJECTIVE: Inability of continuous wave (CW) optical spectroscopy to measure changes in scattering, and the use of an arbitrary rather than an actual baseline, makes the CW method highly susceptible to errors that can lead to a false-positive or false-negative diagnosis. Our objective was to assess whether, and to what extent, the use of quantitative frequency domain spectroscopy would improve our ability to detect and monitor the development of brain hemorrhage. METHODS: A dual-channel frequency-domain tissue spectrometer (Model 96208, ISS, Inc., Champaign, IL) was used to monitor the development of experimental subcortical and periventricular-intraventricular hemorrhage (IVH) in 10 newborn piglets (blood injection model). The multidistance approach was employed to calculate the absorption and reduced scattering coefficients and hemoglobin changes from the ac, dc, and phase values acquired at four different source-detector distances and at 752 nm and 830 nm. RESULTS: There were significant absorption and scattering changes in the subcortical hematoma (n = 5) and the IVH groups (n = 5). The smallest detectable amount of blood in the brain was 0.04 ml. Changes associated with subcortical hematoma were several times higher than those associated with IVH, and correlated better with the estimated cross-sectional area of the hematoma than with the volume of the injected blood. As opposed to IVH, there was a significant absorption difference between the injured (subcortical hematoma) and normal side of the brain, probably because in case of IVH a significant volume of the injected blood had accumulated/spread beyond the reach of the probe. CONCLUSION: Clearly, frequency-domain spectroscopy cannot increase our ability to quantify the volume (size) or the oxygenation of the injected blood, especially in the case of IVH. However, the ability to quantify the baseline tissue absorption and scattering would significantly improve diagnostic performance, and may allow for early identification and treatment of neonatal brain hemorrhage.

Low-dose oral contraceptives and bone mineral density: an evidence-based analysis.

We reviewed studies of the association of oral contraceptive (OC) use and bone mineral density (BMD). We limited the review to studies of women using low-dose oral contraceptives and that measured BMD by bone densitometry. A total of 13 studies met the inclusion criteria. Nine of these showed a positive effect of OC use on BMD, and four did not show an association. However, none of the studies showed a decrease in BMD with OC use. We classified the level of evidence from each study according to the guidelines of the US Preventive Services Task Force. The level of evidence supporting a positive association between OC use and increased BMD is II-1. There is fair evidence (Category B) to support the position that OC use has a favorable effect on BMD. We made suggestions for a study design that could yield Level I evidence.

PIP: The authors reviewed studies of the association of oral contraceptive (OC) use and bone mineral density (BMD). They limited the review to studies of women using low-dose OCs and that measured BMD by bone densitometry. A total of 13 studies met the inclusion criteria; 9 of these showed a positive effect of OC use on BMD, and 4 did not show an association. However, none of the studies showed a decrease in BMD with OC use. They classified the level of evidence from each study according to the guidelines of the US Preventive Services Task Force. There is evidence supporting a positive association between OC use and increased BMD. There is fair evidence to support the position that OC use has a favorable effect on BMD. The authors made suggestions for a study design that could yield level I evidence.

Use of radiographic atlases in a mass fatality.

In May and June of 1996, a forensic anthropology team from the C.A. Pound Human Identification Laboratory at the University of Florida identified 9 of 10 juveniles from the crash of ValuJet 592. The team relied primarily on a radiographic atlas developed and used by clinical practitioners to determine skeletal age. Postmortem radiographs of the juvenile victims were compared with radiographic standards to determine skeletal age. Skeletal age was then compared to a passenger list indicating the sex, weight, height, and chronological age of each individual. Tentative identifications based on the atlas method were organized into an exclusion matrix. Final identifications were based on this assessment in conjunction with other anthropological data such as appearance and fusion of ossification centers and estimation of stature.

Real-time optical imaging of experimental brain ischemia and hemorrhage in neonatal piglets.

Our objective was to study the development of experimental brain ischemia and hemorrhage by real-time optical imaging. Optical imaging is based on the ability of near infrared light to non-invasively penetrate through the intact scalp and skull and measure brain concentrations of oxy- and deoxyhemoglobin, dominant brain absorbers. Optical imaging was performed in 7 anesthetized, instrumented, and ventilated newborn piglets subjected to the injection of 0.3 cc of saline followed by 2 cc of blood into the left frontal subcortical brain region via a needle inserted through the skull with stereotactic guidance. The image-acquisition rate of 5.26 images per sec allowed for real-time imaging. The detection threshold of the imager at the estimated depth of 1-1.5 cm was approximately 70 microL for saline and approximately 40 microL for blood. The imager readily detected five subcortical hematomas and two large bilateral subarachnoid hemorrhages. The imager detected a global decrease in brain absorption associated with the volume-injection-related increase in intracranial pressure in the surrounding ipsilateral and contralateral brain. Any decrease in brain absorption is an equivalent to brain ischemia. This study demonstrates the capability of optical imaging in detecting brain ischemia and hemorrhage in real-time with high temporal and spatial resolution.

Non-invasive optical monitoring of the newborn piglet brain using continuous-wave and frequency-domain spectroscopy.

We have used continuous-wave (CW) and frequency-domain spectroscopy to investigate the optical properties of the newborn piglet brain in vivo and non-invasively. Three anaesthetized, intubated, ventilated and instrumented newborn piglets were placed into a stereotaxic instrument for optimal experimental stability, reproducible probe-to-scalp optical contact and 3D adjustment of the optical probe. By measuring the absolute values of the brain absorption and reduced scattering coefficients at two wavelengths (758 and 830 nm), frequency-domain spectroscopy provided absolute readings (in contrast to the relative readings of CW spectroscopy) of cerebral haemoglobin concentration and saturation during experimentally induced perturbations in cerebral haemodynamics and oxygenation. Such perturbations included a modulation of the inspired oxygen concentration, transient brain asphyxia, carotid artery occlusion and terminal brain asphyxia. The baseline cerebral haemoglobin saturation and concentration, measured with frequency-domain spectroscopy, were about 60% and 42 microM respectively. The cerebral saturation values ranged from a minimum of 17% (during transient brain asphyxia) to a maximum of 80% (during recovery from transient brain asphyxia). To analyse the CW optical data, we have (a) derived a mathematical relationship between the cerebral optical properties and the differential pathlength factor and (b) introduced a method based on the spatial dependence of the detected intensity (dc slope method). The analysis of the cerebral optical signals associated with the arterial pulse and with respiration demonstrates that motion artefacts can significantly affect the intensity recorded from a single optode pair. Motion artefacts can be strongly reduced by combining data from multiple optodes to provide relative readings in the dc slope method. We also report significant biphasic changes (initial decrease and successive increase) in the reduced scattering coefficient measured in the brain after the piglet had been sacrificed.

Homicide or accident off the coast of Florida: trauma analysis of mutilated human remains.

In the many years Dr. William R. Maples served as a forensic anthropologist, he saw diverse sources of trauma presented in the victims of violent crime, accident and suicide in the state of Florida. In 1996 the District 18 Medical Examiner's Office of Florida requested the assistance of Dr. Maples in the analysis of human remains recovered by the U.S. Coast Guard. The deceased was in an advanced state of decomposition characterized by skin slippage and discoloration. The torso bore multiple lacerations, including nearly parallel lacerations in the skin of the back. Specimens were carefully macerated and the fractures reconstructed. The skeletal trauma was caused by a device capable of delivering robust cuts and blunt trauma in linear paths, as is consistent with propeller trauma. Unusual in this case were blows to the ventral and dorsal surfaces of the body. Based on the anthropological analysis and interviews with the family of the deceased, the F.B.I. proceeded with the case as a homicide investigation.

Non-invasive optical mapping of the piglet brain in real time.

We have performed non-invasive, real-time optical mapping of the piglet brain during a subcortical injection of autologous blood. The time resolution of the optical maps is 192 ms, thus allowing us to generate a real-time video of the growing subcortical hematoma. The increased absorption at the site of blood injection is accompanied by a decreased absorption at the contralateral brain side. This contralateral decrease in the optical absorption and the corresponding time traces of the cerebral hemoglobin parameters are consistent with a reduced cerebral blood flow caused by the increased intracranial pressure.

Single dose methotrexate therapy: application to interstitial ectopic pregnancy.

A woman with a small (6-mm gestational sac) interstitial pregnancy had complete resolution after medical therapy alone. A single cycle of methotrexate 50 mg/m2 was used as outpatient treatment without any operative procedure either for diagnosis or intervention. The guidelines that have evolved for selection of women for single dose methotrexate treatment for both intrauterine and tubal ectopic pregnancies may be applicable to interstitial ectopic pregnancy as well. A suggested framework for treatment decisions is presented.

Fetal atrial septal aneurysm. Prenatal diagnosis by ultrasonography.

OBJECTIVE: To assess prenatal diagnosis by ultrasonography in five cases of fetal atrial septal aneurysm. STUDY DESIGN: Five cases of fetal atrial septal aneurysm were diagnosed prenatally by ultrasound. Postpartum fetal cardiac echocardiography was performed in three of five infants from the first to the fourth day of life. The medical records of the five cases were reviewed and analyzed after delivery. RESULTS: Echocardiograms confirmed atrial septal aneurysm in two of the three neonates. One of the two infants was also found to have a patent foramen ovale, and the other infant had patent duct arteriosis in addition to a patent foramen ovale. Two had fetal cardiac arrythmias that resolved after birth. CONCLUSION: Atrial septal aneurysm in fetuses may be a natural transition in spontaneous closure of the associated patent foramen ovale or septal defect. The same phenomenon has been found in children and infants. Due to the uniqueness of the fetal circulation, atrial septal aneurysm may predispose to fetal arrythmias.

Septic shock, adult respiratory distress syndrome, and disseminated intravascular coagulopathy following midtrimester genetic amniocentesis.

BACKGROUND: Midtrimester genetic amniocentesis is a commonly performed procedure, with acknowledgment of some risk to mother and fetus. CASE: We present an unusual case of midtrimester genetic amniocentesis with bowel injury and resulting septic shock, adult respiratory distress syndrome, and disseminated intravascular coagulation. A total abdominal hysterectomy and bilateral salpingoophorectomy were required for resolution of sepsis. The patient also required prolonged ventilatory support postoperatively. CONCLUSION: Although relatively safe, genetic amniocentesis can result in serious morbidity, and attention to technique should be maintained.

Massive vulvar edema complicating tocolysis in a patient with twins. A case report.

BACKGROUND: Severe vulvar edema is an extremely rare complication of pregnancy. One other case of tocolysis-induced vulvar edema has been reported, as have five cases of postpartum vulvar edema, associated with an 80% maternal mortality rate. CASE: A multipara with a twin gestation presented with premature labor at 31 weeks. The patient had no history of trauma, lymphatic obstruction, venous obstruction or infection. On the fifth day of tocolysis with magnesium sulfate, nifedipine, terbutaline and betamethasone, edema developed in both labia. The following day the vulvar edema had increased and spread to the sacrum. The patient was normotensive and afebrile. Resolution occurred in spite of continuous tocolytic therapy, which was stopped at 35 weeks. Two days later, on hospital day 27, the patient spontaneously delivered two healthy, male infants. CONCLUSION: The two reported cases of tocolysis-induced vulvar edema were not fatal and resolved after repositioning the patient in one case and by cesarean section in the other. However, since maternal death has occurred with postpartum vulvar edema, the patient with vulvar edema merits special attention. The WBC count should be determined and the patient's circulatory status evaluated to rule out hypovolemia.

Prenatal diagnosis of fetal bladder and cloacal exstrophy by ultrasound. A report of three cases.

BACKGROUND: Bladder and cloacal exstrophy can be diagnosed with prenatal ultrasound. CASES: Three cases of bladder and cloacal exstrophy were diagnosed prenatally by ultrasound and confirmed at birth. The ultrasound findings were a soft tissue mass in the lower abdominal wall (which appeared larger and more heterogeneous in cloacal exstrophy than in bladder exstrophy), absent bladder, malformation of the external genitalia and normal kidneys along with normal amniotic fluid volume. CONCLUSION: Prenatal diagnosis of these defects will allow appropriate referrals prior to birth.

Randomized controlled trial of vaginal misoprostol and intracervical prostaglandin E2 gel for induction of labor at term.

OBJECTIVE: To compare misoprostol 25 micrograms administered at 2-hour intervals with intracervical prostaglandin (PG) E2 in women with Bishop scores of 5 or less. METHODS: Subjects were randomly assigned to receive either misoprostol 25 micrograms every 2 hours or a commercially available intracervical preparation containing 0.5 mg of PGE2 gel administered at 6-hour intervals for a maximum of two doses. RESULTS: Women who received misoprostol experienced a significantly reduced mean time (+/- standard deviation) from drug administration to onset of three contractions in 10 minutes, 6.7 +/- 5.8 versus 12.4 +/- 9.6 hours (P = .007). Mean time to rupture of membranes was also shorter in the misoprostol group, 9.7 +/- 5.5 versus 13.6 +/- 6.8 hours (P = .01), as was the mean time to delivery, 16.0 +/- 7.7 versus 22.4 +/- 10.9 hours (P = .006). Three patients in the misoprostol group experienced uterine hypertonus but not related fetal morbidity. CONCLUSION: Misoprostol is more effective than intracervical PGE2 in bringing about labor and delivery, but further work is needed to determine the ideal dosing regimen.

Effect of labor analgesia with nalbuphine hydrochloride on fetal response to vibroacoustic stimulation.

OBJECTIVE: To evaluate the effect of labor analgesia with nalbuphine hydrochloride on the fetal response to vibroacoustic stimulation. STUDY DESIGN: The response to fetal acoustic stimulation (FAS) was recorded in 27 laboring patients before analgesia. After analgesia with 5 mg nalbuphine hydrochloride administered subcutaneously, the response to FAS was again recorded. RESULTS: No ominous fetal heart rate (FHR) patterns were observed. FAS reliably increased FHR baseline and long-term FHR variability and produced FHR accelerations. Nalbuphine hydrochloride analgesia did not produce a significant decrease in long-term FHR variability or alter FHR baseline but did reduce the number of FHR accelerations recorded. CONCLUSION: FAS-induced FHR accelerations did not differ from those observed before analgesia. Analgesia with low doses of nalbuphine did not alter fetal response to FAS, which therefore offers a means of assessing fetal well-being even in the narcotized fetus.

Evaluating the role of incidental diagnostic dilation and curettage in young women undergoing elective laparoscopic sterilization.

Two hundred twenty-two women undergoing incidental diagnostic dilation and curettage (D&C) at the time of elective laparoscopic tubal ligation were studied retrospectively to ascertain if the risks of a D&C were warranted in a group of young, healthy women with a low risk of endometrial pathology. The endometrial sampling was associated with five uterine perforations and one readmission for bleeding and did not uncover any significant pathology in women under 35. The endocervical curettings did yield pathology of some clinical significance in women of all ages. The risk of uterine perforation was significantly higher in women who were < 15 weeks postpartum. We conclude that in a population of asymptomatic women under the age of 35, a diagnostic D&C is not indicated at the time of elective laparoscopic tubal ligation.

PIP: The question of whether the significant risks associated with a dilatation and curettage (D&C) are warranted in a population of young, healthy women prompted a closer examination of performing an incidental diagnostic D&C routinely to detect asymptomatic endometrial pathology. All charts of patients undergoing elective laparoscopic tubal ligation (LTL) with an incidental D&C at Maine Medical Center in the years 1989 and 1990 were reviewed. Parameters examined were age, gravidity, and parity. The medical history was reviewed, noting any history of menstrual abnormalities, bleeding, or abnormal cytologic smears. 222 charts were reviewed. The mean age of the LTL/D&C patients was 33.3 years, mean gravidity was 2.7, and mean parity was 2.0. Five patients sustained uterine perforation at the time of D&C. Four of the 5 perforations occurred in women who were 15 weeks postpartum; only 17 of the 189 parous women without perforation (9%) were 15 weeks postpartum (relative risk, 33.0). These 4 women averaged 10.5 weeks postpartum (range, 7-15). One additional patient required hospital admission postoperatively for excessive bleeding. Pathologic findings of endometrial specimens were normal in 200 cases; the diagnosis was either proliferative, secretory, menstrual, or inactive endometrium. Endocervical curettage pathology was normal in 152: the findings were read as benign, squamous metaplasia, cervicitis, or squamous metaplasia with cervicitis. In 53 cases no endocervical specimen was sent. 17 patients had findings that could have been of clinical significance. 16 patients gave a history of an abnormal cytologic smear. Of the 129 women under the age of 35, only 2 had endometrial lesions of possible significance. All other endometrial lesions occurred in women over 35 years, thus sampling the endometrium may be warranted in them. A routinely performed D&C is not warranted in women less than 35 years old who have no history of abnormal vaginal bleeding. The results also indicate that the risk of uterine perforation appears to be markedly increased up to 15 weeks postpartum.

A pilot study of cyclosporine for the prevention of postsurgical adhesion formation in rats.

OBJECTIVE: Our purpose was to evaluate the efficacy of cyclosporine in preventing primary postsurgical adhesions in the rat model. STUDY DESIGN: Thirty-two Sprague-Dawley rats underwent unilateral uterine horn injury with a combination of unipolar and bipolar cautery. Sixteen of the rats were randomized to the treatment group and received preoperative and daily cyclosporine dosing (10 mg/kg) by gavage for 14 days. At the end of the study all animals were killed, and a standard adhesion scoring system was applied by a blinded examiner. RESULTS: Adhesions were present in 75% of rats in both groups. Treatment did not affect the total adhesion score. CONCLUSION: Cyclosporine does not appear promising as a means to decrease postsurgical adhesion formation.