Maternal magnesium sulfate and the development of neonatal periventricular leucomalacia and intraventricular hemorrhage.

OBJECTIVE: Neonatal periventricular leucomalacia and intraventricular hemorrhage are strong correlates of cerebral palsy. Our objective was to evaluate the effect of maternal magnesium sulfate exposure on the incidence and severity of periventricular leucomalacia and intraventricular hemorrhage in preterm neonates. METHODS: Nine hundred eighteen consecutive inborn neonates with birth weights from 500 to 1750 g were divided primarily into two groups on the basis of maternal exposure to magnesium sulfate. The groups were divided secondarily into two clinical groups, a physician-initiated group, which consisted of neonates delivered for maternal or fetal indications, and a preterm delivery group, which included neonates delivered as a result of preterm labor or preterm premature rupture of membranes. These clinical groups were stratified further into magnesium sulfate-exposed and -unexposed subgroups. Neonatal neurosonograms were performed on days 3 and 7 of life and described as normal or abnormal. Abnormal sonograms included any periventricular leucomalacia or intraventricular hemorrhage. Severe lesions included periventricular leucomalacia, periventricular leucomalacia with intraventricular hemorrhage, or grades 3 or 4 intraventricular hemorrhage. The magnesium sulfate groups and the clinical groups with their magnesium sulfate strata were compared for the incidence and severity of abnormal sonograms. They also were compared for maternal and neonatal characteristics. RESULTS: Maternal magnesium sulfate exposure was not associated with reduction in the incidence of abnormal sonograms when compared with the unexposed group (27% compared with 33%, P = .06). However, fewer severe lesions were observed in the exposed group (14% compared with 21%, P = .004). When clinical groups were examined, magnesium sulfate was not associated with a decrease in abnormal sonograms (adjusted odds ratio [OR] 1.09, 95% confidence interval [CI] 0.78, 1.52, P = .40) or severe lesions (adjusted OR 1.11, 95% CI 0.73, 1.68, P = .42). Logistic regression analyses of magnesium sulfate exposure within clinical groups controlling for the confounding effects of maternal and neonatal characteristics revealed no protective effect of magnesium sulfate exposure on the incidence of abnormal sonograms (adjusted OR 1.01, 95% CI 0.70, 1.44, P = .97) or severe lesions (adjusted OR 1.01, 95% CI 0.70, 1.74, P = .69). Within clinical groups, the preterm delivery group exhibited an increased risk for abnormal sonograms (adjusted OR 1.63, 95% CI 1.01, 2.67, P = .05) and severe lesions (adjusted OR 9.79, 95% CI 3.27, 29.29, P = .001) when compared with the physician-initiated delivery group, independent of maternal magnesium sulfate exposure. CONCLUSION: Maternal magnesium sulfate exposure had no protective effect on the incidence or severity of periventricular leucomalacia and intraventricular hemorrhage in preterm neonates. The prevalence of these lesions was correlated better with the clinical group of origin and indication for its use.

Screening for asymptomatic bacteriuria with Microstix.

The Microstix-3 test was evaluated for its reliability in screening for asymptomatic bacteriuria. When correlated with quantitative cultures this test was found to have high specificity but low sensitivity. Since several positive cases were missed, we conclude that this test is not reliable for use in screening for asymptomatic bacteriuria in pregnancy.

Cerebral function monitor in the neonate. I: Normal patterns.

The cerebral function monitor (CFM) is a monitoring device which records integrated encephalograms (EEGs on slow-running paper, allowing continuous observations of cerebral activity for prolonged periods. The CFM was assessed in 49 normal neonates of different gestational ages and was found to reflect EEG activity accurately. Gestational age and sleep-wake states could be differentiated and normal patterns were defined. The establishment of normal patterns will allow further assessment of the CFM as a screening tool for the neonate at risk for cerebral hypoxic ischemic injury.

Cerebral function monitor in the neonate. II: Birth asphyxia.

The cerebral function monitor (CFM) records an integrated electroencephalogram on slow-running paper, and therefore is suited to long-term, continuous monitoring. This study describes CFM patterns of 31 neonates with birth asphyxia. Three distinct types emerged: (1) a normal pattern compatible with gestational age was uniformly associated with favorable clinical outcome; (2) a completely disorganized pattern was associated with sever injury and fatal outcome; and (3) a more subtle pattern showed reversal to a more immature gestational age. The three infants with the third pattern all survived, but with varying degrees of neurological deficit. It is concluded that the CFM can be of advantage in predicting outcome for asphyxiated neonates.

Correlation of maternal serum C-reactive protein with outcome of tocolysis.

Subclinical intrauterine infection is an important cause of preterm labor, specifically where tocolysis has failed. Fifty patients in preterm labor with singleton pregnancies were studied prospectively to determine whether the presence or absence of C-reactive protein, a nonspecific marker for infection, would correlate with success or failure of tocolysis. Of the 50 patients, tocolysis failed in 11 of 15 women with a positive C-reactive protein determination. Tocolysis succeeded in 33 of 35 cases where C-reactive protein was negative (P less than .0005). Urinary tract infection occurred in 40% of the study patients, but was not a confounding factor in the interpretation of C-reactive protein.

Terbutaline in the management of acute intrapartum fetal acidosis.

A beta 2-mimetic agent, terbutaline, was used before full cervical dilatation in 10 of 18 cases of fetal distress evidenced by fetal scalp blood pH (FSB-pH) less than 7.25. A reduction in uterine activity with an improvement in the fetal heart rate trace was seen in all the cases. In addition, a significant improvement in FSB-pH, when compared with umbilical artery pH (p less than 0.05), was noted whereas there was no significant change in the untreated cases. An Apgar score of less than or equal to 6 at five minutes occurred in two of eight untreated patients but not in any treated patients.

Prenatal diagnosis of conjoined twins.

A case of conjoined twins with open spina bifida prenatally diagnosed at the twenty-third week of gestation is presented. The early detection of this rare and unusual malformation was initiated by the observation of markedly elevated maternal serum alphafetoprotein values. Ultrasound evidence of a misshaped cephalic pole and the appearance of one fetal body on real-time ultrasound was strongly suggestive. Elective midtrimester termination confirmed the prenatal diagnosis and was followed by a benign postpartum course.

Effects of maternal ethanol infusion during pregnancy on the growth and development of children at four to seven years of age.

Twenty-five children whose mothers had been given ethanol for the arrest of preterm labor were evaluated at 4 to 7 years of age and compared with matched control subjects. The group as a whole showed no major differences from control subjects. However, when a subgroup of children born during or within 15 hours of termination of the infusion was investigated, significant pathology in developmental and personality evaluations were noted. It is concluded that if ethanol infusion is to be used, the patient should be carefully evaluated during the infusion. If it appears that labor is progressing, the infusion should be discontinued so as to allow a maximal drug-free interval before delivery.

Effect of tocolysis on incidence of low birth weight.

Tocolysis was attempted in only 2.5% of 570 consecutive low birth weight deliveries in the years 1980 through 1981. The reasons for rejecting therapy in the majority of cases are discussed. Prospectively, tocolysis was attempted in only 13.8% of all patients in preterm labor, with an 82% success rate. If tocolytic therapy were not used, and a calculation made with allowance for usually acceptable false diagnosis and failure rate, the general low birth weight rate would rise minimally and insignificantly (P = 1.4). It is concluded that availability of tocolytic agents must not be expected to lower the overall low birth weight rate, although it will benefit the appropriately selected individual patient.

Prenatal diagnosis of triploidy.

Two cases of late midtrimester triploid gestation are presented. This unusual condition might be suspected in cases of first and second trimester bleeding when the uterus appears to be unusually large as estimated by the menstrual history. Early presence of gestational hypertension also points suggestively toward a triploid fetus. Ultrasound examination of the placenta typically shows multiple sonolucent areas. Confirmation of diagnosis is made by karyotyping cells obtained from amniotic fluid. The condition is incompatible with life and termination of pregnancy is indicated. It is considered prudent to follow HCG levels for evidence of persistent trophoblastic tissue.

Four- to seven-year evaluation in two groups of small-for-gestational age infants.

Fifty-five small-for-gestational age neonates were tested for intellectual and neurologic development at 4 to 7 years of age. When infants of mothers who had hypertensive disease (Group A) were compared with those who had no such disease (Group B), it was found that Group A scored generally better on developmental testing than Group B. Within Group B, it was found that heavier neonates of more advanced gestational ages tested higher unlike Group A where lighter neonates delivered earlier tested better, indicating terminal compromise in this group. Major neurologic problems were found more commonly in Group A than Group B, indicating a greater intrapartum vulnerability. It is concluded that in Group A, earlier delivery after the establishment of lung maturity followed by fully monitored delivery would result in better long-term outcome.

Terbutaline sulfate in the prevention of recurrence of premature labor.

Forty-six patients in premature labor were initially successfully treated with ethanol infusion. Twenty-three of these patients were then given prolonged oral terbutaline sulfate therapy until 38 weeks' gestation, and the remaining 23 patients were given placebo. The treated group gained significantly more time in gestation than the placebo group (P < .05), although the placebo group started with a higher Bishop score. In addition, idiopathic respiratory distress syndrome was seen significantly less often in the treated group. There was no perinatal mortality in either group.

Screening for SGA by the roll-over test.

The roll-over test (ROT) was evaluated in normal pregnant patients between 28 and 34 weeks' gestation and found to be an accurate method of screening for small-for-gestational age (SGA) infants and for preeclampsia. Patients with a positive ROT had a significant risk of SGA or preeclampsia or both. In patients with a positive ROT, the development of SGA may be further predicted by an examination of maternal prepregnancy weight and weight gain. Patients with a prepregnancy weight of 50 kg or less, total weight gain of 10 kg or less, and/or differential weight gain of 20% or less have a highly significant risk of developing an SGA fetus. In contrast, patients with a negative ROT have a significantly decreased risk for SGA and/or preeclampsia.

Preinduction ripening of the cervix with laminaria in the nulliparous patient.

Laminaria tents were used to ripen the unfavorable cervices of 45 nulliparas prior to induction of labor. Successful induction of labor was significantly more frequent in this group than in matched controls in whom induction was attempted without prior laminaria application.

PIP: Based on favorable results from a pilot study, this study evaluated cervical ripening by laminaria tents previous to induction in nulliparous patients with unfavorable Bishop scores. 91 nulliparas were studied; 46 were study patients and 45 were maternal age- and gestational age-matched controls. In the study group, 3 or 4 laminaria were inserted beyond the internal cervical os and were removed 12 hours later, at which time Bishop scores were reassessed. Before laminaria treatment, Bishop scores in the 2 groups were not significantly different. After treatment, Bishop scores of the study group changed significantly from 3.3+ or -1.2 before to 6.5+ or -2.2 (P .0005) after laminaria removal. 33 patients were successfully induced in the study group compared with 5 in the control group. 31 of the 33 could deliver vaginally. 4 of the 5 control patients delivered vaginally.

Ripening of the term cervix with laminaria.

Laminaria tents were used to ripen the cervix in cases where induction of labor was indicated and the Bishop score was less than or equal to 5. Induction of labor was significantly more successful in these cases as compared with a matched control group where the cervix had not been ripened.

Modern management of hypertensive disorders of pregnancy.

Hypertensive disorders of pregnancy contribute significantly to perinatal mortality. Successful application of modern tests of antepartum fetal status and appropriately timed delivery, with monitored labor and liberal use of cesarean section led to significantly improved fetal and neonatal salvage in 242 patients with hypertensive disorders of pregnancy between 1973 and 1975. The reduction in perinatal mortality to a corrected rate of 12/1000 in the years 1973-1975, compared to a previous rate of 75/1000 between 1970 and 1972, justifies the modern aggressive management of hypertensive disorders in pregnancy.

Paracervical block with 2-chloroprocaine.

Thirty healthy term gravidas in active labor received a paracervical block (PCB) with the ester-type local anesthetic, 2-chloroprocaine (2CP). Good to excellent pain relief resulted in all but 1 case. The duration of action was short (mean 38.9 min), requiring repeat blocks in 6/30 cases. Fetal heart rate and uterine contractions were electronically monitored, and fetal acid-base status was periodically checked by fetal scalp pH measurements. PCB-related fetal bradycardia was observed in 3 cases, but in only 1 case was PCB the only cause for the bradycardia. Fetal acidosis was not observed. No instance of neonatal depression or acidosis as expressed by the 1- and 5-minute Apgar scores and cord blood acid-base evaluation was observed. No maternal complications were observed. It is concluded that paracervical block using 2CP is an effective though short-acting method of pain relief which, when properly monitored, is safe for both mother and fetus.