Amnioinfusion-induced malpresentation.

Amnioinfusion is a valuable and common intrapartum procedure for the relief of cord compression and to dilute thick meconium. Like most procedures, it is not without risk and we report a case of malpresentation following amnioinfusion. Intrapartum fetal demise occurred after malpresentation during amnioinfusion resulting in a change of fetal presentation from vertex to unrecognized shoulder presentation. Further study is needed regarding changes in volume of amniotic fluid and saline as well as intrauterine manipulation and the effect on fetal presentation. Careful attention must be paid to infused volumes during amnioinfusion.

Neonatal electrolyte response to amnioinfusion with lactated Ringer's solution vs. normal saline. A prospective study.

OBJECTIVE: To determine if amnioinfusion with normal saline vs. lactated Ringer's solution crystalloids causes electrolyte imbalance in the human neonate. STUDY DESIGN: Over two months, all parturients undergoing amnioinfusion in the active phase of labor were prospectively randomized to receive either normal saline (n = 37) or lactated Ringer's solution (n = 30). Maternal electrolytes were obtained prior to amnioinfusion, and neonatal electrolytes were obtained from cord blood samples at the time of delivery. RESULTS: Our results showed the two groups were similar in maternal age, ethnicity, gravidity, parity, gestational age, maternal electrolyte levels prior to amnioinfusion, amount of solution amnioinfused, duration of labor after amnioinfusion, mode of delivery and mean birth weight. The chloride concentrations were nearly identical among neonates who had received normal saline and those who had received lactated Ringer's solution (102 +/- 2.1 SD and 104 +/- 2.4 mmol/L, respectively; P = 1.0). Other electrolytes were likewise not significantly different regardless of the crystalloid infused. CONCLUSION: Unlike the fetal sheep model, amnioinfusion with normal saline is not associated with hyperchloremia in the human neonate.

Estimating birth weight in twins. Comparison of eight sonographic models.

OBJECTIVE: To establish the relative accuracy of eight sonographic models that use one to four fetal biometric measurements to derive birth weight in twin pregnancies. STUDY DESIGN: Over three years, 181 twin gestations with sonographic mensuration of biparietal diameter, head circumference, abdominal circumference (AC) and femur length (FL) within 96 hours of delivery were analyzed. Analysis of variance followed by Student-Newman-Keul's test was used to determine the relative accuracy of the eight models. A receiver-operating characteristic (ROC) curve was constructed to determine the sonographic estimate that would consistently identify a nonvertex twin B with a birth weight of < or = 1,500 g. RESULTS: The mean gestational age was 32.4 +/- 4.3 (SD) weeks, and the mean birth weights for twins A and B were 1,851 +/- 676 and 1,883 +/- 655 g, respectively. For both fetuses, the mean standardized absolute error was significantly higher for estimates based on one fetal parameter (AC or FL). Regardless of presentation (A or B, vertex or nonvertex) or whether the actual birth weight was < or = 1,500 or > 1,500 g, accuracy was similar between the six models that used two or more fetal parameters to predict the newborn's weight. ROC analysis revealed that among nonvertex twins B, an estimate of birth weight (based on BPD and AC or AC and FL) < or = 1,700 g will consistently identify the newborn with a birth weight < or = 1,500 g. CONCLUSION: Sonographic models that use two fetal parameters are adequate for assessing birth weight in twin gestations regardless of position or if the birth weight is < or = or > 1,500 g.

Infectious morbidity, operative blood loss, and length of the operative procedure after cesarean delivery by method of placental removal and site of uterine repair.

OBJECTIVE: This study was done to determine the impact of the method of placental removal and the site of uterine repair on postcesarean infectious morbidity rates in women receiving prophylactic antibiotics at cesarean delivery. STUDY DESIGN: This prospective study included 284 women who underwent cesarean delivery and who were randomly assigned to four groups based on the method of placental removal and the site of uterine repair: group 1, spontaneous placental removal and in situ uterine repair; group 2, spontaneous placental removal and exteriorized uterine repair; group 3, manual placental removal and in situ uterine repair; and group 4, manual placental removal with exteriorized uterine repair. Exclusion criteria were repeat cesarean deliveries without labor, active infection at the time of cesarean delivery, and patient refusal to participate. RESULTS: There was no significant difference among the groups in maternal age, race, parity, weight, the length of time from rupture of membranes (ROM) or the number of vaginal examinations from ROM to cesarean delivery, or preoperative hematocrit. Intraoperatively, the type of uterine incision, anesthesia administered, incidence of meconium-stained amniotic fluid, Apgar scores, and cord gases were similar between groups. The incidence of postcesarean endometritis was greater in group 4 (32 [45 percent] of 71, p = 0.003) compared with group 1 (17 [24 percent] of 71), group 2 (12 [30 percent] of 71); and group 3 (13 [18 percent] of 71). CONCLUSIONS: Manual placental removal and exteriorization of the uterus for repair of the surgical incision increases the infectious morbidity rate in women receiving prophylactic antibiotics at the time of cesarean delivery and increases the length of hospitalization.

A randomized study to assess the efficacy of the amniotic fluid index as a fetal admission test.

OBJECTIVE: To determine whether there is a difference in the incidence of abdominal delivery for presumed fetal distress in women who have an intrapartum fluid index assessment and those who do not. METHODS: Over a 7-month period, parturients at 26-42 weeks' gestation and in early labor were randomized to the study (measured amniotic fluid index [AFI] on admission) or a control group (no sonographic assessment of amniotic fluid [AF] volume). The labor and delivery staff were aware of the AFI results of the study subjects. All patients had continuous electronic fetal monitoring, and none had an abnormal tracing on admission. Student t test or chi 2 was used for statistical analysis. P < .05 was considered significant. RESULTS: The study (N = 447) and control groups (N = 436) had similar maternal demographics as well as medical and obstetric complications. In the study group, the incidence of abdominal delivery for fetal distress (29 of 447) was significantly higher than among controls (14 of 436) (P = .02; relative risk 1.3, 95% confidence interval 1.1-1.7). Among parturients who had abdominal delivery for fetal distress, the decision-to-incision times (mean +/- standard deviation) were similar for parturients who had undergone assessment of AFI and those who had not (38.5 +/- 14.7 versus 32.5 +/- 14.7 minutes, respectively; P = .47). Mean birth weight, incidence of low birth weight, macrosomia, Apgar scores less than 7, and the number of admissions to the neonatal intensive care unit were not significantly different in the two groups. CONCLUSIONS: Patients having an intrapartum assessment of AFI as a fetal admission test are significantly more likely to have abdominal delivery for presumed fetal distress. However, the decision-to-incision time is not decreased and the perinatal outcome is not improved if the status of AF volume is known for patients in early labor.

Massive congenital intracranial teratoma with skull rupture at delivery.

The majority of case reports concerning intracerebral tumors are almost equally divided between teratomas and gliomas. We report a case of congenital intracranial teratoma with suggested management. An 18-year-old woman at 30 weeks' gestation in active labor because of severe fetal hydrocephalus and polyhydramnios was delivered by cesarean section. Spontaneous rupture of the neonatal skull led to delivery of a stillborn infant; a congenital teratoma was found. Although intracranial teratoma is a well-recognized entity in the differential diagnosis of pediatric brain tumors, massive congenital teratoma replacing cerebral hemispheres of a fetus has been seldom reported. Antenatal diagnosis of the neoplasm and abdominal delivery may not improve outcome.

Corticosteroid-induced arrest of HELLP syndrome progression in a marginally-viable pregnancy.

Corticosteroid therapy in preterm pregnancy complicated by severe pre-eclampsia as HELLP syndrome temporarily stabilizes the HELLP syndrome. One such patient complicated by extreme prematurity was treated with long-term high-dose corticosteroid therapy. The HELLP syndrome was temporarily stabilized and additional in utero fetal maturation was gained.

Hemorrhage associated with cesarean delivery: when is transfusion needed?

Our objective was to determine the incidence of blood administration after cesarean delivery and whether such transfusions are always beneficial. In this retrospective study 1610 women underwent cesarean delivery during a 2-year period and 127 of these patients had hemorrhage during or after operation. Of these subjects 103 received blood because of intraoperative hemorrhage, a reduction in the hematocrit of more than 10 points, or because the postoperative hematocrit was < 24%. These subjects were compared with the remaining women (n = 24) who met the same criteria for hemorrhage but did not receive transfusion. The maternal age, race, and parity were similar in both groups. The estimated blood loss (873 +/- 484 ml) and the preoperative hematocrit (33.4% +/- 6.4%) in the women who did not receive transfusion were not significantly different from those of patients who received packed red blood cells (854 +/- 576 ml and 30.0% +/- 5.4%, respectively). The postdelivery hematocrit was similar in both groups: 25.9% +/- 4.3% in the nontransfused group and 24.5% +/- 5.6% in the transfused group. Patients in the transfused group received a mean of 3.8 +/- 4.9 units of packed red blood cells, with a range of 1 to 40 units. The mean equilibrated (stable) hematocrit after transfusion was 28.4% +/- 5.4%, which was significantly greater than the mean equilibrated postoperative hematocrit of 22.7% +/- 4.6% in patients who did not receive transfusion (p < 0.0001). Nonetheless, the hospital stay, incidence of postoperative infection, and incidence of wound complications were similar in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The irritable uterus: a risk factor for preterm birth?

OBJECTIVE: Our aim was to determine the incidence and preterm delivery rate along with the indication for delivery in patients with uterine irritability. STUDY POPULATION: In this retrospective, descriptive study, 17,186 patients with well-defined high-risk factors were compared with 2637 women with uterine irritability. RESULTS: The incidence of preterm labor in patients with uterine irritability was 18.7%, significantly less than in those with other high-risk factors (odds ratio 0.35, 0.31 < odds ratio < 0.38). However, women with uterine irritability who experience preterm labor, compared with other high-risk factors, are much more likely to deliver before 34 weeks' gestation (odds ratio 2.50, 2.07 < odds ratio < 3.03) and more than twice as likely to deliver as a result of advanced preterm labor or membrane rupture (odds ratio 2.20, 1.75 < odds ratio < 2.78). CONCLUSIONS: The incidence of preterm labor in women with uterine irritability is not as frequent as in patients with other high-risk factors. However, preterm labor does occur in patients with uterine irritability at a rate higher than that in the general obstetric population (18.7% vs 11.0%). Because it appears that women with uterine irritability have more resistance to conventional tocolytic therapy, this condition should prompt the physician to use more aggressive perinatal assessment.

Repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus (prespinous) fascia.

OBJECTIVES: We reviewed our experience with the use of iliococcygeus fascia for repair of vaginal vault prolapse. STUDY DESIGN: A retrospective chart review identified 110 patients who had repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus fascia from March 1981 to April 1991. All patients were followed for a minimum of 3 years. RESULTS: Thirty-seven (33.6%) patients had uterine prolapse with enterocele. Posthysterectomy enterocele was present in 73 (66.4%) patients. All had a complex pelvic floor defect including cystocele or rectocele. Mean age was 54.5 +/- 14.6 years and mean parity was 4.1 +/- 3.2 births. Forty-two (38%) were grand multiparous patients. Five were nulliparous. Length of the procedure was 163.2 +/- 11.4 minutes. Estimated blood loss was 358.2 +/- 253.6 ml. Postoperative urinary catheterization was required for 6.1 +/- 4.1 days. Duration of hospital stay was 5.5 +/- 2.0 days. Three patients had hemorrhage > 750 ml and two required transfusion. One bowel injury and one bladder injury occurred. Forty-one patients had postoperative complications. The patients have been followed up for a minimum of 3 years, and four have had recurrent defects. All recurrent defects involved the anterior vaginal wall. CONCLUSIONS: Suspension of the vagina to the iliococcygeus fascia for repair of vaginal vault prolapse provides excellent long-term results. Critical to the success of vaginal vault suspension are adequate dissection and repair of all fascial defects. Adequate repair of the perineal body also plays a pivotal role. The anterior vaginal wall remains susceptible to recurrence.

Assessment of fetal well-being using the nonstress test in the home setting.

OBJECTIVE: To determine the feasibility of performing nonstress tests (NSTs) in the home setting instead of the health clinic environment. METHODS: In this prospective study, ten women were tested using a Sonicaid TEAM portable monitor and a Hewlett-Packard device in the health clinic. The women were then instructed on use of the Sonicaid device and were tested once a week in the home as well as in the high-risk clinic. All tests were reviewed independently by two of the authors to assess agreement in interpreting the NST. In the health clinic setting, a nonreactive NST was followed by a nipple stimulation contraction stress test (CST); in the home, a nonreactive NST was followed by maternal voice acoustic stimulation. RESULTS: There was 100% correlation during the concurrent study. Two blinded authors agreed on all tests. During the second phase, eight of the ten subjects had NSTs that were consistently reactive in both the home and office settings. In one woman, a nonreactive NST in the clinic was followed by a negative CST. In the remaining patient, a reactive NST in the health clinic was followed 3 days later by a nonreactive NST in the home, which persisted in the provider's office. CONCLUSION: Nonstress testing in the home appears to be an accurate method of antenatal fetal health assessment that adds convenience and potential cost savings.

Clinical estimate of birth-weight in labour: factors influencing its accuracy.

Clinical assessments of birth-weight were made among 88 parturients at term, to determine what maternal and neonatal factors influence the accuracy of predicting neonatal weight. An estimate within +/- 10% of actual weight was considered accurate, while a prediction off by more than 10% was classified as inaccurate. Seventy-one per cent (63 of 88) of the estimates were considered accurate and 28% (25 of 88) inaccurate. Among these 2 groups of patients, univariate analysis did not identify maternal age, gravidity, parity, gestational age, maternal height, prepregnancy weight and maternal body mass index, maternal weight and maternal body mass index at the time of delivery, change in body mass index during pregnancy, intrapartum amniotic fluid index, newborn's weight, length, and ponderal index as being significant correlates of an accurate clinical estimate of the birth-weight. Over 2 years, as the provider gained experience in predicting the neonatal weight, the accuracy of the clinical estimate of birth-weight did not improve.

Intrapartum assessment by house staff of birth weight among twins.

OBJECTIVE: To determine among twins in labor: 1) the relative accuracy of an intrapartum sonographic estimate of the birth weight for both fetuses using biparietal diameter and abdominal circumference, 2) the accuracy of detecting discordant growth (difference in actual birth weights greater than or equal to 15%), and 3) the estimate of fetal weight for nonvertex twin B that would reliably avoid breech extraction of infants less than 1500 g. METHODS: Retrospectively, we identified and analyzed parturients with twins who had an intrapartum sonogram performed by a house officer assigned to the labor and delivery suite. RESULTS: The mean birth weight (+/- standard deviation) for the twin A group was 1910 +/- 628 g and for twin B was 1869 +/- 668 g. The mean standardized absolute errors for the twin A group (121 +/- 118 g/kg) and the twin B group (92 +/- 67 g/kg) were not significantly different (P = .06). Analysis of variance revealed that regardless of the presentation of the fetuses, the mean standardized absolute error was not significantly different (P = .10). Using a difference in the estimates of birth weight of 15% or greater, the positive and negative predictive values of detecting discordant growth within a twin pair were 53 and 83%, respectively. Among 30 vertex-nonvertex twin pairs, 12 of the second fetuses had actual birth weights of 1500 g or less, and all were estimated to weigh less than 1700 g. CONCLUSIONS: The intrapartum sonographic estimate of fetal weight in twin pregnancy by house staff appears reliable, and the accuracy of prediction is similar regardless of presentation, discordance, or actual birth weight greater or less than 1500 g. To avoid vaginal delivery of a persistent nonvertex twin B with a birth weight of 1500 g or less, a sonographic estimate of 1700 g for the second fetus may be adequate.

Summertime respiratory syncytial virus infection: epidemiology and clinical manifestations.

Respiratory syncytial virus (RSV) is a common serious pathogen known to produce annual winter epidemics in young children. A 2-year study of children with significant respiratory disease during the summer revealed a 21% incidence of RSV infection. Respiratory secretions collected from ill children in the LSUMC outpatient clinics, from children seen by private physicians, and from children hospitalized with respiratory tract disease were assayed for RSV antigens. Approximately 39% of those surveyed in 1987 and 13% of those studied in 1988 were positive. As this prevalence was significant, we compared RSV-induced disease in 20 patients hospitalized in summer and 20 hospitalized in winter (1989). The patients were matched by age, weight, sex, and race. Comparisons included subjective severity of disease, presenting symptoms, physical findings, chest roentgenograms, treatment, and average length of hospital stay. No significant differences in disease severity and/or clinical presentation were found. Our findings show that RSV induces disease in the summertime more frequently than generally recognized, and severe disease requiring hospitalization is not infrequent. Physicians should consider RSV in children with serious respiratory disease throughout the year.