Preterm premature rupture of the membranes before viability.

Although relatively uncommon, VPPROM remains a devastating complication of pregnancy. Current management options offer some hope of improved survival, but morbidity and mortality remain high. Counseling the patient and family following this diagnosis is challenging, and often requires input from both perinatal and neonatal staff. For those patients choosing expectant management who then reach viability, tertiary care should be considered to improve survival risks.

Induction of labor and the relationship to cesarean delivery: A review of 7001 consecutive inductions.

OBJECTIVE: The goal of this project was to study the increasing risk of induction of labor in a community hospital and to determine whether it had an adverse effect on the rate of cesarean delivery. STUDY DESIGN: From January 1, 1990, through July 31, 1997, 18,055 consecutive singleton pregnancies in women who were candidates for labor were reviewed via a comprehensive perinatal database. The risk of and indication for induction were reviewed. Cesarean delivery rates were calculated for nulliparous and multiparous patients by indication for induction and were compared with rates for patients who had spontaneous labor. Overall trends in cesarean delivery were reviewed for the duration of the study period. RESULTS: The annual induction rate significantly rose from 32% to 43% at the conclusion of the study period. Labor was induced in nearly 40% of nulliparous patients. Postdate pregnancy was the most common indication for induction, although few patients were at or beyond 42 weeks' gestation. The cesarean delivery rate remained at or below 20% for the years of the study. No increase was noted in spite of the increasing risk of induction. However, for nulliparous patients who had elective induction of labor, the risk of cesarean delivery was twice that of nulliparous patients who had spontaneous labor. CONCLUSION: The use of induction methods has significantly increased in this community hospital. More than 40% of patients are now candidates for induction. The cesarean delivery rate remains low in this facility in spite of a marked increase in risk of operative delivery for nulliparous patients who undergo induction.

Changing patterns in regionalization of perinatal care and the impact on neonatal mortality.

OBJECTIVE: Our goal was to study changing patterns of low-birth-weight outcome over the past decade as deregionalized perinatal care has occurred. STUDY DESIGN: Live births and neonatal mortality for two 5-year periods (1982 to 1986 vs 1990 to 1994) were calculated by hospital of delivery in the state of Missouri. Self-designated level of perinatal care was contrasted with number of deliveries and nursery census to evaluate outcome. Regression models were constructed to compare outcome between levels of care. RESULTS: There has been a significant shift of deliveries into self-designated level II and III perinatal centers. However, this is largely a result of redesignation of care rather than an actual increase in acuity or census. The relative risk of neonatal mortality for very-low-birth-weight infants is 2.28 in level II centers compared with level III centers, and is unchanged (2.57) from 10 years earlier. Nearly 14% of very-low-birth-weight deliveries still occur at non-level III centers. CONCLUSION: Changing patterns of perinatal regionalization have not improved outcome for inborn infants < 1500 gm except in level III centers. Attempts should be made to deliver very-low-birth-weight infants in level III centers.

Defining limits of survival: lethal pulmonary hypoplasia after midtrimester premature rupture of membranes.

OBJECTIVE: Our purpose was to determine prospectively whether sequential ultrasonographic assessment of amniotic fluid volume (< 1 cm vertical pocket constitutes severe oligohydramnios), in conjunction with other readily available clinical data, could predict the occurrence of pulmonary hypoplasia and neonatal mortality in pregnancies complicated by second-trimester premature rupture of membranes. STUDY DESIGN: Singleton pregnancies complicated by premature rupture of membranes at < 29 weeks' gestation were prospectively monitored by weekly ultrasonographic assessments. Stepwise multiple logistic regression analysis was used to determine the independent predictive value of ultrasonographically determined factors in the development of lethal pulmonary hypoplasia, neonatal mortality, and skeletal deformations. RESULTS: Neonatal mortality and pulmonary hypoplasia were statistically predicted by gestational age at rupture of membranes and interaction of premature rupture of membranes of > 14 days' duration with severe oligohydramnios. The occurrence of skeletal deformations was related to the interaction of duration of premature rupture of membranes and severe oligodramnios (p < 0.0001). Fetal breathing, fetal movements, and thoracic circumference/abdominal circumference ratios were not predictive of outcome. CONCLUSIONS: Both duration of severe oligohydramnios exposure and gestational age at premature rupture of membranes were independent significant predictors of increased neonatal risk. Severe oligohydramnios > 14 days after premature rupture of membranes at < 25 weeks' gestation has a predicted neonatal mortality of > 90%.

The relationship between oxygen saturation and pH in umbilical blood: implications for intrapartum fetal oxygen saturation monitoring.

OBJECTIVE: Our purpose was to evaluate the relationship between umbilical arterial blood oxygen saturation determined by hemoximetry (Sao2) and umbilical arterial blood pH and base excess determined by blood gas analysis to establish a "critical threshold" for fetal preductal arterial oxygen saturation determined by reflectance pulse oximetry (Spo2). STUDY DESIGN: Umbilical artery and vein blood specimens were obtained at delivery. Blood gas analysis and hemoximetry were performed. Polynomial regression analysis and receiver-operator characteristic curves were calculated for umbilical arterial blood Sao2 and theoretic preductal arterial blood Sao2 versus umbilical arterial blood pH and base excess. RESULTS: A total of 1101 paired umbilical artery and vein specimens were obtained. When the umbilical arterial blood Sao2 was > or = 30%, umbilical arterial blood pH was > or = 7.13 in 99.0% (388/392) of cases and < 7.13 in 1.0% (4/392) of cases. When umbilical arterial blood Sao2 was < 30%, umbilical arterial blood pH was > or = 7.13 in 91.4% (648/709) of cases and < 7.13 in 8.6% (61/709) of cases. CONCLUSIONS: From these analyses, it appears that an Spo2 cutoff value of 30% would be reasonable in clinical trials of intrapartum fetal pulse oximetry.

Combined antenatal vitamin K and phenobarbital therapy for preventing intracranial hemorrhage in newborns less than 34 weeks' gestation.

UNLABELLED: ok--q----_xD-xD whether maternal antenatal therapy with vitamin K and phenobarbital prevents intracranial hemorrhage in premature newborns. METHODS: Women at high risk for spontaneous or indicated premature delivery before 34 weeks' gestation were randomly assigned to receive either placebo or vitamin K and phenobarbital. All patients received betamethasone and antibiotics and were managed uniformly by a single perinatal group in one hospital. All newborns were managed uniformly in the same nursery by one neonatal group. Two independent interpretations of neonatal head ultrasound examinations were obtained. RESULTS: The duration of gestation at study entry and at delivery were similar in the placebo (181 mothers) and treatment (191) groups. With the hospital radiology group (the primary interpreter), the incidence rates of severe intracranial hemorrhage (8 versus 7%) and mild intracranial hemorrhage (38 versus 32%) were similar for both groups. With the secondary interpreter (a single pediatric radiologist), the incidence rates of severe intracranial hemorrhage (9 versus 7%) and mild intracranial hemorrhage (27 versus 26%) were also similar. Neonatal mortality was equivalent in both the placebo and treatment groups (8 versus 10%). CONCLUSION: Combined antenatal therapy with vitamin K and phenobarbital does not reduce the frequency or severity of intracranial hemorrhage in premature newborns.

Heparin versus normal saline as a peripheral line flush in maintenance of intermittent intravenous lines in obstetric patients.

OBJECTIVE: To compare heparin sodium (100 United States Pharmacopeia U/mL) with 0.9% sodium chloride for use in the maintenance of intermittent intravenous (IV) devices during pregnancy. METHODS: Women at 26-34 weeks' gestation who required serial phlebotomy were assigned randomly to heparin or normal saline flush, administered in a double-blind fashion. Catheter sites were examined and flushed with the study solution at least once every 6 hours. Partial thromboplastin times (PTTs) were measured at catheter insertion and 48 hours later. Statistical analysis was performed with Student t test, Mann-Whitney U test, Fisher exact test, log-rank, and X2 analysis, as appropriate. RESULTS: There was a significant increase in catheter patency rate at 48 and 72 hours in the heparin group (26 of 31 versus 17 of 33, and 21 of 31 versus nine of 33, respectively; P < .01). In addition, there was a significantly lower rate of catheter complications in the heparin group (four of 31 versus 13 of 33; P < .01). There were no differences in PTTs. CONCLUSION: During pregnancy, dilute heparin flush to maintain patency of intermittent IV site devices results in the following: a greater catheter patency rate at 48 and 72 hours after insertion of the catheter, a lower rate of catheter complications requiring therapy, and no alteration in PTT.

The effect of maternal oxygen administration during the second stage of labor on umbilical cord blood gas values: a randomized controlled prospective trial.

OBJECTIVE: Our aim was to determine whether supplemental oxygen during the second stage of normal labor affects cord blood gas and cooximetry values. STUDY DESIGN: Patients at term pregnancy were prospectively randomized to the control or treatment group at the onset of the second stage of labor. The treatment group received 10 L/min oxygen by face mask, which result in a mean fractional inspired oxygen concentration of 0.81. RESULTS: There were 86 patients randomized into the study. In the oxygen group there were significantly more cord arterial pH values < 7.20 (9/41 vs 2/44, p < 0.05). The control group was compared with two subgroups of patients receiving oxygen: those receiving oxygen therapy for < or = 10 minutes and those receiving oxygen for > 10 minutes. Analysis of variance demonstrated significant differences (7.285 +/- 0.058, 7.312 +/- 0.056, 7.237 +/- 0.064; F test 8.3, p = 0.0005). Among several independent variables, regression analysis demonstrated that only duration of oxygen therapy had a significant inverse relation to cord arterial pH (F test = 15.6, p = 0.0002). CONCLUSIONS: Prolonged oxygen treatment during the second stage of normal labor resulted in a deterioration of cord blood gas values at birth.

Epidural analgesia in labor and cesarean delivery for dystocia.

Published studies assessing the effect of epidural analgesia in nulliparous labor on the frequency of cesarean delivery for dystocia are reviewed. There are at least four retrospective studies and two prospective studies that suggest that epidural analgesia may increase the risk of cesarean delivery for dystocia in first labors. The potential for epidural to increase the frequency of cesarean delivery for dystocia is likely influenced by multiple variables including parity, cervical dilatation at epidural placement, technique of epidural placement, management of epidural during labor, and the obstetrical management of labor after placement of epidural analgesia. Two studies suggest that delaying placement of the epidural until 5 cm of cervical dilatation or greater may reduce the risk of cesarean birth. Epidural is safe and may be a superior labor analgesic when compared with narcotics. However, patients should be informed that epidural analgesia may increase the risk of cesarean birth in first labors.

The risk of pulmonary edema and colloid osmotic pressure changes during magnesium sulfate infusion.

OBJECTIVES: The purposes of this study were to evaluate the effect of magnesium sulfate therapy on colloid osmotic pressure and to determine whether changes in colloid osmotic pressure increased the risk of pulmonary edema. STUDY DESIGN: During a 1-year time period 294 patients received parenteral magnesium sulfate for the treatment of preterm labor or preeclampsia. Both changes in colloid osmotic pressure and magnesium sulfate values and their relationship to clinical outcome parameters were analyzed. RESULTS: Serum magnesium levels were similar for both patients with preeclampsia and patients with preterm labor. Pulmonary edema developed in only four patients, all of whom had preeclampsia and low colloid osmotic pressure values. CONCLUSIONS: This study demonstrated that parenteral magnesium sulfate therapy does not cause significant changes in colloid osmotic pressure values until nearly 48 hours of continuous therapy.

The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial.

OBJECTIVE: Our purpose was to determine the effect of epidural analgesia on nulliparous labor and delivery. STUDY DESIGN: Normal term nulliparous women in early spontaneous labor were randomized to receive either narcotic or epidural analgesia. RESULTS: When compared with the group receiving narcotic analgesia (n = 45), the group receiving epidural analgesia (n = 48) had a significant prolongation in the first and second stages of labor, an increased requirement for oxytocin augmentation, and a significant slowing in the rate of cervical dilatation. Epidural analgesia was associated with a significant increase in malposition (4.4% vs 18.8%, p < 0.05). Cesarean delivery occurred more frequently in the epidural group (2.2% vs 25%, p < 0.05), primarily related to an increase in cesarean section for dystocia (2.2% vs 16.7%, p < 0.05). CONCLUSIONS: In a randomized, controlled, prospective trial epidural analgesia resulted in a significant prolongation in the first and second stages of labor and a significant increase in the frequency of cesarean delivery, primarily related to dystocia.

Iatrogenic omental percutaneous shunt and resolution of obstructive fetal uropathy. A case report.

A double pigtail stent was placed to decompress an obstructed fetal kidney. The stent was dislodged, causing an iatrogenic marsupialization between the renal pelvis omentum and skin. The omentum acted as a drain, decompressing the kidney.

Cervical ripening: a randomized study comparing prostaglandin E2 gel to prostaglandin E2 suppositories.

Prostaglandin (PG) E2 has proven effective in many studies as a pre-induction agent for cervical ripening. The purpose of this study was to compare the efficacy of a 5-mg dose of PGE2 prepared gel with that of a quartered PGE2 20-mg suppository. Previous studies have documented uniform distribution of PGE2 in the suppository. After 90 patients entered the study, there appeared to be an unacceptable rate of hyperstimulation following the induction dose using the suppository. The study was discontinued, and data analysis revealed a 24% hyperstimulation rate with the quartered suppository versus 0% with the gel. The successful vaginal delivery rates were equivalent, at 75% for the gel and 66% for the suppository. The 5-mg quartered suppository appeared to initiate an unacceptable amount of uterine activity, much greater than with the 5-mg gel dose.

Nonimmune hydrops caused by massive fetomaternal hemorrhage and treated by intravascular transfusion.

Fetal hydrops at 26 weeks' gestation was diagnosed following a massive fetomaternal hemorrhage. Fetal intravascular transfusion was performed, and the hydrops completely resolved within 72 hours. The fetus required one more transfusion at 27 weeks' gestation. A subsequent percutaneous umbilical blood sampling at 30 weeks' gestation demonstrated a normal fetal hematocrit. A vaginal delivery at term resulted in a normal newborn. Massive fetomaternal hemorrhage is a well-known cause of nonimmune hydrops and may occur spontaneously in an otherwise normal pregnancy. Confirmation by percutaneous umbilical blood sampling and treatment by intravascular transfusion is recommended when massive fetomaternal hemorrhage causes hydrops in preterm gestations.

Percutaneous balloon mitral valvuloplasty in a pregnant woman with mitral stenosis, sickle cell crisis and acute pulmonary edema. A case report.

A woman with acute congestive heart failure secondary to mitral stenosis and sickle cell crisis was treated successfully with a combination of an exchange transfusion and percutaneous balloon valvuloplasty. That combination provided an alternative to surgical mitral commissurotomy, with its significant risks for both the mother and fetus. The patient was able to undergo an uncomplicated pregnancy course despite the increased risk of cardiac decompensation in the intrapartum and postpartum period.

Hyporegenerative anemia associated with intrauterine transfusion in rhesus hemolytic disease.

Serial erythropoietin and ferritin levels were monitored in a fetus and newborn requiring three intravascular transfusions (in utero) for severe Rh disease. The newborn had a hematocrit of 37% at birth; however a hyporegenerative transfusion-dependent anemia developed and lasted approximately 3 months. The prolonged hyporegenerative anemia may be caused in part by erythropoietin suppression as a result of the fetal intravascular transfusions. In addition, anti-D antibody may also contribute to this anemia by a direct toxic effect on erythroid precursors and by peripheral hemolysis of reticulocytes.