Anticoagulation.

Outpatient management of women requiring treatment and prophylaxis against thromboembolic conditions during pregnancy and the postpartum period requires a coordinated effort between the patient, her obstetrician and, in certain cases, a hematologic consultant. The anticoagulation regimen should be tailored to the clinical situation, with patient compliance and cost taken into consideration.

Applicability of the third-generation, thyroid-stimulating hormone assay in pregnancy.

Use of the third-generation, thyroid-stimulating hormone (TSH) assay in gravid patients has not been validated. We obtained serum from 93 healthy women with a singleton gestation and measured TSH using a two-site immunochemiluminescent ("sandwich") assay. Standard immunoassays were employed for total T4, free T4, and T3 levels. Reference ranges (RR) established by the kit manufacturer were used for comparison. Although the mean TSH level for our population was within the RR, 12/93 women (13%) had a TSH value below the lower limit of normal. None, however, had clinical hyperthyroidism or an elevated free T4. Established RR for the third-generation TSH assay may not apply to pregnant women, and isolated TSH measurements during pregnancy should be interpreted with caution.

In utero progression of isolated renal pelvis dilation.

The objective of this study to determine the risk of in uteroprogression of renal pelvis dilation when detected on antenatal ultrasound examination. We reviewed 230 fetuses with evidence of renal pelvis dilation. At least one exam was subsequently performed prior to delivery in all cases. Renal pelvis dilation was defined as an anterior-posterior renal pelvis measurement > 4 mm at < 32 weeks' and > 7 mm at > or = 32 weeks' gestation. Hydronephrosis was considered to be present when the renal pelvis measured +10 mm independent of gestational age. Multiple gestations and fetuses with additional congenital anomalies were excluded. The mean gestational age at diagnosis was 24 weeks. Renal pelvis dilation progressed to hydronephrosis in a total of 10.9% (25 of 230) of fetuses. There was a 3.3% chance of unilateral renal pelvis dilation progressing to hydronephrosis versus 26.0% in bilateral dilation (OR 10.4 [95% Cl 3.5-33.3]). Of those fetuses with progression, 80% had bilateral dilation (p < 0.0001). There was no difference in progression between right and left kidneys. Additionally, gender, gestational age at diagnosis and delivery, and birth weight did not differ between those fetuses with and without progression. The hydronephrosis in 7 of 25 (28%) regressed to pyelectasis on a subsequent ultrasound exam. Thus, the overall rate of progression of renal pelvis dilation to persistent hydronephrosis was 7.8% (18 of 230). In conclusion, the risk of isolated renal pelvis dilation progressing to hydronephrosis is low. Although bilateral pelvis dilation carries a higher risk for progression, no fetus in our study required in utero intervention. A follow up scan prior to delivery may be considered to identify those fetuses who will require postpartum intervention.

Is the 50-gram glucose screening test ever diagnostic?

The standard criteria for the diagnosis of gestational diabetes (GDM) is based on two abnormal values of a 3-h-100-g oral glucose tolerance test (GTT). Although a markedly elevated 1 h-50-g screen value has been suggested to support a diagnosis of GDM, limited data are available to substantiate this empiric observation. Our purpose was to examine the utility of various 50-g screen cutoff values in establishing the diagnosis of gestational diabetes. We identified 422 gravidas with a positive 50-g screen (> or = 135 mg/dl) who underwent additional glucose testing. GDM was defined according to the National Diabetes Data Group (NDDG) standards for the 3-h GTT. An analysis employing the criteria of Carpenter and Coustan was performed for comparison. If a patient had an elevated 50-g value and no 3-h GTT was performed, a fasting serum glucose > or = 140 mg/ dl was considered evidence of gestational diabetes. One hundred twenty four (29.4%) had GDM as defined by the NDDG criteria; this increased to 161 (38%) when the diagnosis was based on Carpenter and Coustan's criteria. The mean (+/- SD) gestational age at screening was 24 +/- 7 weeks. As expected, the prevalence of GDM increased in relation to an increasing 50-g value. All subjects with a 50-g screen > 216 mg/dl had evidence of gestational diabetes and required insulin for glycemic control. Patients with a 50-g screen > or = 220 mg/dl do not all require a 3-h GTT. Those with a fasting serum glucose of > or = 140 mg/dl may begin diet therapy, glucose monitoring, and insulin as indicated. If the fasting serum glucose is < 140 mg/dl, a 3-h GTT should be performed for confirmation of GDM. This approach will facilitate rapid therapeutic intervention and reduce the cost of care in this subset of patients. Gravidas with a very high 50-g screen are at significant risk of requiring insulin to maintain euglycemia during pregnancy.

Changes in health care delivery: a threat to academic obstetrics.

OBJECTIVE: Our purpose was to examine the effect of anticipated health care policy changes on delivery trends at leading academic obstetric institutions. STUDY DESIGN: The 51 centers in the United States with the most Society of Perinatal Obstetricians presentations in the past 2 years were surveyed regarding annual deliveries from 1990 to 1993 and reasons for any changes. Analysis of variance and chi 2 analysis were used as appropriate. RESULTS: Complete data were available from 43 hospitals representing 39 institutions. Their 1990 to 1993 delivery rates declined faster than United States delivery rates (12.3% vs 2.0%, p < 0.0001). The largest hospitals (> 6000 deliveries) had a decline of 18.2% compared with declines of 9.0% for medium and 0.9% for small hospitals (< 2500 deliveries). Regionally the greatest impact was seen in the West and the South, with 22% and 12% declines, respectively (p < 0.05). Reasons cited for the decline included competition from private or community physicians or hospitals (59%) and managed care (15%). CONCLUSION: As the national health care debate focuses on cost containment and coverage, we believe the potential effects of national policy on research and education should be considered. Continued selective reduction in deliveries at academic institutions can be expected to adversely affect research and education.

Underappreciated risks of the elderly multipara.

OBJECTIVE: Our purpose was to identify the age-related increased risks of the elderly gravida by clarifying the effects of age and parity, their combination, and their interaction. STUDY DESIGN: We studied 9556 singleton pregnancies in women aged 20 to 29 years or > or = 35 years delivered over an 8-year period. Data were analyzed by stepwise multiway contingency table analysis, with p < 0.002 considered significant. RESULTS: Many of the previously reported risks of the elderly gravida are expected on the basis of age and parity. Significant associations (primarily related to advanced age) included higher frequencies of obesity, chronic hypertension, gestational diabetes, and large-for-gestational-age and macrosomic infants. These elderly gravidas, on the other hand, had fewer postdates pregnancies. Although often overlooked, the greatest age-related increases in risk for induction (1.8 times), preeclampsia (2.7 times), gestational diabetes (4.5 times), clinical diabetes (3.2 times), oxytocin use (1.7 times), and macrosomia (1.6 times) occur in multiparas, not nulliparas. The risk for preeclampsia in the elderly multipara is significantly higher than expected on the basis of age and parity. CONCLUSION: The increased risks of the elderly multipara may have been overshadowed by the previous focus on the elderly nullipara. It is important to recognize the increases in age-related risks of the elderly multipara to appropriately counsel and manage this group of patients.

A thrombogenic uterine pack for postpartum hemorrhage.

BACKGROUND: A low-lying placenta or placenta previa is frequently associated with postpartum hemorrhage from a low implantation site. We describe the successful use of a thrombin-soaked uterine pack for this condition. CASE: A 30-year-old woman, gravida 3, para 0-0-2-0, had placenta previa diagnosed by ultrasound at 26 weeks' gestation. A repeat examination at 35 weeks demonstrated a low-lying placenta. The patient had an uncomplicated intrapartum course and was delivered by vacuum extraction, but excessive vaginal bleeding was noted 3 hours after spontaneous delivery of the placenta. Oxytocin, prostaglandin, and uterine curettage failed to control the hemorrhage. In an attempt to avoid laparotomy, we placed a thrombin-soaked uterine pack over the bleeding site. There was minimal vaginal bleeding during the following 8 hours, so the pack was removed. The patient had no further complications and was released 3 days after delivery. CONCLUSION: A thrombin-soaked uterine pack may successfully control lower uterine segment bleeding following delivery of a patient with a low-lying placenta. This technique offers the obstetrician another treatment option in selected cases of postpartum hemorrhage.