Obtaining the four-chamber view to diagnose fetal cardiac anomalies.

Four-chamber view screening of the fetal heart was greeted with significant optimism in the mid-1980s. This screening technique was initially expected to detect most congenital heart disease in utero; however, recent studies demonstrate a 4% to 40% sensitivity of four-chamber view screening. It is therefore probable that the dream of antepartum diagnosis of most congenital heart disease in utero will remain unfulfilled. This is particularly true with increasing funding constraints for health care provision imposed by both the federal government and third-party payors.

Second trimester uterine atony imitating ectopic pregnancy: magnetic resonance diagnosis.

When an obstetrical patient was referred for inability to auscultate fetal heart tones at 18 weeks' gestation, ultrasound identified a single living fetus in the maternal right upper quadrant. Magnetic resonance imaging (MRI) ruled out a suspected uterine ectopic pregnancy and avoided laparotomy. The patient experienced an uncomplicated term delivery. MRI is a useful adjunct to ultrasound for mid-trimester pregnancy localization when the differential diagnosis includes uterine eccyesis.

Risk of preterm delivery from preterm labor in high-risk patients.

This study aimed to determine the incidence of preterm labor and birth (< 37 weeks' gestation) in patients at high risk for early delivery. In this retrospective, descriptive study, 17,186 women with high-risk factors for early delivery were studied over a five-year period (1986-1990). Study groups included women with prior preterm delivery, multifetal gestations, uterine abnormalities and cervical factors. The rate of preterm labor for all patients averaged 40% (range, 30-46%). The rate of preterm delivery in the four groups ranged from 14% to 30% and averaged 19.7%. In those who experienced preterm delivery, only 32% of cases were due to preterm labor with advanced cervical dilatation, failed tocolysis or preterm premature rupture of membranes. The majority of early deliveries were due to medical or obstetric disorders as well as to patient/physician factors. The incidence of preterm labor remains significant when women have high-risk factors for preterm delivery. However, the incidence of preterm delivery, particularly that due to avoidable factors, such as failed tocolysis and preterm rupture of the membranes, is considerably lower than that quoted in the literature.

Monoamniotic twins discordant for anencephaly: diagnosis by CT amniography.

Prenatal diagnosis of monoamnionicity is necessary for optimal care of a twin gestation. When the fetuses are discordant for a lethal anomaly, unequivocal confirmation is imperative. Ultrasound evaluation of our patient revealed a twin gestation discordant for anencephaly and with possible monoamnionicity. When sonography was inconclusive, CT amniography confirmed a single amniotic cavity, permitting appropriate parental counseling and pregnancy management. CT amniography is a useful adjunct to ultrasound in evaluating twins discordant for a lethal anomaly when monoamnionicity is suspected.

Clinical application of the Kleihauer-Betke test.

A prospective study was performed to investigate the benefit of serial quantitation of fetomaternal hemorrhage with the Kleihauer-Betke test for the prediction of neonatal/maternal outcome in pregnancies at risk for such bleeding. Of 65 patients, 14 (22%) had a positive Kleihauer test. Six of these women (43%) had evidence of placental abruption. Neonatal anemia (hematocrit < 48%) was present in only 2 of the 14 patients with a positive Kleihauer test (14%). Morbidity in the newborn correlated with gestational age at delivery, not with neonatal hematocrit. Maternal morbidity was not associated with a positive test. We conclude that Kleihauer-Betke testing is of limited value in patients at risk for fetomaternal hemorrhage.

Intrapartum fetal heart rate assessment: monitoring by auscultation or electronic means.

OBJECTIVE: Our purpose was to assess the frequency with which auscultation could be used as the primary mode of fetal assessment during labor in a busy labor and delivery suite by means of published criteria. STUDY DESIGN: During a 3-month period, 862 patients in labor with live fetuses between 24 and 43 weeks of gestation were available for auscultation in the prospective study. Auscultation was initiated during a contraction and extended for 30 seconds after uterine activity ceased. It was repeated every 15 minutes in the first stage and every 5 minutes in the second stage of labor. RESULTS: In 420 patients this modality was not begun because of inability of the nurses to meet 1:1 staffing requirements. In 19 patients auscultation was not performed because of obesity (12) or patient refusal (7). Of the 423 assessed by auscultation 392 were unable to complete monitoring caused by the frequency requirement (n = 212) or the recording criteria (n = 163). Of the 31 patients where auscultation was successfully completed, there was a 1:1 nurse ratio during the entire labor. CONCLUSIONS: Auscultation with stringent evaluation and recording frequency is not feasible under normal labor and delivery room conditions unless 1:1 nursing care is always available.

Does method of placental removal or site of uterine incision repair alter endometritis after cesarean delivery?

OBJECTIVE: his investigation was undertaken to evaluate the relationship between postcesarean endometritis and (1) method of placental removal and (2) site for uterine repair. METHODS: This prospective, randomized study included 120 patients who underwent primary or repeat abdominal delivery for arrest of progress in labor, fetal distress, or breech presentation. Parturients were divided into four groups: I-spontaneous placental detachment, in situ uterine repair; II-spontaneous placental detachment, exteriorized uterine repair; III-manual placental removal, in situ uterine repair; and IV-manual placental removal, exteriorized uterine repair. Prophylactic antibiotics were not used. RESULTS: Endometritis was significantly increased in the manual removal/exteriorized uterine repair group versus all the other groups including the spontaneous removal in situ (group I, P = 0.012), the spontaneous removal/exteriorized repair group (group II, P = 0.034), and the manual removal/in situ repair group (group III, P = 0.043). Comparison of group IV (manual removal/ exteriorized repair) with the combined groups I, II, and III (spontaneous removal/in situ repair, spontaneous removal/exteriorized repair, and manual removal/in situ repair) was significantly different (P = 0.005). Prior to delivery, use of an internal monitoring system, skill of the operating surgeon, and type of anesthesia were similar among groups. CONCLUSIONS: The findings of this investigation suggest that; when other known causes of infectious morbidity are constant, manual placental removal in association with exteriorization for uterine repair significantly increases postcesarean endometritis.

Autoimmune diseases in pregnancy.

Autoimmune diseases are a significant problem in women of reproductive age. This article reviews some of the more common autoimmune disorders and discusses their diagnosis and management during pregnancy. The effects of the autoimmune disorder on pregnancy and the effects of pregnancy on the course of the autoimmune disorder are also discussed with an emphasis on the implications for clinical management.

Interval to delivery in high-risk patients: do tocolytic agents really work?

Some question whether tocolytic drugs reduce uterine activity and prolong gestation. The interval from discontinuance of tocolytics until spontaneous labor and delivery in patients (n = 69) with documented preterm labor (PTL) versus subjects receiving prophylactic tocolytic therapy (n = 41) was studied. Women with documented PTL delivered sooner after cessation of tocolytics (6.1 +/- 6.9 days) than control (C) patients (14.7 +/- 10.8 days, P less than 0.001). Also, 28 of the 69 (41%) patients in the PTL group delivered within 24 h of discontinuation of tocolysis compared to 4 (10%) in the C group (P less than 0.0004). We conclude that tocolytic therapy for documented preterm labor suppresses uterine activity and when these agents are discontinued, contractions return and labor ensues.

Administration of heparin by subcutaneous infusion with a programmable pump.

Heparin has a short half-life (8 to 12 hours) and therefore must be administered by continuous infusion or by intermittent subcutaneous injection. Intermittent subcutaneous injection may lead to fluctuation in the levels of anticoagulation attained. In correcting this deficiency, the programmable automated subcutaneous infusion pump in conjunction with weekly home nursing visits has been used. Eight pregnant women with documented deep venous thrombosis or embolic events before pregnancy who received such therapy were studied. Eight similar subjects who received intermittent subcutaneous injection, matched for age, parity, site of deep venous thrombosis, and days on a regimen of heparin therapy, served as the control group. The mean daily dose of heparin by subcutaneous infusion pump was higher (29,445 vs 13,822 U), resulting in smoother, more therapeutic heparinization (mean partial thromboplastin time, 20.6 vs 10.4 seconds above control) when compared with the intermittent subcutaneous injection group (p less than 0.05, p less than 0.007). There were two complications (hematoma, site infection) in the intermittent subcutaneous injection group while none occurred in the subcutaneous infusion pump group. When used in concert with weekly home visits, the subcutaneous infusion pump method of administration allowed more even control of anticoagulation, appeared to result in fewer complications (although not statistically significant), and subjectively was better received by patients than the intermittent subcutaneous injection technique.

Cordocentesis (funipuncture) by maternal-fetal fellows: the learning curve.

One hundred cordocenteses were attempted at the University of Mississippi Medical Center between July 1, 1989, and June 1, 1991. There were 1.3 attempts for each successful umbilical blood sampling. The overall success rate was 94%. The first-year fellows-in-training attempted 61 procedures with a 90.2% success rate within two attempts and an overall success rate of 95.1%. Second-year fellows attempted 32 procedures with a 93.8% success rate within two attempts and an overall success rate of 93.8%. Procedure-related complications included five episodes of fetal bradycardia (one resulting in a stillbirth at 20 weeks) and a single case of chorioamnionitis. Of the three perinatal deaths, two were associated with severe congenital anomalies resulting in a corrected procedure-related mortality rate of 1%. The morbidity and mortality associated with cordocentesis appears to be relatively low and fellows-in-training can perform such procedures with no apparent increase in complications if appropriately supervised.

Use of continuous flow erythrocytapheresis in pregnant patients with sickle cell disease.

The role of partial prophylactic red cell exchange transfusion in the management of pregnant patients with major sickle hemoglobinopathies is unclear. Over a 10-year period, 131 pregnant patients with major hemoglobinopathies (HbS 101, HbS-C 30) were managed by the same group of physicians. Of these, 103 received partial prophylactic exchange transfusion early during prenatal care while 28 received blood only when serious complications developed (control group). Patients treated with exchange transfusion received continuous flow erythrocytapheresis on an outpatient basis. The results indicate that there were fewer crises (P = .0001), a reduction in other significant medical complications (P = .002), and a decrease in maternal hospital days (P = .05) in those receiving prophylactic transfusions compared to women in the control group. The number of preterm deliveries (P = .004), the prevalence of low birthweight infants (P = .01), and the perinatal death rate (P = .01) were significantly lower among those who were routinely transfused. Two patients developed hepatitis, five had transfusion reactions, and 11 were found to have alloantibodies among those receiving prophylactic transfusions versus one, two, and five patients, respectively, in the control group. The results indicate a benefit of this methodology in the treatment of pregnant sickle cell patients in our population. However, a national collaborative randomized study is needed to adequately address the controversy regarding the use of red cell exchange in the pregnant sickler.