Antepartum testing in the hypertensive patient: when to begin.

Antepartum testing has been recommended for patients whose pregnancies are complicated by hypertension. Although this is considered accepted practice, there are little data available to help the clinician know when to start testing. To help answer this question in patients with chronic hypertension and nonproteinuric pregnancy-induced hypertension, we reviewed the results of all antepartum tests between 1976 and 1987 in patients with these diagnoses. The primary mode of surveillance in the majority of our patients was the contraction stress test. We determined when patients first had positive contraction stress test results and when intervention occurred because of an abnormal antepartum test result. There were a total of 917 patients tested with these diagnoses. Fifty-three (5.8%) of these patients had at least one positive contraction stress test result. Twenty-two patients were delivered of infants before 35 weeks' gestation because of abnormal antepartum test results. Those with early intervention (less than 35 weeks' gestation) could not be differentiated from those with later intervention (greater than or equal to 35 weeks' gestation) by maternal age, diastolic blood pressure, or systolic blood pressure at the time of testing. The majority of patients who were delivered of infants before 35 weeks' gestation had a concomitant diagnosis of systemic lupus erythematosus, intrauterine growth retardation, diabetes mellitus, or superimposed preeclampsia. On the basis of when compromise was evident, patients with these diagnoses may require testing to be started as early as the fetus is considered viable. However, in those without these diagnoses, the clinician may delay the beginning of testing until 33 weeks' gestation without significant risk of pregnancy loss before testing.

Gram stain results from amniocentesis in patients with preterm premature rupture of membranes--comparison of maternal and fetal characteristics.

A total of 108 patients with preterm premature rupture of membranes who had undergone amniocentesis were retrospectively analyzed. Seventy-seven patients had negative amniotic fluid Gram stains and were managed expectantly. Thirty-one patients had positive amniotic fluid Gram stains confirmed by subsequent cultures and were delivered of infants on that basis. A univariate comparison of various parameters revealed significant differences in maternal temperature, pulse, and white blood cell count. Patients with positive Gram stains had lower mean gestational age, higher baseline fetal heart rate, and nonreactive fetal heart rate tracings. On the basis of a multivariate stepwise discriminate analysis, fetal heart rate greater than 150 beats/min or nonreactive nonstress test were the best predictors of the Gram stain findings, with a sensitivity of 71%, specificity of 76%, and negative predictive value of 87%. These data suggest that in patients with preterm premature rupture of membranes and fetal tachycardia or nonreactive nonstress test, amniocentesis should be performed in the initial evaluation.

Diagnosis of preterm rupture of membranes: is testing for alpha-fetoprotein better than ferning or nitrazine?

This article evaluates the role of alpha-fetoprotein (AFP) testing in the diagnosis of ruptured membranes in the preterm patient. AFP is normally found in amniotic fluid and is not present in vaginal secretions. Testing for AFP in vaginal fluid was compared with nitrazine evaluation and ferning in two groups of preterm patients, those with intact membranes and those with ruptured membranes. There was no difference in the sensitivities of AFP, nitrazine, or ferning in diagnosing ruptured membranes. The specificities of AFP and ferning were similar and both were significantly better than nitrazine. Duration of membrane rupture for greater than 24 hours negatively affected the accuracy of all three tests. Blood-tinged amniotic fluid interfered with AFP and nitrazine evaluation. AFP does not appear to offer a significant advantage over nitrazine testing and ferning in the evaluation of patients with possible ruptured membranes.

Maternal serum alpha-fetoprotein and fetal triploidy.

Fetal triploidy is commonly found in early pregnancy. The majority of these pregnancies spontaneously abort in the first trimester. Occasionally, the pregnancy progresses to the second and third trimesters. We reviewed the maternal serum alpha-fetoprotein (MSAFP), amniotic fluid alpha-fetoprotein (AFP), amniotic fluid acetylcholinesterase (ACHE), fetal pathology, and placental pathology in sex second-trimester pregnancies complicated by fetal triploidy. Four of these patients had MSAFP values greater than 7.5 multiples of the median (MoM). Five of six pregnancies had MSAFP values greater than 2.25 MoM. All five of these patients had a partial mole. Four patients had amniotic fluid AFP values greater than 2.0 MoM. Two fetuses had associated neural tube defects. These were the only patients with positive amniotic fluid ACHE. None of the other patients had fetuses with anomalies that are known to be associated with an elevated MSAFP. The elevated MSAFP appeared to be related to the presence of a partial mole. Two of the five cases with an MSAFP greater than 2.25 MoM did not have sonographic evidence of a significant anomaly. Therefore, karyotyping can be of benefit in evaluating patients with elevated MSAFP.

Ultrasound findings in pregnancies complicated by fetal triploidy.

Antepartum ultrasound scans of seven pregnancies complicated by fetal triploidy were reviewed. Estimated gestational age (EGA) by ultrasound lagged EGA by last menstrual period in six of seven patients. Normal interval growth of biparietal diameter in the second trimester was demonstrated in all fetuses that had serial scans. Sonographic features commonly associated with fetal triploidy; such as oligohydramnios and cephalocorporal disproportion, were seen in only two cases. Fetal anomalies were evident by ultrasound in five of seven patients. Six of seven patients had partial moles. All of these patients had placentas that appeared abnormal. The ultrasound appearance of the placenta, however, was not the same with each case. Therefore, sonographic features of pregnancies complicated by fetal triploidy are not uniform and the diagnosis cannot be made by ultrasound alone.

Management of the nonvertex second twin: primary cesarean section, external version, or primary breech extraction.

Six hundred eighty-two consecutive twin deliveries were reviewed. Included in the study were 136 sets of vertex-nonvertex twins with birth weights greater than 1500 gm. A primary attempt at delivery of the second twin by external version was performed on 41 twins, 55 twins underwent attempted breech extraction, and 40 patients had a primary cesarean section solely because of physician preference. There were no differences in the incidence of neonatal morbidity or mortality among the modes of delivery. External version was associated with a higher failure rate than primary breech extraction (p less than 0.01). External version was associated with complications (fetal distress, cord prolapse, and compound presentation) that were not seen in the other two groups. Primary breech extraction of the second nonvertex twin weighing greater than 1500 gm appears to be a reasonable alternative to either cesarean section or external version.

Electrical shock in pregnancy: a case report.

Electrical shock in pregnancy is associated with significant perinatal morbidity and mortality. A case of such an electrical shock in pregnancy is reported. A review of the literature follows. The severity of maternal injury does not correlate with the injury sustained by the fetus. Close fetal surveillance following electrical injury is necessary.