The effect of intrathecal analgesia on the success of external cephalic version.

UNLABELLED: External cephalic version (ECV), the procedure whereby a fetus in the breech position is converted to vertex, is often performed to avoid an operative delivery. Potential benefits of epidural and spinal anesthesia for this procedure are controversial. Several previous studies have evaluated the use of epidural anesthesia with varying results. We sought to determine whether analgesia produced by subarachnoid sufentanil would safely improve the success of ECV. Patients who received subarachnoid analgesia (n = 20) were compared with those who did not (n = 15) in regard to success of ECV, level of pain during ECV, and satisfaction. ECV was successful in 21 patients (60%), with more frequent success in women who received spinal analgesia as compared with those who did not (80% vs 33%, respectively; P = 0.005). Patients who received spinals also reported smaller pain scores and were more satisfied with ECV. None of the women who received spinal analgesia developed a postdural puncture headache, and the only case of fetal bradycardia occurred in a patient who did not receive spinal analgesia. More profound patient comfort after spinal analgesia may have permitted greater manipulation of the abdomen during ECV, thus improving success rates of ECV without increasing risk. IMPLICATIONS: The success of external cephalic version (ECV) was compared in women who received spinal analgesia and those who did not. Successful ECV occurred more frequently in those women who received spinal analgesia. Because term singleton pregnancies associated with breech position usually require cesarean delivery, an increase in success of ECV may decrease the number of cesarean deliveries performed.

Acupressure versus intravenous metoclopramide to prevent nausea and vomiting during spinal anesthesia for cesarean section.

Nausea and vomiting occur frequently during cesarean section under spinal anesthesia. Metoclopramide reduces intraoperative nausea and vomiting, but not without potential side effects. Acupressure, a noninvasive variation of acupuncture that involves constant pressure on the wrist, has been suggested as an alternative method to prevent nausea and vomiting. The aim of this study was to compare acupressure and intravenous (IV) metoclopramide for the prevention of nausea and vomiting during elective cesarean section under spinal anesthesia. Seventy-five patients were studied in a randomized, prospective, double-blind comparative trial. Group I patients received acupressure bands + 2 mLIV saline, Group II patients received placebo wrist bands + 10 mg IV metoclopramide, and Group III patients received placebo wrist bands + 2 mL IV saline. Patients who received either acupressure or metoclopramide prior to initiation of spinal anesthesia for cesarean section had much less nausea than patients in the placebo group. Acupressure is an effective, non-pharmacologic method to reduce intraoperative nausea during elective cesarean section in the awake patient.

Cocaine screening of parturients without prenatal care: an evaluation of a rapid screening assay.

Illicit drugs are used widely by inner city patients in our society. Because cocaine ingestion can produce life-threatening arrhythmias and interact with anesthetic drugs, it is potentially useful for the anesthesiologist to know a high-risk patient's cocaine status before administering anesthesia. The commonly used methods to detect cocaine abuse, however, often require 1-3 days for laboratory processing. With these tests, anesthesiologists are unable to test for recent cocaine use in an emergency setting. A new rapid latex agglutination assay for urinary metabolites of cocaine (OnTrak Abuscreen; Roche Diagnostic Systems Inc., Branchburg, NJ) was compared with an assay used by many hospital laboratories. The prevalence of cocaine abuse in the group of unregistered parturients was found to be 68%, with the latex agglutination results exactly matching the hospital laboratory results (kappa = 1.0). A sensitive and specific method now exists that allows anesthesiologists to assess cocaine use rapidly, so that they can use this information when planning a patient's anesthetic.

Pregnancy among obstetricians: a comparison of births before, during, and after residency.

Questionnaires were sent to 1025 female board-certified obstetricians, and information was retrieved about pregnancy outcome. A total of 454 pregnancies, one third of which occurred during residency, were evaluated, and the relationship between pregnancy outcome and residency was assessed. Children of primiparous women who were delivered during or after residency had significantly lower mean birth weights than those who were delivered before residency (p less than 0.001 and p less than 0.005, respectively), whereas birth weights of infants born to multiparous women were not significantly different. The low birth weight rate (less than 2500 gm) was significantly increased during residency (p less than 0.002), and infants born during residency were 7.5 times more likely to be growth retarded than those born outside residency (p less than 0.002). The incidence of other pregnancy complications was not found to be increased during residency. Our data suggest a potentially negative impact of residency on the birth weights of infants born to female obstetricians in training.

Twin gestation and perinatal follow-up in a woman with severe chronic renal failure managed without dialysis. A case report.

Severe renal insufficiency (serum creatinine greater than 2 mg/dL) during pregnancy has been associated with poor perinatal outcome. Even in the absence of maternal indications, hemodialysis has been suggested for fetal indications, although the influence of maternal renal failure on the newborn's development is unknown. The effects of the abnormal biochemical environment of dialysis on fetal growth and development are also unknown, and the small numbers of reported cases make it difficult to assess the indications for hemodialysis. A 35-year-old woman had a twin gestation and severe chronic renal failure. The pregnancy was managed without hemodialysis, and at 33 weeks' gestation two healthy newborns were delivered with cesarean section. Bailey scales of infant development at 14 months of age showed normal infant development. Hemodialysis is not indicated solely for fetal reasons in the patient with severe but stable renal failure in the absence of severe hypertension, pre-eclampsia, deteriorating renal status or intrauterine growth retardation.

Relationship of vaginal pH and Papanicolaou smear results to vaginal flora and pregnancy outcome.

Prematurity is a major cause of perinatal morbidity. Studies have implicated components of the vaginal flora in the etiology of some cases of preterm birth. Current scoring systems do not include factors which directly reflect the vaginal flora. Since Papanicolaou smears and the vaginal pH may be affected by the vaginal flora and are easy tests to perform, we studied their relationship to vaginal flora and pregnancy outcome. Among 231 patients, those with a vaginal pH greater than or equal to 4.4 were significantly more likely to carry Trichomonas vaginalis (P less than 0.03); Bacteroides species (P less than 0.01), and Mycoplasma hominis (P less than 0.001), and to have premature rupture of the membranes (P less than 0.01), and preterm rupture of the membranes (P less than 0.05). Patients with atypia reported on Papanicolaou smear more frequently carried M. hominis (P less than 0.01), and had premature rupture of the membranes (P less than 0.01). Although the high sensitivity and negative predictive value of those tests may make them useful additions to current scoring systems, their low specificity prevents them from being independent predictors of risk.

Pneumococcal polysaccharide antibody levels in patients with term and preterm pregnancies.

Serum antibody levels against 12 serotypes of pneumococcal polysaccharide were assessed in pregnant women as well as in cord bloods of their infants. Twelve women were evaluated during the first trimester, second trimester, and in labor at term, and eight women were assessed in the first trimester and in preterm labor. Antibody levels significantly decreased from the first trimester to delivery both in patients with term (339 versus 281 ng AbN/mL; P less than .001), and preterm (448 versus 299 ng AbN/mL; P less than .001) deliveries. There was no significant difference in mean antibody levels or their rate of decline between term and preterm pregnancies.

Effect of Lamaze childbirth preparation on maternal plasma beta-endorphin immunoreactivity in active labor.

Previous studies have documented a reduction in plasma beta-endorphin levels with the use of various analgesic techniques in labor, such as segmental epidural anesthesia or intrathecal morphine. The Lamaze method of childbirth preparation, which has been found to reduce the need for medication during childbirth and to decrease the subjective perception of pain during labor and delivery, has not been studied in this regard. In this study plasma beta-endorphin immunoreactivity levels were measured during the active phase of labor in 26 patients who had Lamaze classes and in 28 patients who did not have Lamaze classes. The Lamaze group had significantly lower plasma beta-endorphin immunoreactivity (37.2 vs. 68.5 pg/ml; P less than 0.001) and significantly shorter first stages of labor (8.28 hrs. vs. 9.86 hrs; P less than 0.02). It can be theorized that both lower beta-endorphin immunoreactivity and shorter labor in patients in the Lamaze group were related to the reduction of fear, tension, and the emotional stress of labor.

Relationship of vaginitis to the sex of conceptuses.

The relative viability of X-bearing and Y-bearing spermatozoa is influenced by factors in the vagina such as pH. The vaginal environment, in turn, is influenced by its flora. This study examined the relationship of the vaginal flora to the sex of conceptuses. It was found that women who carried Trichomonas vaginalis or Bacteroides sp or who had nonspecific vaginitis at first prenatal visit were significantly more likely to deliver females than women who carried none of these organisms (54 versus 37%, P less than .02).

Diagnosis of intracranial hemorrhage in utero after a maternal seizure.

Reported is a patient who noted decreased fetal movements after a seizure at 32 weeks' gestation. Sonography revealed fetal death and findings consistent with an intraventricular hemorrhage. The possible explanations for and the significance of an association between a maternal seizure and fetal intraventricular hemorrhage are discussed.

Risk factors for prematurity and premature rupture of membranes: a prospective study of the vaginal flora in pregnancy.

Prematurity remains a major cause of perinatal mortality in the United States. Some research has indicated that infectious agents play a role in either initiating preterm labor, causing premature rupture of the membranes, or preventing tocolysis. This study attempted to determine if the presence of various vaginal pathogens in early pregnancy was associated with the subsequent development of premature rupture of membranes or preterm labor. We found that among 233 evaluable patients those with Trichomonas vaginalis were significantly more likely to have premature rupture of the membranes (p less than 0.03), and those with Bacteroides sp. were more likely to be delivered of their infants before 37 weeks (p less than 0.03) and to have infants weighing less than 2500 gm (p less than 0.05). Those with Ureaplasma urealyticum more frequently began preterm labor (p less than 0.05). Preterm premature rupture of the membranes was found significantly more often among patients with Bacteroides sp. Stepwise multiple logistic regression analysis indicated that those associations were not related to the number of previous abortions, deliveries, or preterm deliveries or to maternal age. We conclude that microbiologic screening in early pregnancy may aid in the assessment of patient risk for preterm delivery.

The relationship of maternal antibody levels to post-cesarean section endometritis.

One hundred eight pneumococcal polysaccharide antibody levels were determined by radioimmunoassay preoperatively in 18 patients who underwent elective repeat cesarean section. Eight patients developed post-cesarean section endometritis, and 10 did not. The endometritis group did not vary significantly from the noninfected group in preoperative hematocrit, social status, number of previous pregnancies, maternal and newborn weights, length of operation, and Apgar scores. Mean antibody levels in the endometritis group were significantly lower than those in the control group (49 versus 103 ng/ml; p less than 0.05). Mean antibody levels for the six serotypes in the endometritis group were significantly lower than those in the control group (p less than 0.05). This study indicated that a healthy maternal immune system may play an important role in preventing post-cesarean section morbidity. Pneumococcal polysaccharide antibody levels may be used in pregnancy to assess the risk for post-cesarean section infections.

Association of human papillomavirus infection with cervical intraepithelial neoplasia.

Human papillomavirus infections of the cervix were assessed in patients attending a colposcopy clinic. Of 348 patients with cervical biopsies, 134 (38.5%) had human papillomavirus infections, and of 251 patients with cervical intraepithelial neoplasia (CIN) 112 (44.6%) had human papillomavirus. The majority of patients with human papillomavirus had concurrent CIN (83.6%; 112/134). Patients with human papillomavirus were significantly younger than patients without human papillomavirus (24.4 versus 29.9 years mean age; P less than .001), had significantly milder degrees of CIN (84% versus 43% mild/moderate dysplasia; P less than .001), and had a significantly lower mean number of pregnancies (2.16 versus 3.05; P less than .001). A matched pairs analysis of 69 pairs showed the same distribution of CIN in both human papillomavirus and nonhuman papillomavirus patients. Electron microscopy of human papillomavirus--specific koilocytes confirmed the presence of human papillomavirus particles in the nuclei.

Adenomatoid tumor of the uterus simulating interstitial pregnancy.

A case of an adenomatoid tumor of the uterus is presented. The 22-year-old patient was admitted with classic signs and symptoms of an interstitial pregnancy. However, emergency surgery confirmed the diagnosis of an adenomatoid tumor of the uterus concomitant with an intrauterine pregnancy. Although rare, adenomatoid tumors of the uterus may present as a uterine abnormality, possibly causing problems in the differential diagnosis of it and an interstitial pregnancy.

The 100th anniversary of tubal sterilization.

PIP: Tubal sterilization is a relatively new operation within gynecology. The history of tubal sterilization since 1809 is traced through old medical texts. Certain details of the procedures being performed to effect tubal sterilization are reviewed. Although laparoscopic tubal sterilization seems to have been tried 1st in 1941, more than 1/4 of a century elapsed before it gained in popularity as a method of sterilization.^ieng