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.

Leuprolide acetate depot for the treatment of uterine leiomyomas. Changes in bone density, uterine volume and uterine vascular resistive index.

This study measured the changes in uterine volume, uterine vascular resistive index and lumbar vertebral bone density before and after a six-month course of leuprolide acetate depot in women with uterine leiomyomas. All nine patients studied were black. The high baseline bone density of black women may provide a greater scope for the use of gonadotropin agonists as compared to women in the general population. A significant reduction in uterine volume was achieved in the patients with leuprolide therapy. Uterine vascular resistive indices were not altered consistently following leuprolide therapy in women with leiomyomas.

Pregnancy in a woman with an automatic implantable cardioverter-defibrillator. A case report.

Two years after insertion of an automatic implantable cardioverter-defibrillator, a 33-year-old woman had an uneventful cesarean delivery.

Management of cardiovascular disease in pregnancy.

Pregnancy itself poses risks of morbidity and mortality to even the young, healthy woman. The nature of these risks may vary from country to country and, within the United States, from state to state. Hemorrhage, eclampsia, and infection, in general, are common obstetric risks. One of the most important nonobstetric causes of maternal death, and the focus of this article, is heart disease.

Measurement of amniotic fluid volume: accuracy of ultrasonography techniques.

OBJECTIVE: Our purpose was to determine amniotic fluid volume by the dye-dilution technique and compare it with the amniotic fluid index, largest vertical pocket, and two-diameter pocket (defined as vertical x horizontal of the largest vertical pocket). STUDY DESIGN: This prospective study involved 40 women undergoing amniocentesis in late pregnancy to detect fetal lung maturity or evidence of chorioamnionitis. The amniotic fluid volume was quantified ultrasonographically by means of the amniotic fluid index, largest vertical pocket, and two-diameter pocket. During amniocentesis the fluid volume was calculated by the dye-dilution technique of Charles and Jacoby. RESULTS: Ultrasonographic measurements by amniotic fluid index, largest vertical pocket, and two-diameter pocket correctly predicted normal amniotic fluid and hydramnios (74%). A new measurement, two-diameter pocket, gave a significantly more accurate estimate of oligohydramnios than did amniotic fluid index (p < 0.002) or largest vertical pocket (p < 0.0003). CONCLUSION: All three indices are moderately accurate in identifying normal amniotic fluid volume and hydramnios. Two-diameter pocket is the most accurate test to predict oligohydramnios.

Prophylactic intrapartum amnioinfusion for patients with oligohydramnios. A prospective randomized study.

This prospective study evaluated whether prophylactic saline amnioinfusion among patients with amniotic fluid index (AFI) < or = 5.0 cm decreases the incidence of adverse fetal outcomes. Randomization of 53 patients with decreased AFI at term, resulted in 21 patients' receiving prophylactic saline amnioinfusion early in labor, prior to development of an abnormal fetal heart rate tracing. For the treatment group the mean AFI on admission was 3.0 cm, and the postamnioinfusion AFI was 8.9 cm. For 32 comparison (noninfusion) patients, the mean AFI was 2.9 cm; the group consisted of 17 patients randomized to receive no amnioinfusion (control group) and 15 patients who refused to participate in the study. There was no statistically significant difference between the amnioinfused and nonamnioinfused patients with regard to age, parity, gestational age, AFI at admission or duration of first or second stage of labor. Amnioinfusion resulted in no statistically significant reduction in the incidence of recurrent variable decelerations/bradycardia (26.3% vs. 46.6%), intrapartum resuscitation with terbutaline (5.2% vs. 10.0%), cesarean section for fetal distress (9.5% vs. 9.3%), fetal-acidosis (10.5% vs. 12.0%) or Apgar scores < 7 at five minutes (5.2% vs. 0%) in patients with oligohydramnios.

Oral magnesium and the prevention of preterm labor in a high-risk group of patients.

OBJECTIVE: The null hypothesis of this study is that treatment with oral magnesium gluconate 1 gm four times daily will not decrease the rate of preterm labor and delivery in a high-risk group of pregnant women. STUDY DESIGN: Fifty-four women at risk for preterm delivery were selected randomly to receive magnesium gluconate 1 gm orally four times daily or placebo. These women were monitored prospectively for signs and symptoms of preterm labor. A subgroup of 31 women also received a home uterine activity monitor. The serum magnesium level was measured initially and again 2 weeks after study enrollment. The data were analyzed with Fisher's exact test and analysis of variance. RESULTS: Preterm labor developed in 15 women in the placebo group and in 16 women in the magnesium group. There were no differences in birth weight or gestational age at delivery. The mean increase in serum magnesium level while the patients were taking magnesium gluconate was 0.10 mg/dl (p = not significant). Five women did not have an increase in serum magnesium level and preterm labor developed in all of them. CONCLUSION: Magnesium gluconate in a dose of 1 gm four times daily is not effective for preventing preterm delivery in a high-risk group of patients.

Effect of pregnancy on the accuracy of light-reflection rheography.

Light-reflection rheography is a noninvasive method to detect venous obstruction by indirectly measuring venous emptying time. In nonpregnant women it has greater than 90% sensitivity when compared with venography but has not been tested during gestation. To determine if the nonthrombotic occlusion of venous outflow by the pregnant uterus might alter the performance of light-reflection rheography, we examined 17 normal patients with a vascular Accuscan (Hemodynamics, Inc., Boca Raton, Fla.) in the third trimester of pregnancy and 11 patients during the early second trimester. These results were compared with the defined normal (nonpregnant) rate of venous emptying (slope 0.54 +/- 0.06). The mean (+/- SD) for the entire sample was 0.58 +/- 0.23 mm/sec in the right leg and 0.52 +/- 0.19 mm/sec in the left leg measured in the standard sitting position (p = 0.21). The results did not vary with gestational age. A subset of patients in late pregnancy were used to compare the effect of various positions (supine, lateral decubitus, and sitting) on test performance. Positions other than sitting provided results that were inconsistent. It appears that the large pregnant uterus does not significantly obstruct venous outflow from the lower extremities in the standard sitting position; thus the results of light-reflection rheography are not affected. Comparison of light-reflection rheography versus venography in pregnant patients with suspected venous thrombosis is being investigated.

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.

The natural history of HELLP syndrome: patterns of disease progression and regression.

Despite much recent interest in HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), there is little published information about the natural history of this unique form of severe preeclampsia-eclampsia. The time course and pattern of laboratory abnormalities for 158 patients with HELLP syndrome managed in a single tertiary referral center between 1980 and 1989 were studied retrospectively. Despite considerable patient variation, most gravid women with HELLP syndrome had decreasing platelet counts until 24 to 48 hours after delivery. Conversely, lactate dehydrogenase concentrations usually peaked 24 to 48 hours post partum. In all patients who recovered, a platelet count greater than 1,000,000/mm3 was spontaneously achieved by the sixth postpartum day or within 72 hours of platelet nadir. An upward trend in platelet count and a downward trend in lactate dehydrogenase concentrations should be apparent in patients without complications by the fourth postpartum day. These data provide baseline information against which the course of individual patients can be compared and the infrequent, atypical case identified for interventive therapy.

Acute gestational pyelonephritis: the impact on colloid osmotic pressure, plasma fibronectin, and arterial oxygen saturation.

Acute gestational pyelonephritis infrequently leads to nonhydrostatic permeability pulmonary edema known clinically as acute respiratory distress syndrome (ARDS). In this form of ARDS, sepsis is considered the primary cause of pulmonary dysfunction. Decreases in colloid osmotic pressure, plasma fibronectin, and arterial oxygen saturation are associated with a worsening prognosis in septic conditions. We sought to investigate the changes in these parameters with acute gestational pyelonephritis to gain insight into the factors that may place the patient at risk for sepsis-related morbidity. Colloid osmotic pressure, plasma fibronectin, and arterial oxygen saturation via pulse oximetry were prospectively measured during the inpatient treatment of 17 pregnant patients with acute gestational pyelonephritis. All three parameters achieved their nadir within 24 hours of hospitalization and the initiation of therapy. Although no patient developed significant pulmonary dysfunction, we believe that patient susceptibility for pulmonary edema and general morbidity could be maximal in the first 24 hours after therapy. Future studies using a larger number of patients may identify one or more of these laboratory parameters as helpful in identifying gravid patients who are at risk of developing gestational ARDS.

Pregnancy after Fontan repair of tricuspid atresia.

We have described a patient who had a cyanotic congenital heart disease (type Ib tricuspid atresia), with initial palliation accomplished in childhood via a Glenn procedure. In 1985, she had a Fontan repair with the Bjork modification; 3 years later she achieved her first pregnancy at age 27. Maternal Doppler echocardiography in early pregnancy showed good flow through the constructed conduit, with normal left ventricular size and function. Fetal echocardiography at 22 weeks' gestation via two-dimensional, M-mode, pulsed Doppler, and color flow mapping revealed no evidence of fetal cardiac disease. At 25 weeks' gestation recalcitrant preterm labor developed, and the infant was delivered spontaneously. Labor, delivery, and puerperium were uncomplicated, and the newborn (though too premature to survive) was of appropriate weight for gestational age, without evidence of congenital heart disease or other anomalies. We believe this is the first report of pregnancy and spontaneous delivery in a patient who has had Fontan repair of a congenital heart defect.

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.

Correlation of uterine activity using the Term Guard monitor versus standard external tocodynamometry compared with the intrauterine pressure catheter.

Uterine activity monitoring to detect preterm contractions and thus to manage patients in active labor is valuable to the clinician. Uterine activity measured by external devices using the guard ring principle or by standard tocodynamometers has been shown to be accurate concerning the frequency of uterine activity as compared with intrauterine pressure catheter-derived data in the third trimester. In this study, 26 women from 19-34 weeks in documented preterm labor had their uterine activity measured by a standard in-hospital monitor and a Term Guard tocodynamometer simultaneously. The standard monitor reflected 16-91% of the frequency of contractions noted by the Term Guard device, with a reduction in the correlation at gestational ages under 30 weeks. In another 20 patients between 17-36 weeks' gestation, these two methods of external tocodynamometry were compared with a transcervical catheter which measured actual intrauterine pressure and frequency of contractions. There was a good correlation between the Term Guard device and transcervically measured contractions (94.6%). At gestational ages of 28 weeks or less, there was poor performance from standard devices (less than 38% correlation with the intrauterine pressure catheter). These data have important implications for clinicians who monitor preterm patients on an ambulatory basis for early detection of preterm labor and also have clinical impact for the management of patients at early gestational ages in active labor.

Characteristics of uterine activity in gestations less than 20 weeks.

Ambulatory tocodynamometry has been used for some time to record uterine activity during pregnancy. Most studies, however, have been performed in the third trimester (more than 24 weeks). The current study was initiated to assess uterine activity at earlier gestational ages. One hundred thirty-seven patients were studied between 14-19 weeks' gestation (inclusive). Seven patients who were being monitored were noted to have preterm labor, and six of these seven were found to have increased uterine activity before the diagnosis of preterm labor. There was no difficulty encountered in the vast majority of cases in recording objective, accurate uterine activity information even at these early gestational ages. There was an increase in the uterine activity (during the 18th and 19th weeks) in patients destined to develop preterm labor later in gestation as compared with the contraction pattern of those who labored at term. This study demonstrates that accurate uterine activity information can be gained at these early gestational ages and that when increased contraction frequency is present, it is related to preterm labor.

Fetal echocardiography.

Fetal echocardiography has become an essential tool for the thorough evaluation of the fetus at risk for congenital heart disease. This examination is now a part of standard medical practice and should no longer be considered investigational. Widespread use of fetal echocardiography is providing valuable insights into fetal cardiac embryology and physiology that have not been previously possible.

Successful pregnancy outcome following mid-gestational uterine rupture and repair using Gore-Tex soft tissue patch.

The first reported gestational use of the Gore-Tex soft tissue patch (expanded polytetrafluoroethylene) for uterine repair and support is presented in a pregnant woman whose partially dehisced, congenitally abnormal uterus was operated upon at 19 weeks' gestation. Use of the expanded polytetrafluoroethylene Gore-Tex soft tissue patch for assisted uterine integrity in combination with a program of uterine tocolysis and close maternal/fetal surveillance averted a pregnancy loss.

Plasma exchange for preeclampsia. I. Postpartum use for persistently severe preeclampsia-eclampsia with HELLP syndrome.

The postpartum use of plasma exchange with fresh-frozen plasma was assessed in a group of seven women with severe preeclampsia-eclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) that persisted greater than 72 hours after delivery. During the study interval in which a total of 107 gravid women with HELLP syndrome were seen in our referral center, these seven patients (6.5%) demonstrated persistent thrombocytopenia (platelet count usually less than 30,000/mm3), rising lactic dehydrogenase (greater than 1000 IU/L) and evidence of multiorgan dysfunction. The seven case histories emphasize the variety of clinical and laboratory profiles that can be encountered in this small group of gravid women at risk for severe morbidity or mortality. Up to three 3 L plasma exchanges were required to effect permanent disease arrest and reversal. Utilization of the IBM 2997 Cell Separator system permitted bedside performance of procedures with enhanced convenience and optimal medical management. Successful plasma exchange was associated with (1) sustained increases in the mean platelet count at 24, 48, and 72 hours that were 2.2, 3.6, and 4.5 times the preexchange platelet counts and (2) a decreasing trend in lactic dehydrogenase concentrations below 1000 IU/L within 48 hours of exchange plasmapheresis. The current series of patients supports our recommendation that a trial of plasma exchange(s) with fresh-frozen plasma be considered for treatment of the infrequent postpartum case of HELLP syndrome that fails to abate within 72 hours of delivery and in which other evidence develops of an ongoing, widespread, and life-threatening thrombotic microangiopathy.