Safety and efficacy of vaginal prostaglandin E2 suppositories in the management of third-trimester fetal demise.

Prostaglandin E2 vaginal suppositories are well established in the management of intrauterine fetal demise in the second trimester of pregnancy. However, approval for their use in the third trimester has been withheld pending evaluation of safety and efficacy. In this study 46 patients with intrauterine fetal demise in the third trimester were managed in a similar fashion except that only a 10-mg dose of prostaglandin E2 was employed. Forty-four of the 46 patients were delivered successfully. One patient experienced a cervical laceration that necessitated a hysterectomy; in her, oxytocin was used to supplement the prostaglandin. It appears that prostaglandin E2 vaginal suppositories can be used safely in the management of fetal demise in the third trimester of pregnancy. Use of a lower dose of the medication as well as tocodynamometry is recommended because the absorption of and sensitivity to this medication vary from patient to patient. The frequency of administering the medication should depend on the patient's response rather than on any given formula.

PIP: Prostaglandin E2 (PGE2) vaginal suppositories are well established in the management of intrauterine fetal demise in the 2nd trimester of pregnancy. However, approval for their use in the 3rd trimester has been withheld pending evaluation of their safety and efficacy. In this study, 46 patients with intrauterine fetal demise in the 3rd trimester were managed in a similar fashion except that only a 10 mg dose of PGE2 was employed. 44 of the 46 patients were delivered successfully. 1 patient experienced a cervical laceration that necessitated a hysterectomy; in her, oxytocin was used to supplement the PG. It appears that PGE2 vaginal suppositories can use used safely in the management of fetal demise in the 3rd trimester. Use of a lower dose of the medication as well as tocodynamometry is recommended because of the absorption and sensitivity to this medication vary from patient to patient. The frequency of drug administration should depend on the patient's response rather than on any given formula.

Prospective randomized study of corticosteroids in the management of premature rupture of the membranes and the premature gestation.

A prospective randomized study involving patients with premature rupture of the membranes between the twenty-eighth week and the thirty-fourth week of pregnancy was conducted. Patients with chorioamnionitis, advanced labor, and fetal distress, as well as those with mature lecithin/sphingomyelin ratios and/or Gram stains positive for bacteria, were delivered immediately. The remaining patients were randomized. One group received betamethasone. Tocolytic agents were used in this group when necessary. After 48 hours all patients given corticosteroids (CS group) were delivered). The second group was managed expectantly (EM group) and were delivered only when spontaneous labor or infection occurred. A total of 160 patients were randomized, 80 in each group. Maternal outcome, including chorioamnionitis and cesarean section rates, was not different; however, the endometritis rate was significantly higher in the CS group (p less than 0.05). Neonatal outcome did not differ in mean birth weights, perinatal death rates, neonatal infections, or incidences of respiratory distress. The frequency of prolonged hospital stay (greater than 4 weeks) was higher in the neonates in the CS group (p less than 0.01). The conclusion is that corticosteroids and active management in patients with premature rupture of the membranes and premature gestations do not decrease the incidence of respiratory distress syndrome or perinatal mortality and may aggravate certain infectious complications.

The use of amniocentesis in patients with premature rupture of membranes.

A prospective study was conducted to evaluate the usefulness of amniocentesis in patients with premature rupture of membranes (PROM) for the prediction of occult or impending intrauterine infection and the assessment of fetal maturity. Fifty-nine patients with PROM between 28 and 35 weeks' gestation, without apparent infection, were evaluated sonographically for possible amniocentesis. Thirty patients had successful amniocenteses for a success rate of 51%. Fifteen patients had a mature lecithin/sphingomyelin (L/S) ratio and were delivered immediately without respiratory distress syndrome (RDS) or other neonatal complications. All amniotic fluids were evaluated by Gram stains and cultures. Nine of the 30 patients had positive cultures, with a high incidence of subsequent development of amnionitis and other infectious morbidity. In the 21 patients with negative cultures, there were 19 without any infectious morbidity. Amniocentesis appears in this study to be a useful method for selecting the patients who have mature fetuses and/or who are more likely to develop amnionitis.

Fetal heart rate patterns and fetal distress in fetuses with congenital anomalies.

Over a 3-year period at the Long Beach Women's Hospital, where electronic FHR (fetal heart rate) monitoring was routine, there were 8622 live births, including 41 infants born with major congenital malformations. The neonatal death rate in these malformed infants was 44%; 17 were delivered by cesarean section, 11 of which were performed because of fetal distress. There were no characteristic FHR patterns that would specifically identify major congenital malformations. There was a significantly increased incidence of prematurity, breech presentation, and cesarean section delivery in the congenital malformation group as compared to the overall population delivering at the Women's Hospital. The clinical implications of these observations are discussed.

Oxytocin challenge test: achieving the desired goals.

The desired goals of the oxytocin challenge test (OCT) are preventing stillbirth and avoiding unnecessary premature intervention. To effectively reduce stillbirth the test should be done on a significant proportion of those fetuses who would subsequently succumb in utero. To analyze whether or not the OCT is achieving these goals. 5351 deliveries over a 2-year period at the University of California, Irvine, Medical Center were studied retrospectively. Four hundred and thirty of these patients had 823 OCTs performed. There were ten positive and 19 suspicious tests, and five neonatal deaths in these two groups. In patients who were studied with OCTs only one stillbirth occurred (in a patient who was noncompliant). During the same period, all stillbirths were reviewed. In the group in which stillbirth occurred, it was determined that 11 or 35% of the patients had indications for antepartum testing but were not tested. All 11 of these patients were transferred to the University hospital or had no prenatal care. It is suggested that these stillbirths may have been prevented had appropriate prenatal care allowed identification of patients for antepartum testing.

An unusual complication of fetal blood sampling during labor.

A female infant was delivered at term after biophysical and biochemical monitoring during the intrapartum period. At birth excessive bleeding was noted from the scalp incision sites, leading to severe anemia. The infant was also found to have congenital syphilis. The clinical course was complicated by the development of disseminated intravascular coagulation leading to death despite intensive management. Identification and appropriate management of excessive pre- and postnatal bleeding from a sampling incision is emphasized.

Abnormal cervical cytology in the teen-ager: a continuing problem.

Abnormal cervical cytology is being discovered in an alarming number of sexually active teen-agers. Over an 18 month period, cytology consistent with mild dysplasia or worse was noted in 188 of 2,655 teen-agers screened. This represents a rate of 70.8 per thousand. Colposcopically directed biopsies in 65 patients revealed 15 cases of severe dysplasia-carcinoma in situ. Cryosurgery was the principle method of treatment and, combined with colposcopy, is a safe and effective means of managing these patients.

The making of a colposcopist. A safe and sensible approach.

A program was established to determine the accuracy of colposcopy at our institution. Forty-three patients with cytologic or histologic evidence of severe dysplasia or worse underwent diagnostic conization following satisfactory colposcopy. Thirty patients subsequently had either therapeutic conization or hysterectomy preceded by biopsy only. In all 73 cases, the surgical specimen did not reveal a more advanced lesion. However, when the colposcopy was unsatisfactory, the rate of error was 20.8%. It is our opinion that colposcopy is a safe and valuable technique as long as one recognizes the need for training and understands the indications for further diagnostic studies. The use of the colposcope for the evaluation of abnormal cervical cytology has increased steadily over the last few years, and several excellent courses are now offered throughout the United States. Armed with a certificate from such a course, many gynecologists then become self-proclaimed colposcopists in spite of warnings to the contrary by the instructors. In addition, supervision by experienced personnel is not always available. How, then, does one indeed become an accomplished colposcopist to the point that he or she can safely spare the patient the risk, inconvenience and expense of diagnostic cervical conization? Although several recent publications 2,5,6,9,11 document the diagnostic accuracy of colposcopically directly biopsies, we feel each individual should develop and evaluate his or her own skill before altering or abandoning conventional methods of diagnosis and management. The purpose of this report is to present our experience with colposcopy utilizing a program which can perhaps serve as a model to other clinicians.