Premature rupture of membranes at term with an unfavorable cervix: comparison of expectant management, vaginal prostaglandin, and oxytocin induction.

BACKGROUND: Our objective was to determine the best treatment for parturients at term with an unfavorable cervix and premature rupture of membranes (PROM). METHODS: In this prospective study, 96 women with PROM and an unfavorable cervix were randomized into one of three treatment groups: oxytocin induction, vaginal prostaglandin E2 gel followed by oxytocin, or expectant management. RESULTS: Length of labor, cesarean section rate, and maternal/neonatal morbidity were not significantly different. In contrast, the interval from PROM until delivery and length of hospital stay were significantly longer in the expectantly managed group than in the other groups. Four of the patients who received expectant management required delivery because of nonreassuring fetal assessments. CONCLUSIONS: Expectant management of PROM at term significantly prolongs hospital stay without decreasing the incidence of abdominal delivery or infectious morbidity. There appears to be potential for cord compression in patients managed expectantly without continuous electronic fetal surveillance.

Neonatal morbidity between 34 and 37 weeks' gestation.

The objective of this study was to determine the risk of significant neonatal morbidity in women with preterm labor who deliver between 34 and 37 weeks' gestation. A total of 101 women between 34 and 37 weeks' gestation with documented preterm labor met inclusion and exclusion criteria; 90 gave informed consent and were randomly assigned to receive either intravenous magnesium tocolysis (treatment group) or conservative management with hydration, sedation, and observation (control group). Of the 90 women entering the study (45 in the treatment group and 45 in the control group), 2 discontinued tocolytic therapy because of gastrointestinal side effects. The gestational age on admission, cervical dilatation at diagnosis of preterm labor, interval to delivery, and birth weight were not significantly different between the treatment and control groups. There were no serious neonatal complications. In each group, three women had transient tachypnea and one had respiratory distress syndrome. We conclude that neonatal morbidity after delivery between 34 and 37 weeks' gestation is unchanged whether or not attempts to arrest labor are unsuccessful. The extra expense and maternal risk of tocolysis are not justified by beneficial results in the infant.

Effect of the HELLP syndrome on maternal immune function.

The HELLP syndrome occurs in less than 1% of gravidas and is characterized by hemolysis, elevated liver enzymes and low platelet count. The status of immune function in these high-risk patients is not known but may be of great importance in better understanding the basis, if any, of immune dysfunction in pregnancy-associated hypertensive disorders and from the potential compounding effect of infection upon an already debilitated patient. We assessed maternal immune status in patients with the HELLP syndrome using conventional in vitro techniques. The results of these studies clearly show a depression of both T and B cell potential and impaired monocyte handling of intracellular pathogens (up to 33%, 11% and 17% of control values, respectively). The onset of this immunosuppression occurred before the clinical diagnosis of HELLP syndrome was made and persisted for at least 14 days after clinical resolution. Results of cell admixture studies suggest that these effects are mediated by accessory cells or their products and do not represent true lymphocyte dysfunction. The risk of opportunistic infections may therefore be increased in the patient with the HELLP syndrome because of this generalized immunosuppression and profound decrease in monocyte phagocytic and bactericidal activity.

Adjunctive antibiotic treatment of women with preterm rupture of membranes or preterm labor.

Subclinical infection is associated with preterm rupture of the membranes (PROM) and preterm labor (PTL) in many cases. It was hypothesized that antibiotic treatment might delay delivery and/or decrease infectious morbidity in those with PROM or PTL. Patients from 19 to 34 weeks with PROM and no labor or PTL with intact membranes (but not both) were separately randomized to receive ampicillin versus placebo in addition to usual therapy. There were 36 women with PTL (21 ampicillin/15 placebo) and 84 with preterm PROM (41 ampicillin/43 placebo). Demographically, the treatment and placebo groups were similar. Outcome variables analyzed included delivery delay after treatment, maternal chorioamnionitis/endometritis, Apgar score, neonatal infection, or respiratory distress, and hospital stay. There were no significant differences between the ampicillin and placebo groups in those with PTL or preterm PROM as it concerned outcome parameters. Adjunctive ampicillin used for treatment of idiopathic PTL or preterm PROM was not beneficial in this study.

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.

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.

Stripping membranes at term: can it safely reduce the incidence of post-term pregnancies?

Membrane stripping has been used clinically for many years but has not been well studied. An investigation was undertaken to determine whether weekly membrane stripping beginning at 38 weeks could safely reduce post-term pregnancies. One hundred eighty patients with firm gestational dates were randomized to either a treatment or control group. Control subjects received a gentle cervicovaginal examination each week to assess Bishop scores, whereas the treatment group also underwent weekly stripping of membranes. Women who received treatment had earlier delivery (mean +/- SEM 8.60 +/- 0.74 versus 15.14 +/- 0.83 days; P less than .0001) and fewer post-term deliveries than those in the control group (three versus 14; P less than .004). The reduction of post-term pregnancies was most notable in nulliparous women with unfavorable Bishop scores. Complications were similar in both groups. Membrane stripping was safe and was associated with earlier delivery and a decreased incidence of post-term gestation.

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.

Antenatal fetal assessment: an overview.

In the past two decades there have been dramatic changes in antenatal fetal assessment. As experience has been gained with new modalities, it has been possible to further decrease perinatal morbidity and mortality by modifying the indications and the frequency of testing, as well as the time of initiation. More antepartum assessment is performed today than ever before with the advent of new procedures. With the increasing complexity of multiple modalities and confounding risk factors it has become necessary to individualize the management of each high-risk pregnancy. The clinician should attempt to identify which test or group of tests will insure the lowest perinatal mortality for a given risk factor. The specific test(s) utilized will depend on the population, the expertise of the personnel administering the test, and the manpower and equipment available. Antenatal fetal assessment is usually not performed unless one is prepared to modify obstetric management or expedite delivery when significant abnormalities are identified. The risks of delivery (maternal and neonatal) must then be weighed against the potential adverse effects of continuing the pregnancy. It should be recognized that there is no single "best test" for all clinical situations. It is important for the practicing physician to keep abreast of new developments in antenatal assessment and to be aware of recommended modifications in older applications.

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.