Prenatal screening for Tay-Sachs disease by Louisiana obstetricians: a survey study.

BACKGROUND: Tay-Sachs disease has been reported to be more prevalent in the Cajun population of Louisiana. METHODS: Questionnaires were mailed to 744 obstetricians; 151 responded. RESULTS: Of the 151 responding physicians, 95 (63%) reported that they do not routinely screen their prenatal patients for Tay-Sachs disease. Of the 52 responding obstetricians in New Orleans, 29 (58%) offer screening; 8 of 23 obstetricians (32%) in Acadiana (southwest Louisiana) and 19 of 72 (27%) of the remaining Louisiana obstetricians routinely screen their patients. Of 46 obstetricians in practice less than 10 years, 22 (48%) offer screening; of 105 in practice longer, 35 (33%) offer screening. Of 100 obstetricians trained in Louisiana, 32 (32%) offer screening, compared with 25 of 51 (49%) of those trained elsewhere. CONCLUSIONS: Most practicing obstetricians in Louisiana are not routinely offering Tay-Sachs screening to their prenatal patients. Screening may depend on location of practice, duration of practice, and place of training.

Sleep patterns in pregnancy: a longitudinal study of polysomnography recordings during pregnancy.

OBJECTIVE: To evaluate the differences in sleep of women throughout pregnancy compared with those of nonpregnant control subjects. STUDY DESIGN: Four pregnant women were studied longitudinally during their pregnancy using inpatient polysomnography. Measurements included electroencephalography, electrocardiography, and continuous-pulse oximetry. Four healthy nonpregnant women matched for age and weight were used as control subjects. The total sleep time was recorded, and percentages of each sleep stage were generated. RESULTS: Qualitative differences in sleep between pregnancy patients and control subjects were evident. Control subjects displayed a normal appearance of slow-wave sleep in stages 3 and 4 (delta sleep). When pregnant patients did display delta sleep, it appeared abnormal secondary to extensive alpha-wave intrusion. Even when including this abnormal delta sleep in a quantitative comparison, the pregnant patients had a significantly shorter percentage of total sleep time in delta sleep (4.9+/-1.9% vs 21.9+/-6.0%, p=0.03). CONCLUSION: Sleep in pregnancy is characterized by loss of normal slow-wave sleep. Thus, sleep stages 3 and 4 are shortened during pregnancy. This sleep alteration is persistent when followed longitudinally during pregnancy.

A comparative study of ketorolac (Toradol) and magnesium sulfate for arrest of preterm labor.

BACKGROUND: We evaluated the efficacy and safety of ketorolac (Toradol). METHODS: In this prospective trial, 88 women in confirmed preterm labor at < or =32 weeks' gestation were randomized to receive magnesium sulfate given as an initial 6 g intravenous bolus followed by continuous infusion therapy (2 to 6 g/hr) or intramuscularly administered ketorolac (60 mg loading dose) followed by 30 mg every 6 hours for a maximum of 24 hours. RESULTS: The study groups were similar with respect to age, parity, cervical status, and gestational age on admission. Ketorolac was more rapid (2.71 hr+/-2.16) in the arrest of preterm labor than was magnesium sulfate (6.22 hr+/-5.65). No patient required discontinuance of either drug due to adverse effects. There was no difference in the incidence of neonatal complications between the two groups. CONCLUSION: In gestations with preterm labor at <32 weeks, ketorolac appears to be an appropriate first-line tocolytic agent.

A randomized trial of epidural anesthesia to improve external cephalic version success.

OBJECTIVE: This study was designed to determine whether epidural anesthesia would improve external cephalic version success in a safe and effective manner. STUDY DESIGN: All women > 37 weeks' gestation with breech presentation scheduled for external cephalic version at the medical center from Dec. 1, 1993, to July 31, 1996, were randomized to receive an epidural or no epidural anesthesia. Under ultrasonographic guidance up to three version attempts were performed. RESULTS: Sixty-nine women were randomized to receive epidural (n = 35) versus no epidural (n = 34) anesthesia for external cephalic version. There were no statistically significant differences in maternal age, parity, maternal weight, gestational age, estimated fetal weight, or station of the presenting part. The success rate was better for the epidural group (relative risk 2.12, 95% confidence interval 1.24 to 3.62). Neither anterior placentation or oligohydramnios affected the success rate. CONCLUSION: Epidural anesthesia increases success of external cephalic version without any apparent detrimental effect on the maternal-fetal unit.

A randomized trial of two vacuum extraction techniques.

OBJECTIVE: To determine whether two techniques of vacuum extraction delivery-continuous vacuum and intermittent vacuum-have different effects on maternal-fetal outcomes. METHODS: Patients to be delivered by vacuum extraction were randomized to receive continuous or intermittent vacuum. All deliveries were performed using the M-cup. In the continuous group, the level of vacuum was brought to 600 mmHg between contractions and was maintained at that level until delivery of the infant. Active efforts were made to prevent fetal loss-of-station between contractions by maintaining traction. In the intermittent group, the level of vacuum was decreased to 100 mmHg between contractions and no effort was made to prevent fetal loss-of-station. RESULTS: A total of 322 patients were randomized: 164 in the continuous arm and 158 in the intermittent group. The continuous method did not effect delivery faster (continuous 167 +/- 175 seconds versus intermittent 167 +/- 150 seconds; P = .97), nor did it lead to a reduction in method failures (continuous 12, intermittent nine; P = .72). The intermittent method did not appear to offer any benefit to the neonate regarding cephalhematoma formation (continuous 20, intermittent 17; P = .686) or any other measure of neonatal outcome. Maternal lacerations and episiotomy extensions were evenly distributed between the groups. Overall, the efficacy rate of the vacuum cup was 93.5% and the cephalhematoma rate was 11.5%. CONCLUSION: No differences in maternal or fetal outcome could be demonstrated if the level of vacuum was decreased between contractions or if an effort was made to prevent fetal loss-of-station. The clinical results obtained in this trial using the M-cup are similar to the published results with the stainless-steel Malmstrom cup.

A randomized prospective trial of the obstetric forceps versus the M-cup vacuum extractor.

OBJECTIVE: Our purpose was to determine the efficacy of the obstetric forceps versus the M-cup, a new vacuum extractor cup, and maternal-neonatal complication rates. STUDY DESIGN: Over a 10-month period operative vaginal deliveries were randomized between the obstetric forceps and the M-cup vacuum extractor cup. Maternal demographics, indication for intervention, analgesia, position, station, degree of asynclitism, fetal caput-molding, and time from application to delivery were prospectively recorded. Episiotomy and extensions, lacerations, and the reason for abandonment of the randomized instrument were noted in both groups. Fetal weight, Apgar scores, cord arterial gases, hyperbilirubinemia, phototherapy, and any evidence of fetal trauma were documented at delivery or in the nursery. RESULTS: Six hundred thirty-seven women were randomized, 315 in the forceps group and 322 in the M-cup group. There were no differences in maternal demographic variables. The station, position, degree of asynclitism, or requirement for rotation was not different between the groups. The corrected efficacy rates were forceps 92% and M-cup 94% (p = 0.217). The M-cup deliveries were accomplished more rapidly than forceps deliveries (p < 0.001) and were associated with a lower rate of episiotomy (p < 0.001), third-degree (p < 0.001) and fourth-degree (p = 0.002) lacerations, but blood loss as clinically estimated (p = 0.232) or as measured by hemoglobin levels (p = 0.166) was not significantly different. Forceps deliveries were associated with fewer clinically diagnosed cephalhematomas (p = 0.015) than M-cup deliveries were, but there were no differences in the number of neonates diagnosed with hyperbilirubinemia (p = 0.377) or in the number of infants treated with phototherapy (p = 0.660). CONCLUSIONS: The M-cup vacuum extractor cup appears to be as efficient (and faster) than the obstetric forceps but is associated with significantly more fetal cephalhematomas, whereas maternal injuries are more common with the forceps.

Laparoscopic surgery during pregnancy.

BACKGROUND: Animal studies have demonstrated fetal acidosis during carbon dioxide pneumoperitoneum. This finding suggests a potential adverse effect of CO2 pneumoperitoneum on fetal outcome in humans. PATIENTS AND METHODS: We reviewed our recent experience with laparoscopic surgery performed under general anesthesia and with the use of CO2 pneumoperitoneum, in pregnant women with appendicitis or cholecystitis. We compared these women's charts and pregnancy outcomes with those of pregnant women who underwent formal laparotomy during the same period of time. RESULTS: Seven pregnant patients underwent laparoscopic surgery, and there were 4 fetal deaths among them (3 during the first postoperative week, and another 4 weeks postoperatively). Five pregnant patients underwent formal laparotomy, of whom 4 subsequently progressed to term and 1 was lost to follow-up. CONCLUSIONS: Our recent experiences together with the available animal data suggest that caution should be used when considering nonobstetrical laparoscopic surgery in pregnant women. This experience suggests that additional clinical and laboratory investigations may be indicated to evaluate fetal risk associated with such surgery.

Obstetric management of incompetent cervix and bulging fetal membranes.

OBJECTIVE: To evaluate the effect of emergency cerclage on perinatal outcome in patients with incompetent cervix. STUDY DESIGN: In this descriptive retrospective study, the charts of all patients admitted from 1985 to 1992 with a diagnosis of incompetent cervix and cervical dilatation > or = 2 cm were reviewed. Cervical dilatation at the time of cerclage placement, subsequent pregnancy duration and neonatal outcome were analyzed. Statistical analysis was performed using the paired Student t test. RESULTS: During the eight-year period, 42 patients were admitted with a diagnosis of incompetent cervix, cervical dilatation > or = 2 cm, and underwent emergency cerclage. Cerclage resulted in a median (range) continuation of pregnancy of 30 (2-102) days. In 20 of these patients the membranes were not bulging through the external cervical os, and pregnancy was extended a median of 50 (30-102) days. The remaining 22 patients presented with membranes bulging into the vagina, and emergency cervical cerclage resulted in a median pregnancy extension of 16 (2-98) days. Parturients with bulging membranes were then analyzed according to cervical dilatation. Cerclage success was significantly lower when attempted at a cervical dilation > or = 4 cm. Median pregnancy duration was 6 (2-15) versus 21 (5-98) days in patients with cervical dilatation < 4 cm. CONCLUSION: The results of this study support emergency cerclage in patients without bulging membranes. The data do not support the use of emergency cervical cerclage in patients with bulging membranes and dilatation > or = 4 cm. In those patients, the use of cerclage should be individualized.

The diagnosis and management of breast problems during pregnancy and lactation.

BACKGROUND: In addition to mastitis, lactational breast abscesses, and several other benign conditions unique to the puerperium, pregnant women may develop any of the other breast problems seen in the nonpregnant female population. This review deals with the diagnosis and management of breast problems during pregnancy and lactation. DATA SOURCES: A literature review of the evaluation, technique of biopsy, and treatment of cancer in pregnant women was conducted. CONCLUSIONS: The most common problems fall into a spectrum of infectious complications from milk stasis or mastitis to frank abscess formation. Galactoceles, noninfected milk-filled cysts, present as tender masses; aspiration is both diagnostic and curative. Benign fibroadenomas occasionally enlarge significantly or infarct during pregnancy. A physiologic nipple discharge is common during pregnancy, and may be bloody. Rare cases of massive breast hypertrophy during pregnancy have been reported. The mortality of breast cancer during pregnancy is related to delay: compared stage-for-stage with nonpregnant controls, the prognosis is similar. As a general rule, the cancer should be treated surgically and the pregnancy may be allowed to progress.

Psychiatric emergencies.

Psychiatric emergencies can arise during pregnancy and the puerperium. When faced with a gravida presenting with the symptoms of an acute psychiatric illness, the obstetrician must consider the possibilities of organic disorders and substance abuse before initiating psychotropic therapy with the consulting psychiatrist. Generally, patients with psychiatric illness have difficulty caring for themselves and hospitalization may be indicated at least initially. Emotional support, a quiet environment, and psychotherapy are often the most important aspects of treatment. Suicide gestures should always be taken seriously. Immediate psychiatric consultation is imperative. Finally, anyone caring for pregnant women should be aware of the possibility of domestic violence. Pregnant women are unlikely to volunteer information about an abusive situation. Detection hinges on willingness of the physician to ask probing questions.

Laser lithotripsy in pregnancy. A case report.

Laser lithotripsy is a new method of treating symptomatic urolithiasis. The pulsed dye laser lithotripter uses coumarin to deliver energy with a visible peak wave-length of 504 nm. This energy is transmitted to the calculus through an optical fiber, and mechanical disruption of the stone occurs when multiple pulses of laser energy are applied to the surface of the stone. The method is safe and effective for impacted ureteral calculi. A woman at 20 weeks of pregnancy experienced intractable pain secondary to a 9-mm, distal ureteral stone. She was treated successfully with endoscopic fragmentation using pulsed dye laser lithotripsy.