Amniotic fluid index as a predictor of latency after preterm premature rupture of the membranes.

To determine if latency following preterm premature rupture of membranes can be predicted using the amniotic fluid index, a retrospective observational study was performed using patient records to identify those admitted with a diagnosis of preterm premature rupture of membranes. Fifty-one patients with initial evaluation within 48 hours of rupture and gestational age 26 to 34 weeks were identified. Amniotic fluid index was evaluated along with a biophysical profile; these were followed serially until delivery. Delivery was accomplished because of spontaneous labor or chorioamnionitis. Amniotic fluid index at initial evaluation was stratified into three groups: Low (less than 5.0), reduced (4.0 to 7.9), and normal (8.0 or higher). Latency in days from preterm premature rupture of membranes to delivery was evaluated for these groups. A difference was noted in that latency was significantly longer in the group with normal versus low or reduced amniotic fluid index groups. The amount of residual amniotic fluid, as measured by the amniotic fluid index, following preterm premature rupture of membranes, is predictive of latency.

The serum insulin-like growth factor-II/mannose-6-phosphate receptor in normal and diabetic pregnancy.

The extracellular domain of the insulin-like growth factor-II/mannose-6-phosphate (IGF-II/Man-6-P) receptor is present in the circulation of several species including man. The purpose of the present study was to establish whether this truncated receptor is present in higher concentrations in fetal sera compared with adult sera and whether the metabolic status of the individual alters serum concentrations of this protein. Nondiabetic and diabetic pregnant women were studied throughout gestation, and at term fetal cord sera were obtained. Levels of IGF-I increased throughout pregnancy in normal and diabetic women. IGF-II levels significantly increased during the third trimester in both groups and levels of IGF-I and IGF-II were significantly elevated in fetal cord samples from diabetic women only. Serum samples were gel-filtered on Sephadex G-200, and column fractions were assayed for binding of radiolabeled IGF-II and IGF-I. There was specific binding (SB) of IGF-II in the void volume fractions in all samples examined. Normal women had 3% +/- 0.5% SB, whereas in cord sera SB was 5% +/- 0.7% and in pregnant sera 10% +/- 2%. There was no difference in SB in fetal cord or pregnant samples from normal and diabetic women. In addition, there was a peak of binding activity of both IGF-I and -II in gamma-globulin and postalbumin fractions of the columns in pregnant and nonpregnant women, but only in postalbumin fractions in fetal cord samples.(ABSTRACT TRUNCATED AT 250 WORDS)

Prenatal diagnosis and obstetric management of Larsen syndrome.

BACKGROUND: Larsen syndrome is a disease of generalized defect in collagen formation including multiple disorders of the joints and cardiac anomalies. A review of the literature revealed no previous reported cases in pregnancy. CASE: A 29-year-old woman with known Larsen syndrome thought to be of the autosomal recessive type presented in pregnancy; second-trimester ultrasound suggested fetal involvement with Larsen syndrome. The patient was followed with serial ultrasounds, and she had pediatric and anesthesiologic consultations. She was delivered by cesarean of a female infant whose neck was immediately stabilized. The infant was then taken to the neonatal intensive care unit, where a diagnosis of Larsen syndrome was confirmed. CONCLUSIONS: Larsen syndrome, which may be diagnosed prenatally, is a rare and unique condition that requires multidisciplinary care. Obstetric management must take into account the increased anesthetic and surgical risks to the mother and the risk of fetal injury including cervical spine instability. The genetics of Larsen syndrome are also discussed.

Vaginal birth after cesarean section: the patient's point of view.

Advocacy of vaginal birth after cesarean section (VBAC) is the current standard of care. We interviewed patients in our program about their attitudes toward VBAC and cesarean section. The success rate in our VBAC program is similar to rates reported in the literature (65 percent). However, interviews with our patients revealed that 40 percent had no desire to participate in the VBAC program, although they fulfilled the criteria for eligibility. The main reasons given for declining a trial of VBAC were the convenience of an elective cesarean section and fear of another prolonged, painful and potentially dangerous labor. Thirty-two percent of patients in whom VBAC was successful were dissatisfied with the experience and would have preferred an elective cesarean section. The reasons patients gave for attempting VBAC were different from the medical reasons proposed to them. The main reasons given were a desire to deliver "naturally," a fear of surgery and the concern that cesarean section might harm them or their baby.

The clinical significance of resolving polyhydramnios.

Polyhydramnios is associated with multiple maternal and fetal abnormalities. Although the risks of persistent polyhydramnios are well described, the clinical implications of polyhydramnios that resolves prior to delivery are not. Thirty-four non-diabetic patients with resolving polyhydramnios were studied. An amniotic acid index of >or= 20 was used to define polyhydramnios. Antepartum and postpartum outcomes were compared with those patients with persistent polyhydramnios, and a control group of 102 singleton term deliveries. Patients with resolving polyhydramnios did not have a significant increase in congenital anomalies. An 8% incidence of congenital anomalies was noted in patients with persistent polyhydramnios; this was significant compared with controls (p < 0.05). Idiopathic resolving polyhydramnios was associated with a higher mean birth weight (p < 0.05) than controls, with significantly more babies weighing more than 4200 g. An increase in placental thrombus formation was noted in patients with idiopathic resolving and persistent polyhydramnios compared to the control group (p < 0.01). The etiology of this is unclear. Obstetricians should be aware of the risk of macrosomia and the possibility of placental disease in these fetuses.

Pleural effusion in aneuploidy.

Three consecutive cases of isolated pleural effusion in aneuploid fetuses are reported. The presence of pleural effusion in trisomy 13 had not been described in the literature previously. Early development of pleural effusion is usually associated with fetal hydrops and carries a poor prognosis. Late development of pleural effusion can be treated in utero. A karyotype should be performed in all cases of pleural effusion prior to in utero pleuroamniotic shunting.

Doppler umbilical artery velocimetry in fetuses with polyhydramnios.

Polyhydramnios is a condition of multiple etiologies, many of a benign nature, but some of which are incompatible with life. To evaluate Doppler velocimetry results as a prognostic parameter in these fetuses, we reviewed all of our cases of polyhydramnios that underwent Doppler analysis in the third trimester. Fifty-four fetuses were studied. Eleven (20.4%) had abnormal waveforms and 43 (79.6%) had normal waveforms. An abnormal waveform was associated with a significantly higher incidence of congenital anomalies, perinatal mortality and intrauterine growth retardation. Six of the 11 fetuses had abnormal karyotypes. Macrosomia was present in 37.2% of fetuses with normal waveforms and in no fetus with an abnormal waveform. Doppler analysis may aid in the counseling and management of patients with polyhydramnios. In cases with an abnormal ratio, the physician and patients should be prepared for a poor outcome and third trimester genetic analysis should be strongly considered.

Amniotic fluid index: an appropriate predictor of perinatal outcome.

Qualitative amniotic fluid volume determination is a routine part of the fetal biophysical profile score. Quantitative amniotic fluid volume measurement, however, is not a factor in the determination of the standard biophysical profile score. This study is a retrospective analysis of antepartum assessment of amniotic fluid volumes and their relationship to neonatal outcomes. The amniotic fluid index was calculated for all patients examined and perinatal outcome was studied for all patients assessed. Patients with reduced or increased amniotic fluid volume had a significant increase in meconium-stained amniotic fluid, Apgar scores less than 7 at 1 and 5 minutes, major congenital anomalies, admission to the neonatal intensive care unit, and were more likely to require delivery by cesarean section for fetal distress. This study suggests that a quantitative ultrasound measurement of amniotic fluid volume represents an effective discriminatory test to be used in pregnancy evaluation.

Fetal hydrocele: a persistent finding?

A transient type of fetal hydrocele is described. This type of hydrocele resolves in utero spontaneously and may be a variant of normal testicular development.

Mode of delivery in multiple birth of higher order.

A retrospective review of triplets delivered at a Boston perinatal center from 1977 to 1986 was performed. Comparison was made between this group (study group) and previously published data on triplets in our institution (control group). Since 1977 there was a more liberal use of abdominal delivery. Cesarean sections (CS) of all triplets with malpresentation was our protocol. Of the 15 sets of triplet pregnancies in the study group, 11 were delivered by CS and 4 by vaginal delivery, vs only 1 CS in the control group which consisted also of 15 triplets. The corrected mortality rate in the study group was lower than in the control group (2.6% vs 7.1%) but did not reach statistical significance. Apgar scores at 1 and 5 minutes were significantly higher in the study group (P less than 0.002). Apgar scores for the third triplet were also higher in the study group (P less than 0.05). In comparing the combined mortality and morbidity between the study group and the control group, no difference was found in the first triplet, but those of the second and third triplets were significantly lower in the study group. Of interest is the finding that the combined mortality and morbidity was not different statistically among the first, second, and third triplets in the study group, while in the control group an increase from the first to the third triplet was noted (21%, 31%, and 43%, respectively). A more liberal approach toward abdominal delivery of pregnancies of higher fetal number is advocated.

Serial amniocenteses in the treatment of twin to twin transfusion complicated with acute polyhydramnios.

Twin to twin transfusion, complicated by acute polyhydramnios in a monozygous twin pregnancy, is a difficult clinical problem. A precipitous course usually results in termination of the pregnancy within a few days and often is associated with a high perinatal mortality rate. Two cases are presented that were treated with repeated amniocenteses for the relief of extreme abdominal discomfort and to prevent imminent premature labor. The amount of amniotic fluid removed each time varied from 300 cc to 1200 cc, which was enough to relieve symptoms but not enough to induce uncontrolled uterine activity. A total of 3500 cc and 4750 cc of amniotic fluid were removed from the first and the second patient, respectively. The procedure was found to be safe and resulted in prolonging the pregnancies by 14 and 11 days, respectively. This management, with the addition of tocolysis and close fetal surveillance can offer some hope in an otherwise hopeless situation.