Management of the extreme premature delivery.

Generally speaking the answer, how early is too early, can't be exactly answered. For practical reasons it seems advisable to draw that line about 25 completed weeks of gestation but of course it is desirable to make individual decisions in each case when time and experience allows that. If possible, mothers with threatening very premature delivery should be transported to a stage 3 hospital. When one is prepaired to make maximal efforts for the survival of the infant, modern supervision of the fetus should be applied. In uncomplicated cases of idiopatic premature labour vaginal delivery should be allowed. Due to the fragility of the immature fetus any kind of birth trauma should be minimized. Caesarean section might be used on liberal indications and cases with beginning acidosis should be promptly delivered in the most suitable way. When complicated by breech presentation the delivery seems to be best performed by the abdominal route. I like to emphasize that to me, the most important item concerning the management of the very preterm birth is the correct dating of the pregnancy. Without reliable data one can hardly make any proper decisions on how early is too early and solve the problems connected to that question. In my opinion the emergency weight estimation with ultrasound is not satisfactory, only the knowledge of the length of the pregnancy allows you to do so.

Modern oral contraceptives and dysmenorrhoea.

Women with primary dysmenorrhoea not sufficiently helped by triphasic oral contraceptives (OCs) were offered a modern, low-dose monophasic OC containing 30 micrograms of ethinylestradiol and 150 micrograms of desogestrel. The study shows that for these women, the monophasic pill was the better alternative. The fact that 19 of 23 women who continue treatment on the monophasic OC indicates that this type of pill may be chosen as the first alternative for women with primary dysmenorrhoea.

PIP: The effectiveness of a monophasic oral contraceptive was compared to that of a triphasic for relief of primary dysmenorrhea in an open crossover study in 30 women who had been previously taking triphasics. The pills formerly used contained ethinyl estradiol and either norethisterone (3) or levonorgestrel (27). Women took the monophasic pill containing 150 mcg desogestrel and 30 mcg estradiol [sic] for 3 months, then resumed their former prescription. Dysmenorrhea pain, marked on 10 mm scale, was lessened in 18 and increased in 4 women during monophasic intake (p0.01). Total duration of pain was reported as 2081 hours on the monophasic, and 2237 hours on the triphasic. The amount of bleeding reported as light, medium or heavy on a calendar was less on the monophasic for 18 women, the same in 2 and less on the triphasic for 4 women. Analgesic use during the monophasic was reported as less by 13, the same by 1, and more by 6 women. 19 women expressed a desire to continue with the monophasic after the study. It is likely that monophasic pills relieve dysmenorrhea more effectively because of their more consistent inhibition of ovulation.

Fetal and uteroplacental haemodynamics during short-term atenolol treatment of hypertension in pregnancy.

Fetal circulation was studied by means of combined real-time and pulsed Doppler ultrasound in 14 women with pregnancy-associated hypertension before and during the first and third days of treatment with the beta 1-selective blocker, atenolol; in seven of the women the maternal uterine arcuate blood velocity waveform was also studied. Blood flow characteristics were normal both in the fetus and in the maternal arcuate artery, compared with those in uncomplicated pregnancies of corresponding gestational ages. Volume blood flow remained unchanged in the fetal descending aorta, and in the umbilical vein during atenolol treatment, whereas the pulsatility index increased in the fetal descending aorta and in the arcuate artery. This suggests that the peripheral vascular resistance, both on the maternal and fetal side of the placenta, increased during short-term antihypertensive treatment with atenolol.

The influence of a high-fibre diet on body weight, serum lipids and blood pressure in slightly overweight persons. A randomized, double-blind, placebo-controlled investigation with diet and fibre tablets (DumoVital).

Sixty slightly overweight women were treated with a weight-reducing diet for 12 weeks in a randomized, double-blind, placebo-controlled study. In addition to the diet 30 women received dietary fibre tablets, whereas the remaining 30 women received identical-looking placebo tablets. During the trial both groups experienced a significant reduction in body weight (P less than 0.01). The mean weight loss 8.5 kg (7.5-9.5 kg) in the fibre group was significantly higher than that of the placebo group 6.7 kg (4.8-8.0 kg) (P less than 0.01). Both serum triglyceride and serum cholesterol concentrations were significantly lowered (P less than or equal to 0.02) after treatment in both groups. No significant differences were detected between the groups. Both systolic and diastolic blood pressure were significantly reduced (P less than 0.01) in the fibre group. No significant reduction in blood pressure was found in the placebo group. Side-effects, which were gastrointestinal in nature, were of low frequency. We conclude that supplementation with dietary fibre of the form used in this study is useful in the treatment of overweight women.

Fetal distress during labour in diabetic pregnancy.

The frequency of fetal distress in labour was studied in 46 diabetic women and in 46 non-diabetic matched controls. Fetal distress was assessed by electronic fetal heart rate (FHR) monitoring and fetal scalp blood pH determinations in late first stage of labour. Ominous FHR and/or low pH (less than 7.26) was more common in the diabetic group than in the control group (17.4% and 10.9%, respectively) but the difference was not statistically significant. The frequency of caesarean section and low Apgar score at 1 min was significantly higher in the diabetic group (P less than 0.05). There was no correlation between maternal blood glucose regulation and the occurrence of fetal distress in the diabetic group. The results suggest that fetal distress may be slightly more common in labour in diabetic women compared with controls managed in a similar way. Careful FHR monitoring and liberal use of fetal scalp blood pH determinations is recommended.

Fetal surveillance in diabetic pregnancy. I. Predictive value of the nonstress test.

Ninety-nine consecutive diabetic pregnancies (101 infants) were monitored with altogether 2672 nonstress tests (NSTs) from about 30 weeks of gestation until parturition. In 96% of the women the last NST was performed within 2 days of delivery. Fifty-nine percent had normal NSTs throughout pregnancy. Only 3.7% of the 2 672 tests were classified as pathological. When performed within 2 days antepartum, a normal NST predicted the 1-min Apgar score to be greater than or equal to 7 in 92%, and at 5 and 10 min in 99%. When all NSTs ever performed were included, the predictive value improved to 100%. The baby's first cry within 1 min after birth was predicted in 96%. Furthermore, the predictive value of a normal NST regarding the absence of ominous intrapartum cardiotocographic (CTG) patterns, normal pulmonary function and normal metabolic balance, was about 80%. The perinatal mortality was 1%. The specificity was in general good (86-96%), whereas the predictive value of pathological tests and the sensitivity almost without exception were poor. It is concluded that the very low rate of pathological NSTs indicates that obstetric interventions were made soon after the occurrence of the first sign of fetal jeopardy. Only then, and with meticulous care, is it possible to obtain good results. A normal NST is an excellent predictor of a normal Apgar score at 5 and 10 min, and also very good for a normal 1-min Apgar and an early cry from the baby. The predictive value is quite acceptable concerning the intrapartum CTG and the neonatal course likewise regarding the pulmonary function and metabolic balance.(ABSTRACT TRUNCATED AT 250 WORDS)

Fetal surveillance in diabetic pregnancy. II. The nonstress test versus the oxytocin challenge test.

At the Department of Obstetrics and Gynecology, University of Lund, it has been the routine management in diabetic pregnancy to use both nonstress test (NST) and oxytocin challenge test (OCT) for fetal surveillance. The study material reported comprised 61 pregnant diabetics, 1,882 NSTs and 90 OCTs. Evaluations were made separately for the time interval 0-2 days antepartum, within 1 week antepartum, and all tests included. Predictive value, specificity and sensitivity were calculated for both the NSTs and the OCTs according to the following variables of neonatal outcome: Apgar scores at 1, 5 and 10 min, baby's first cry (or not) within 1 min of birth, pulmonary function, and metabolic balance. No perinatal deaths occurred. There were no statistically significant differences between the NSTs and OCTs in the antepartum time intervals 0-2 days and less than or equal to 1 week regarding any variable. When all tests were included, the OCT proved superior in that there were fewer falsely pathological tests, though biased by the fact that most of the NSTs evaluated were older than the oldest OCT in this context. Nevertheless, it is concluded that the OCT does not favor the NST for routine fetal surveillance in diabetic pregnancy.

Classification of the nonstress test and fetal outcome in 1,056 pregnancies.

During a 2 1/2-year period, 1 056 pregnant women (1 072 fetuses) were monitored with the nonstress test (NST) in the antenatal period. Testing time was 30 minutes. The NST was classified into one of four classes: normal, suspect pathological, slight pathological, and severe pathological. In 88.5% of the pregnancies, all NSTs were normal. Suspect, slight, or severe pathological NSTs occurred at least once in 8.1%, 2.1%, and 1.3% of the women respectively. All women with a severe pathological NST had high-risk complications. Lethal malformations excluded, there were only two perinatal deaths among the tested women. In the four different classes, the frequencies of cesarean section were 11%, 17%, 41%, and 79%. One-minute Apgar scores were less than 7 in 5%, 12%, 41%, and 64%. The need for referral to neonatal intensive care was 19%, 40%, 41%, and 93% respectively. A normal NST predicted normal fetal outcome in an excellent way, while the three pathological classes appeared to represent different degrees of impending fetal jeopardy.

Influence of the beta 1-adrenoceptor blocker atenolol on antenatal cardiotocography.

Forty term patients with pregnancy-induced hypertension were treated with the beta 1-adrenoceptor blocker atenolol (Tenormin R; ICI) for at least 7 days prior to parturition. The antenatal cardiotocography (CTG) was visually analysed before and during treatment. The mean basal fetal heart rate (FHR) decreased from 143 +/- 7 beats per minute (bpm) to 133 +/- 8 bpm. In 13.1% of the recordings in treated patients there was a decrease in long-term variability for a period of more than 20 minutes; this was observed in only 2.3% prior to treatment. The amplitude of the accelerations was reduced from 23 +/- 6 bpm to 18 +/- 4 bpm. It was demonstrated that atenolol affected antenatal CTG, and this has to be taken into consideration when interpreting antenatal CTG as one parameter for evaluation of fetal well-being.

Changing panorama of perinatal and infant mortality in diabetic pregnancy.

In a 21-year study covering 1960 to 1980, perinatal and infant mortality in 237 infants of diabetic mothers were analysed. The study was divided into three 7-year periods related to changes in management. In period I (1960-66) the perinatal mortality was 24.3%, decreasing to 5.0% in period II (1967-73) and to 1.1% in period III (1974-80). The corresponding figures for infant mortality were 31.4%, 7.5% and 4.6% respectively. Today the difference between the perinatal mortality rate in diabetic vs. non-diabetic pregnancies is almost negligible. However, perinatal mortality may give a false impression of pregnancy outcome, since owing to the high rate of lethal malformations in period III, infant mortality was still twice that of the non-diabetic population. During the 21-year period studied, complications of diabetic pregnancies such as severity and duration according to the White classification, hypertension and pyelonephritis in pregnancy and preterm delivery all decreased. Consequently the influence of these complicating factors on the overall outcome of diabetic pregnancies has declined.

The accuracy of ultrasonic fetal cardiography.

The present work investigated the accuracy of ultrasound cardiography (uFCG) in registering the fetal heart rate variability. Five patients in early labour were studied. Two cardiotocographs (HP 8030A) were simultaneously recording uFCG and direct fetal electrocardiography (dFECG). The information was stored in an analogue FM tape recorder for further data processing. The number of beats registered by the two methods were counted, and the time intervals between the beats were calculated. The short term variability (STV) and the long term variability (LTV) were investigated according to the definitions of DE HAAN [3]. To get an acceptable correlation coefficient in STV of 0.78, a difference as high as 5 beats per minute (bpm) between the two registrations had to be allowed. For LTV, a correlation coefficient of 0.70 was reached at a difference of 2 bpm. The results of the study show that the uFCG can hardly be used in interpretation of the STV. As the visual examination of the cardiotocograms reflects the LTV rather than the STV [7, 9], the uFCG can be used for interpretation of LTV provided that "jitter" is absent on the tracing.

Intrapartum electronic fetal monitoring in low-risk pregnancies.

The value of fetal monitoring in low-risk pregnancies was evaluated in 4278 deliveries, 85% of all low-risk patients delivered in 1977 and 1978 at the University Hospital of Lund. An irreproachable tracing was recorded in less than half the cases. Fetal heart rate changes demanding scalp pH measurements or operative intervention for fetal distress occurred in about 10% of all deliveries. In only 30 patients (0.7%) was cesarean section performed for fetal distress. No intrapartal deaths occurred. The perinatal mortality (antenatal deaths excluded) was 0.14%. Only 3 of 1000 newborns had an Apgar score less than 7 at 5 minutes. The reported negative implications of routine fetal monitoring, such as overdiagnosis of fetal distress, cannot be verified in this study when electronic fetal monitoring and pH measurements are combined. The excellent fetal outcome suggests benefits from routine electronic fetal monitoring even in low-risk pregnancies.

Selection criteria for oxytocin stress test.

The main aim of the investigation was to study in which patients oxytocin stress test (OST) should be used. From 1071 patients routinely monitored with antenatal cardiotocography ( = non-stress test) 112 were selected for 151 OSTs for two reasons: 1) normal or suspect pathologic non-stress test (NST) 2) slight or severe pathologic NST regardless of risk classification. In the first group of 85 OSTs, only 2 proved positive. In the second group of 66 OSTs, 22 were positive. The oxytocin stress will give little additional information to the NST when the latter is normal; the OST could be restricted to the relatively few patients with pathologic NST.

Influence of occiput posterior position on the fetal heart rate pattern.

Fetal heart rate (FHR) recordings of 138 deliveries with the fetus in the occiput posterior position (OPP) are compared with recordings of 138 control fetuses in the occiput anterior position (OAP). The 2 groups are comparable in maternal age, parity, duration of first stage of labor, frequency of nerve blocks for analgesia, and incidence of cord complications. Variable decelerations were significantly more frequent and more pronounced in the OPP group than in the controls. The number of newborns with low Apgar scores was similar in both groups, despite a large number of pronounced decelerations in the OPP group. Possible mechanisms for the origin of variable decelerations in the occiput posterior position are discussed.

Effect of ritodrine on labor after premature rupture of the membranes.

The effect on labor of administering ritodrine after a premature rupture of the membranes (PROM) was studied in a double-blind trial in 30 patients. The patients were selected according to the following criteria: 28 to 36 weeks' gestation, only 1 fetus, cervix dilated 4 cm or less, and absence of pyrexia or other signs of uterine infection. Fourteen patients received ritodrine and 16 received a placebo. The 2 groups were statistically comparable. None of the patients receiving ritodrine delivered within 24 hours. The difference between the 2 groups was statistically significant with respect to the number of patients delivered within 24 hours (P less than 0.05). However, after 24 hours, there was no difference between the groups as regards the length of pregnancy. The infections registered in the mothers of infants were few and easily controlled. The incidence of idiopathic respiratory distress syndrome (IRDS) was low in the study and allows no conclusions concerning the benefit of prolonging the pregnancy for more than 24 hours after PROM.

The accuracy of abdominal ECG for fetal electronic monitoring.

The aim of this study was to investigate the quality of the abdominal fetal electrocardiography (aFECG), and compare the short term and long term variability registered by this method with the direct fetal electrocardiography (dFECG). With three cardiotocographs the aFECG, the dFECG and the maternal ECG were registered simultaneously and stored on a magnetic tape. After analogue-digital conversion, the information was calculated in a computer system. The variability registered by aFECG and dFECG was compared allowing a difference of both one beat and two beats/min. From nine patients in early labour 30651 heart beats were registered by dFECG. By aFECg 27720 beats were registered. Within a window of +/- 10 ms 98.5% of all pulses registered by aFECG were found. The correlation coefficients for short term variability were 0.75 and 0.91. For long term variability the correlation coefficients were 0.94 and 0.98. To allow calculations of the short term variability the registration of the instantaneous fetal heart rate is necessary. In the antenatal period only indirect methods for electrocardiography are possible. The present report shows that with the abdominal electrocardiography the short term and long term variability can be judged. the quality of the registrations is good enough to allow computer calculations of the information.