Carl V. Smith

Patterns of uterine activity after intravaginal prostaglandin E2 during preinduction cervical ripening

In a randomized study, uterine activity patterns were characterized with a portable pressure-sensitive device in 40 nonlaboring women at term with an unfavorable cervix who were undergoing preinduction cervical ripening with prostaglandin E2. The prostaglandin E2 was inserted into the posterior vaginal fornix as a single dose of either a 2.5 mg methylcellulose gel (20 cases) or 10 mg controlled-release pessary (20 cases). Uterine activity monitoring began 1 hour before dosing and continued for 12 hours. For those treated with the gel, low-amplitude, high-frequency contractions began within the first hour, reached a peak within 4 hours, and initiated sustained high-amplitude contractions in 10 (50%) cases. With the controlled-release pessary, low-amplitude, high-frequency contractions had a slightly later onset, reached a peak between the fifth and eighth hours, and initiated sustained high-amplitude contractions in 18 (80%) cases. Uterine hyperstimulation occurred in two (10%) pessary cases, with no adverse effect after removal. We conclude that low-amplitude, high-frequency uterine contractions began with either method of intravaginal prostaglandin E2 delivery but led to sustained, high-amplitude contractions primarily with the pessary.

Relation of mild idiopathic polyhydramnios to perinatal outcome

The relation between clinically obvious polyhydramnios and poor perinatal outcome has been described. Much less is known about mild, unexplained polyhydramnios, which usually is initially suggested by sonographic examination late in gestation. The purpose of the present investigation was to relate mild idiopathic polyhydramnios to perinatal outcome. Mild polyhydramnios was defined sonographically as an amniotic fluid index of 24.1-39.9 during fetal biophysical testing. All subjects had singleton gestations not complicated by conditions known to predispose to polyhydramnios. We diagnosed mild polyhydramnios in 97 of 1177 patients (8.2%) undergoing fetal testing at 26-42 gestational weeks. Premature delivery, intrapartum complications, and neonatal depression were no more frequent in the pregnancies complicated by mild, unexplained polyhydramnios than in a comparable control group with normal fluid volume. The mild polyhydramnios group showed a significantly higher incidence of birth weight greater than 4000 g than did the control group (18.6 versus 8.6%; P less than .05). We conclude that mild idiopathic polyhydramnios in late gestation is relatively common. Except for a higher incidence of large for gestational age fetuses, this condition by itself is not associated with an increased risk of adverse perinatal outcomes.

Transvaginal sonography of cervical width and length during pregnancy.

Transvaginal ultrasonography has been proposed as a reliable method of assessing dimensions of the cervix. The purpose of the current investigation was to establish normative data for cervical width and length during pregnancy. This information may be helpful in predicting patients at risk for preterm birth. A transvaginal 5 or 7.5 MHz transducer was used on 132 consecutive low‐risk pregnant women undergoing evaluation for gestational dating purposes. Even in cases of patient obesity or an empty bladder, high resolution was possible and permitted cervical measurement in all but one case. The external cervical width at the vaginal fornices was found to increase with advancing gestation (R = 0.512, P < 0.005). The cervical length from internal os to external os was found not to change with advancing gestation (R = 0.11, P = 0.30). Using these normative data, investigation is recommended to determine whether measuring cervical width and length is useful in predicting preterm labor and delivery.

Influence of intravenous fentanyl on fetal biophysical parameters during labor

The short-acting opioid fentanyl has been shown to be a useful analgesic during labor. The purpose of this prospective, comparative investigation was to determine whether fentanyl influenced fetal biophysical parameters during labor. Twenty-four uncomplicated pregnancies at 37-41 weeks were studied during the early active phase of labor. Those patients who requested analgesia (study group) were given a standard 50-micrograms dose of fentanyl intravenously. The study (N = 12) and control (N = 12) groups were similar in maternal age, parity, and gestational age distribution. Fetal body and breathing movements and heart rate patterns were evaluated continuously for 80 min at 10-min epochs. Unlike the control group, fetuses exposed to fentanyl had fewer body movements between contractions (P < 0.03) and spent less overall time moving (P < 0.02). Breathing was abolished at 10 min postdosing in all fetuses exposed to fentanyl but not in the control group. The FHR beat-to-beat variability was reduced between contractions for the first 30 min in 8 (66%) of study cases and none of the control cases (P < 0.01). A sine wave-like FHR pattern was observed for 30 min in two fetuses exposed to fentanyl. All infants had 1- and 5-minute Apgar scores > 6, an umbilical artery pH > 7.20, and no need for resuscitation. In conclusion, an intravenous dose of fentanyl during early active labor was associated with temporary depressant effects on many fetal biophysical parameters without apparent harm being observed at delivery.

Characterization of fetal body movement recorded by the Hewlett-Packard M-1350-A fetal monitor.

OBJECTIVEnThe purpose of this study was to evaluate the ability of a commercially available monitor, the Hewlett-Packard M-1350-A fetal monitor, to record and discriminate between various fetal body movements.nnnSTUDY DESIGNnTwenty-four patients between 29 and 42 weeks gestation were monitored over a 20 to 30 minute period simultaneously by the Hewlett-Packard instrument and ultrasonography.nnnRESULTSnAll 593 single or clustered fetal movements recorded by the monitor were seen ultrasonographically as being extremity movements that were either isolated or combined with trunk motion. Discriminating between these two types of movements was not possible on the basis of the duration of recorded movements. All adequate fetal heart rate accelerations were attributed to combined trunk and extremity movements. Detection of fetal hiccups was less exact, and recording of fetal hand, mouth, breathing, and rapid eye movements was beyond the sensitivity of the monitor. Signal artifacts were attributable to either motion of the maternal abdomen or Doppler transducer and became less of a problem with experience.nnnCONCLUSIONnFetal extremity movements were recorded with accuracy by this new fetal monitor.

Long-term enteral hyperalimentation in the pregnant woman with insulin-dependent diabetes: A report of two cases

Enteral hyperalimentation has gained wide popularity in the last two decades for the treatment of certain catabolic disease states. Despite its proved effectiveness in gynecologic oncology, its use in obstetrics has been limited. The following reports two instances of its use in insulin-dependent diabetic pregnancies complicated by intractable nausea and vomiting. Long-term enteral hyperalimentation and insulin therapy in a diabetic pregnancy are reviewed.

“White Coat” Hypertension During Pregnancy

Objective: This study attempted to determine whether mildly elevated blood pressure during late pregnancy showed the “white coat” phenomenon, with recordings outside the office being below those during a recent clinic visit.Methods: The study group consisted of healthy, previously normotensive patients whose blood pressures during the most recent office visit were elevated on recordings taken initially by a nurse, and then by a physician. Each patients blood pressures were then recorded automatically by an ambulatory blood pressure monitor (Space Labs 90207) for an average of 106 measurements (over 19 h) per subject. The computer-generated diastolic, systolic, and mean arterial pressure recordings for the next day were averaged for the daytime and nighttime, then compared to those obtained in the recent clinic visit.Results: Thirty (8.0%) of 377 patients followed consecutively in a low-risk clinic had elevated blood pressures during an office visit. In 27 (90.0%) patients, the averaged blood pressures ou...

EFFECT OF A SINGLE DOSE OF ORAL PSEUDOEPHEDRINE ON UTERINE AND FETAL DOPPLER BLOOD FLOW

Pseudoephedrine, a stereoisomer of ephedrine with alpha- and beta-adrenergic properties, is the active ingredient in over-the-counter oral decongestants. Its safety during pregnancy has not been studied adequately. The purpose of this investigation was to evaluate the effects of pseudoephedrine on uterine and fetal Doppler blood flows. Twelve healthy pregnant women between 26-40 weeks gestation ingested a standard 60-mg dose of pseudoephedrine. A pulsed Doppler system was used to perform blood flow measurements of the uterine arcuate artery, fetal aorta, and umbilical artery before dosing, immediately thereafter, and at 15-minute intervals during the first 3 hours after drug ingestion. Blood flow velocities were not altered significantly after dosing in either the maternal or fetal circulation. In no case did absolute fetal or uterine blood flow velocities decrease significantly or systolic/diastolic ratios persistently elevate to abnormal values. We conclude that no significant alterations in the uterine or fetal circulations occur after the ingestion of a single dose of oral pseudoephedrine by healthy pregnant patients in the third trimester.

Double-blind comparison of intravaginal prostaglandin E2 gel and "chip" for preinduction cervical ripening.

The intravaginal application of prostaglandin E2 for preinduction cervical ripening has proved to be advantageous in the management of patients with an unfavorable cervix. The purpose of this double-blind randomized investigation was to compare the efficacy and safety of two methods of prostaglandin E2 delivery. Patients who were to have preinduction cervical ripening because of an unfavorable cervix (Bishop score less than or equal to 4) were randomly assigned to be given a single dose of prostaglandin E2 as either 2.5 mg of gel or a 3.0 mg chip intravaginally in a placebo-controlled manner. Sixty-nine patients received the active prostaglandin E2, 34 in the gel group and 35 in the chip group. The groups were similar in maternal age, race, parity, gestational age, and initial Bishop score. Both forms of prostaglandin E2 were easy to administer and helpful in priming an unfavorable cervix. The need for, duration of, and maximum dose of oxytocin were similar in both groups. Cesarean delivery because of failed induction occurred in 5 of 35 (14.3%) patients receiving a chip and 4 of 34 (11.8%) receiving the gel. However, patients receiving a chip experienced a 20% (7/35) incidence of hyperstimulation, compared with 2.9% (1/36) in those receiving the gel (p less than 0.05). The only case requiring immediate cesarean delivery because of intractable uterine hyperstimulation received a chip. We conclude that both methods were effective for cervical ripening, but the lower incidence of uterine hyperstimulation seen with the gel would suggest that it is preferable to the chip.

Uterine and fetal Doppler flow changes after intravaginal prostaglandin E2 therapy for cervical ripening

Nineteen patients received prostaglandin E2 as a 2.5 mg gel (seven cases), 3.3 mg chip (five cases), or 10 mg controlled-release pessary (seven cases) for preinduction cervical ripening. Blood flow velocities did not change significantly for the uterine arcuate artery, fetal aorta, and umbilical artery circulations after any of the treatments. In no case did systolic/diastolic ratios consistently elevate above baseline values.