Cynthia G. Brumfield

Neonatal complications at term as related to the degree of umbilical artery acidemia

The degree of umbilical arterial acidemia associated with immediate newborn morbidity has not been determined. Therefore we compared 358 term infants with umbilical artery acidemia (pH less than 7.20) with 358 term, nonacidotic matched control infants, to evaluate immediate neonatal complications in both groups. Nonacidotic was defined as an umbilical artery pH greater than or equal to 7.20. Complications included seizures, persistent hypotonia, and/or signs of end-organ damage such as renal or cardiac dysfunction. None of the 693 newborns with an umbilical artery pH greater than or equal to 7.00 had such complications. Two of 23 infants with an umbilical artery pH less than 7.00 had sequelae related to intrapartum asphyxia. In these two infants the umbilical artery pH was less than 7.00, the 1-minute and 5-minute Apgar scores were less than or equal to 3 and the acidemia was metabolic in nature.

Prematurity, postdates, and growth retardation: the influence of use of ultrasonography on reported gestational age.

The preterm and postterm delivery rates and the percentage of infants with intrauterine growth retardation are dependent on the gestational age recorded at delivery. At our institution a sharp increase in the preterm delivery rate and a coincident decrease in the postterm delivery rate and the rate of intrauterine growth retardation were noted. Over a 3-year period, while the characteristics of the obstetric population changed only slightly, the gestational age distribution shifted, with a decrease in the mean gestational age of about 1 week and a risk in the reported preterm delivery rate from 12% to 17%. About 15% of this rise was explained by an increase in obstetric interventions, and another 15% can be explained by changes in the way physicians rounded off gestational age. The majority of the increase in the preterm delivery rate was related to changes involving ultrasonographic examinations. These changes included a greater percentage of the population examined, trends toward earlier examinations, a tendency for the physicians to use ultrasonography rather than the last menstrual period in choosing the final gestational age, the use of different standards, an increase in the number of structures measured, and the weight given to various structures for determination of gestational age. It is apparent that changes in use of ultrasonography had a profound effect on the reported gestational age distribution at our institution.

Preterm premature rupture of membranes: Is there an optimal gestational age for delivery?

OBJECTIVE: To characterize neonatal and maternal morbidity and mortality rates in pregnancies complicated by preterm premature rupture of membranes (PROM) and determine whether there is an optimal delivery gestational age. METHODS: We reviewed maternal and neonatal outcomes of women with PROM 24 weeks or more that resulted in delivery at less than 37 weeks at our institution from August 1998 to August 2000. Standardized management included the use of antibiotics, betamethasone at less than 32 weeks, and expectant management until 24 weeks or more. Outcomes evaluated included neonatal mortality, composite major and minor neonatal morbidity, individual major and minor neonatal morbidity rates, maternal infection morbidity, and maternal and neonatal length of stay. Gestational age–specific maternal and neonatal outcomes were compared with a referent group of pregnancies complicated by preterm PROM that delivered between 36 0/7 and 36 6/7 weeks of gestation. RESULTS: During the study interval, 430 women with preterm PROM were identified. Composite major neonatal morbidity was significantly higher among pregnancies delivered at 33 weeks of gestation or less after preterm PROM as compared with those who delivered at 36 weeks. Composite neonatal minor morbidity was significantly higher among pregnancies delivered at 34 weeks or less after preterm PROM as compared with those who delivered at 36 weeks. However, there was no improvement in the composite major and minor neonatal morbidity rates for those pregnancies delivered beyond 34 weeks of gestation. Both maternal and infant length of stay were significantly longer for cases of preterm PROM delivered at 34 weeks or less as compared with those who delivered at 36 weeks. CONCLUSION: Our findings suggest that expectant management of women at 34 weeks and beyond is of limited benefit. LEVEL OF EVIDENCE: II-3

Prognostic significance of unexplained elevated amniotic fluid alpha-fetoprotein

Objective To compare the prognostic values of unexplained elevated amniotic fluid alpha-fetoprotein (AF AFP ≥ 2.0 multiples of the median [MoM]) and unexplained elevated maternal serum alpha-fetoprotein (MSAFP ≥ 2.5 MoM). Methods We accessed a data base containing the results of MSAFP screening tests, genetic amniocenteses, and pregnancy outcome data on all women undergoing secondtrimester genetic amniocentesis from October 1988 through August 1994. After excluding all patients whose elevated AFP levels had any identifiable cause (positive AF acetylcholinesterase, AF blood contamination, fetal malformation or aneuploidy, multiple gestation, etc), 5743 cases were analyzed. Relative risks (RR) for selected pregnancy complications were determined. Results Elevated MSAFP, with any AF AFP, was associated with fetal growth restriction (RR 2.5, 95% confidence interval [CI] 1.4–4.4), stillbirth (RR 3.5, 95% CI 1.4–8.3), preeclampsia (RR 2.8, 95% CI 1.1–7.0), and preterm delivery (RR 2.8, 95% CI 2.3–3.4). Elevated AF AFP, with any MSAFP, was associated with preeclampsia (RR 4.4, 95% CI 2.0–10.0) and preterm delivery (RR 1.7, 95% CI 1.3‐2.4). Elevation of both AF AFP and MSAFP was associated with preterm delivery (RR 4.0, 95% CI 2.8–5.7). When elevated AF AFP was found in association with a normal MSAFP, the RR to develop preeclampsia was 4.6 (95% CI 1.9–11.2). Conclusion Maternal serum alpha-fetoprotein is a better predictor of late pregnancy complications than AF AFP. However, unexplained elevated AF AFP appears to be especially predictive of preeclampsia.

24-Hour mother-infant discharge with a follow-up home health visit: Results in a selected medicaid population*

Objective To determine safety and cost-effectiveness of 24-hour discharge in selected mothers and newborns. Methods Women delivering at University Hospital (the University of Alabama at Birmingham) were screened to determine their eligibility for 24-hour discharge. Mothers were eligible if they had no medical problems and no history of substance abuse, had an uncomplicated vaginal delivery and postpartum course, were 12 or more hours after postpartum bilateral tubal ligation, and had reached 24 hours after delivery by 6:00 PM on the day of discharge. Newborns were eligible if they were term (37 weeks or greater), weighed 2500 g or greater, and had a normal examination at 24 hours of age. At 48 hours after delivery, each mother and infant pair was examined by a home health nurse. Telephone consultations with a staff physician were noted and outcomes were entered into a data base linked to hospital financial data. Results Of 5621 deliveries from October 1, 1993 to Sep-tember 30, 1995, 972 mothers (17%) and 856 (15%) newborns were discharged at 24 hours. One mother was lost to follow-up after discharge. Nine-hundred fifty-six of 971 mothers (98.5%) had a normal examination at the home visit. Fifteen of 971 mothers (1.5%) had problems that required obstetrician telephone consultation. Seven mothers (0.7%) required a physician visit; two of these women were read-mitted for treatment of an infection. Seven-hundred ninety-five of 856 (93%) newborns had a normal examination. Sixty-one newborns (7%) had problems that required pediatrician telephone consultation, primarily for jaundice, infant care questions, and a cardiac murmur. Twelve infants (1.4%) required a pediatric clinic visit. No infant was readmitted to the hospital. Net cost savings to our hospital for 24-hour discharge in these selected patients was

Prenatally diagnosed hypoplastic left heart syndrome—Outcomes after postnatal surgery

506,139 during a 2-year period. Conclusion In a selected, low-risk, low-income population, mother-infant discharge 24 hours after delivery with a home follow-up visit is safe and cost-effective.

Early postpartum discharge.

OBJECTIVE To identify prenatally diagnosed cases of hypoplastic left heart syndrome (HLHS) and then to determine postnatal outcomes after surgical interventions. METHODS An ultrasound and pediatric cardiology database was used to identify all fetuses diagnosed prenatally from 1991-1996 with HLHS. Fetal karyotypes were performed on cultured amniocytes. After diagnosis, parents were given several management options: pregnancy termination before 22 weeks, postnatal hospice care, or surgery using the Norwood procedure or cardiac transplantation. Ultrasound and echocardiography findings were later compared to karyotype results and postnatal outcome data. RESULTS Fifteen fetuses with HLHS were identified. Two (16%) chromosome abnormalities and three (20%) structural defects were detected. Three mothers (20%) opted for pregnancy termination, two (13%) chose postnatal hospice care, and one aneuploid fetus had an intrauterine death. Nine parents (60%) chose surgery for their infants; however, one infant was not an appropriate surgical candidate due to a coexisting diaphragmatic hernia. Eight infants underwent surgery and two survived (25%). Of the four infants scheduled to undergo the Norwood procedure, one died preoperatively, two died intraoperatively, and one infant survived and is doing well at age 8 months. Of the four infants scheduled for cardiac transplantation, two died awaiting transplant and one died postoperatively. One infant survived cardiac transplantation but has microcephaly and developmental delay at age two. CONCLUSIONS In prenatally diagnosed HLHS at our institution, the survival rate following surgery for infants felt to be the best candidates was only 25%.

A comparison between umbilical artery velocimetry and standard antepartum surveillance in hospitalized high-risk patients

In recent years, the widespread practice of early postpartum discharge has sparked a nationwide debate about the safety and cost effectiveness of shortened maternity stays. Patients, physicians, insurance companies, and legislators have all offered opinions on this subject. New state and federal

Significance of a False-Positive Trisomy 18 Multiple-Marker Screening Test

One hundred forty-six women admitted to the high-risk obstetric unit between November 1987 and December 1988 participated in a study designed to compare Doppler umbilical artery flow studies with standard antepartum testing in the prediction of adverse fetal outcome. A Doppler ultrasound examination was considered abnormal when the average systolic/diastolic ratio was greater than or equal to 4. The antepartum testing consisted of a combined use of nonstress testing and contraction stress testing. If both the Doppler systolic/diastolic ratio and the antepartum testing were abnormal, there was a significantly increased incidence of intrauterine growth retardation (47%), fetal distress necessitating cesarean section (67%), and admission to neonatal intensive care (86%). Doppler umbilical artery flow studies are an important adjunct to antepartum fetal surveillance in high-risk patients but should not determine clinical management when standard antepartum surveillance remains normal.

Amniotic fluid α-fetorotein levels and pregnancy outcome

Objective To determine if a false-positive trisomy 18 multiple-marker screening test (all three analytes low: maternal serum alpha-fetoprotein [AFP] at most 0.75 multiples of the median [MoM], unconjugated estriol at most 0.60 MoM, and hCG at most 0.55 MoM) indicates increased risk for obstetric complications or is related to maternal weight. Methods We accessed our genetic database to obtain multiple-marker screening test results, fetal karyotypes, and pregnancy outcomes from all patients wit a normal multiple-marker screening test (n = 3900) and from all patients with a positive trisomy 18 screening test (n = 103) seen in the prenatal diagnosis clinic from 1992 to 1996. During this period, only maternal serum AFP was adjusted for maternal weight. Results A positive trisomy 18 screen identified five of 12 trisomy 18 fetuses. Women with a false-positive trisomy 18 screen were heavier (175.6 ± 43.8 Ib versus 159.9 ± 37.9 Ib, P < .001) and younger (29.7 ± 6.5 years versus 32.3 ± 6.5 years, P < .001) than women with a normal multiple-marker screening test, but were not at increased risk for pregnancy complication. Weight-adjusting all three analytes reduced the false-positive trisomy 18 screen rate by 42% (from 1.9% to 1.1%) but did not change the trisomy 18 detection rate. Conclusion A false-positive trisomy 18 screening test does not indicate increased risk to develop pregnancy complications and may be related to inadequate correction for increased maternal weight.