Gail V. Anderson

The aggressive management of ruptured membranes

Abstract Experience with a program of active management of ruptured membranes during the last month of pregnancy has been assayed as it relates to amnionitis, maternal mortality, perinatal mortality, and cesarean section. It is felt that there are distinct benefits from such a program to the patient population of this study.

Value of estriol estimations in the management of diabetic pregnancy

Abstract Urinary estriol levels were obtained from 31 normal pregnant women and from 186 women attending the prenatal/diabetic clinic. The latter included 137 Class A (studied in three groups according to the degree of carbohydrate intolerance present), 32 Class B, 7 Class C, and 10 Class D patients. The results were not used to influence the clinical management. Mean values for the entire abnormal group were calculated weekly from 28 weeks until term. These values were used as the basis for comparison of the different classes studied. Only Classes C and D demonstrated depressed levels of excretion. Sixteen perinatal deaths occurred and 9 were considered avoidable had the estriol results been taken into consideration. The “estriol-preventable deaths” are described in detail. It is concluded that the assay presents a potentially valuable adjunct to the clinical management of the pregnant patient with disordered carbohydrate metabolism.

Cephalometry with ultrasound

OBSTETRICIANS have sought accurate knowledge of antepartum fetal size for many years. When elective termination of pregnancy is indicated, it is important to be certain that the fetus is of sufficient maturation to survive in the outside environment. X-ray measurement of the capacity of the maternal pelvis has proved to be an accurate technique. However, no technique heretofore used has enabled physicians to determine with acceptable accuracy the size of the fetus prior to delivery. Within recent years, investigators who used ultrasonic equipment have been able to determine fetal head size, as indicated by the biparietal diameter, with accuracy.1-4 Even though this does not enable the determination of the exact fetal weight, it is quite obvious that there is a relationship between fetal head size and fetal maturation.

Fetal maturation and amniotic fluid

Abstract Amniotic fluid creatinine, bilirubin, and cells as well as serum creatinine have been measured in an attempt to corroborate reported investigations which correlate these values with fetal maturation. An amniotic fluid creatinine value of 2 mg. per 100 ml. or more usually indicates a gestational age of at least 37 weeks. Absence of a bilirubin peak at 450 mμ, the presence of 20 per cent of cells which stain orange with Nile blue sulfate dye, or the presence of a ratio between amnotic fluid creatinine and serum creatinine of 3 or more usually indicates a gestational age of 36 weeks or more. Because a high percentage of these tests are negative beyond 36 to 37 weeks, no single value or combination of values provides absolute evidence of fetal maturation.

The abnormal fetal electrocardiogram

Abstract 1. Nine cases are drawn from records of this laboratory which show that fetal electrocardiogram abnormalities were seen in a variety of instances associated with difficulty for the fetus. 2. The abnormal characteristics of the fetal ECG included wide or unusual wave-forms for the fetal QRS, ST segment depression or elevation, notching of the QRS, beat-to-beat alterations in the amplitude or rhythm of fetal cardiac bioelectric signals. 3. It is believed that wide use of fetal electrocardiographic technique needs to be made in early and late pregnancy, so as to lay the basis for adequate assessment of the fetal electrocardiogram in a given case, in labor. 4. Suggestions are made for a new approach to the grading of intrauterine difficulty for the fetus.

The effect of early versus late cord clamping on signs of respiratory distress

Abstract Of the 424 vaginally delivered infants in our study, 222 were in the early clamp group and 202 in the late clamp group. Thirty infants in the early group and 15 in the late group were low birth weight infants. There was no significant difference in the frequency or severity of respiratory distress between the two groups, in either the term or premature infants. We were unable to demonstrate that the time of the first breath in relation to cord clamping was related to the frequency or severity of respiratory distress.

Adrenal-pituitary responsiveness during therapy with an oral contraceptive.

The effect of the oral contraceptive Norinyl (1 or 2 mg norethindrone 100 mcg mestranol) on the hypothalamic-pituitary-adrenal response to Piromen (Pseudomonas polysaccharide complex) methopyrapone and exogenous ACTH was investigated in 8 subjects. Norinyl use significantly (p less than .001) lowered both urinary excretion of 17-ketogenic steroids (KGS) and 17-ketosteroids. The response to methopyrapone was markedly impaired during Norinyl treatment though the hypophyseal-adrenal response to Piromen was normal. The results indicate that Norinyl and presumably other progestational agents do not affect the pituitary-adrenal response to stress even though the response to methopyrapone was impaired.

Carbohydrate metabolism in pregnancy: A study of 658 patients with the use of the oral glucose tolerance test and the prednisolone glucose tolerance test☆

Abstract Six hundred and fifty-eight pregnant women selected consecutively were evaluated by means of an oral glucose tolerance test (GTT) and an oral prednisolone glucose tolerance test (PGTT). The patients were divided into three groups: (1) control, (2) family history of diabetes (FHD), and (3) obstetric prediabetes (OPD). The findings were as follows: the incidence of overt diabetes in the total group was 2.7 per cent; the incidence of abnormal GTT with a normal fasting blood sugar was 10.9 per cent; the incidence of a positive PGTT in patients with normal GTT was 19.7 per cent. It is suggested that a 2 hour postprandial blood sugar be included in the routine examination in pregnancy. If an abnormal value is detected, a complete GTT is indicated. Patients with FHD or OPD should have 2 hour postprandial sugar determinations monthly during the last trimester, since normal carbohydrate metabolism early in pregnancy does not preclude the deterioration of glucose tolerance later in pregnancy. The significance of a positive PGTT in pregnancy needs further evaluation.

Prospective vs Retrospective Data for Evaluating Emergency Care: A Research Methodology

Emergency department records and patient charts do not provide enough or sufficiently detailed data for audit of quality of care in a high volume emergency department. As a solution, at the Department of Emergency Medicine, University of Southern California School of Medicine, three emergency medical technicians--hospital-based paramedics--were trained as observers of patient process and treatment. In addition to basic identification information, the form completed by observers listed 21 procedural steps and process data such as sequence, time for completion, type of personnel performing, necessary equipment and supplies, and space for comments. Direct observation of patient process was carried out in 442 patients, a total of 3,882 procedures was observed and recorded. The direct observation is perhaps the most accurate method of data collection for auditing purposes because it reflects actual events. This data was used by the Research Peer Review Committee to help rate the quality of patient treatment process.

A unique approach to evaluation of emergency care

A quality care evaluation system was designed to serve as a framework for on-going research in the area of quality assurance in emergency medicine. It included a set of basic evaluation tools, such as direct observation of patient care, record review and analysis, and patient follow-up interview for outcome. These tools are used in an attempt to quantify relationships between quality care and patient outcome.