James Balducci

Relationship between fetal biophysical activities and umbilical cord blood gas values

In a prospective study of 62 patients undergoing cesarean section before the onset of labor a fetal biophysical profile assessment was performed within 3 hours before the cesarean section. The presence or absence of the individual fetal biophysical activities (fetal heart rate reactivity, fetal breathing movements, fetal body movements, and fetal tone) were correlated with umbilical cord blood gas and acid-base measurements (artery and vein). Fetuses with nonreactive nonstress test results or the absence of breathing had significantly lower cord artery pH, PO2 bicarbonate, and base excess measurements but not a significantly different PCO2 level as compared with fetuses that had these activities present. Fetuses with the absence of movements or tone had lower pH, PO2 bicarbonate, and base excess levels and higher PCO2 levels as compared with fetuses with the presence of movements or tone, respectively. These blood gas and acid-base differences were observed in both umbilical cord artery and vein. Subsequent analysis of the blood gas and acid-base measurements of the fetuses with compromised biophysical activities revealed that there are different levels of acidemia, hypoxemia, and hypercapnia at which the individual biophysical activities are compromised. These data suggest that the first manifestations of fetal hypoxemia and acidemia are nonreactive nonstress test results and loss of fetal breathing; in advanced acidemia, hypoxemia, and hypercapnia fetal movements and fetal tone are compromised.

Gap junction formation in human myometrium : a key to preterm labor ?

OBJECTIVE The purpose of this study was to determine if gap junctions are a necessary component of the human laboring uterus and if their presence in myometrium is a prerequisite for both term and preterm labor. STUDY DESIGN We obtained 27 human myometrial samples at cesarean section or nongravid hysterectomy. Gap junction formation was analyzed in a blind fashion by freeze fracture and indirect immunofluorescence. Six samples were obtained from term patients with no labor, six from term patients in labor, six from preterm patients with no labor, six from patients in preterm labor, and three from nongravid hysterectomy specimens. RESULTS Gap junction structures were identified in the human myometrium of patients in term and in preterm labor but not in the other patient samples. In addition, evidence was obtained for the expression of (alpha 1) gap junction ribonucleic acid and (alpha 1) gap junction protein in term samples of human myometrium. CONCLUSION Gap junctions are a necessary component of the human myometrium during term and preterm labor. The formation of gap junctions may be a final common event for the development of labor, and inhibition of gap junction activity could be a novel approach for the treatment of preterm labor.

Fetal Seizures: a Case Study.

Background A review of the literature and an extensive Medline search revealed that this is the first case report of fetal seizures diagnosed by ultrasound. Case A 23-year-old woman was found to have a fetus with bilateral choroid plexus cysts during a second-trimester ultrasound examination. Karyotype and alpha-fetoprotein level were normal. The cysts resolved, but idiopathic polyhydramnios was noted. Fetal testing beginning at 32 weeks revealed abnormal fetal behavior patterns on ultrasound and documented fetal seizures with rapid, repetitive limb movements noted on several occasions and lasting 30-60 seconds. Similar movements continued after birth as tonicclonic seizure activity. Conclusion Qualitative changes in movement patterns are common in neurologically impaired fetuses. Ultrasound may be used to diagnose these neurologic abnormalities that can be connected with clinical outcomes. This will better prepare the parents and hospital staff members for delivery and may also decrease medicolegal risk for the obstetrician because the abnormal behavior predates the birth process.

Does Centralized Monitoring Affect Perinatal Outcome

A retrospective study was performed comparing centralized monitoring to noncentralized monitoring in regard to perinatal outcome. The study was conducted at Lehigh Valley Hospital (Allentown, PA) between August 1994 and February 1995. All deliveries during a 28-week-period were studied retrospectively. The study was designed such that for 14 weeks all patients were centrally monitored (Group A). During the following 14 weeks, no patients were centrally monitored (Group B). Patients not requiring monitoring, such as elective cesarean sections, were excluded from the study. The variables that were studied were the 5-minute Apgar, cord blood pH, perinatal mortality, admissions to the neonatal intensive care unit (NICU), spontaneous vaginal deliveries, cesarean sections, and operative vaginal deliveries. A total of 1,622 deliveries occurred during the 28 weeks of antenatal care. Group A consisted of 805 centralized monitored patients and Group B had 817 noncentralized monitored patients. There was no statistical difference in the 5-minute Apgar, umbilical artery pH, perinatal mortality, or the NICU admissions between the two groups. However, there was a significant statistical difference in the percent of cesarean sections performed for nonreassuring fetal heart rate tracings (Group A, 17.89% vs. Group B, 12.16%; P = 0.02). The overall cesarean section rate was increased in the centrally monitored group (Group A, 23.6% vs. Group B, 18.1%; P = 0.01). There were also statistically significant differences in operative vaginal deliveries (forceps and vacuum) for fetal heart rate abnormalities between Group A, 0.52% vs. Group B, .39% (P = 0.05). Centralized monitoring may be associated with an increase in the overall cesarean section rate. In addition, the rate of operative vaginal and abdominal deliveries appears to be increased for the indication of nonreassuring fetal heart rate tracings with the use of centralized monitoring.

Risk factors for preterm delivery in patients demonstrating sonographic evidence of premature dilation of the internal os, prolapse of the membranes in the endocervical canal and shortening of the distal cervical segment by second trimester ultrasound

To investigate the outcomes and risk factors associated with the second trimester sonographic findings of premature dilation of the internal cervical os, prolapse of the membranes into the endocervical canal and shortening of the distal segment.

Correlation of Uterine Fundal Height with Ultrasonic Measurements in Twin Gestations

Owing to the lack of fundal height (FH) nomograms for normal twin gestations, it has been a standard recommendation to use frequent ultrasound examinations in order to diagnose discordant fetal growth. The validity of such a practice, however, has not been established. The purpose of this study was to establish a nomogram for FH measurements in normal twin gestations and to evaluate it as a means of detecting discordant growth in twins.This is a prospective cross-sectional study of 160 twin pregnancies between 16 and 36 weeks presenting for an ultrasound. FH measurements were obtained by both the Division of Maternal-Fetal Medicine attending physician and fellow. Maternal age, gravidity, parity, height and weight, gestational age (GA), fetal presentation, placentation, amniotic fluid volume, estimated fetal weight, and percent discordance were also recorded. A nomogram for FH in normal twin gestations (n = 143) was developed and it was used to see if FH can detect discordant growth in twins (n = 17).The 1...

Preeclampsia: Immunologic Alteration of Nitabuch's Membrane? Clinical Sequelae

OBJECTIVE To determine if preeclampsia is an immunologic disease process consistent with a host-vs.-graft reaction by examining differences in immunoglobulin deposition at the maternal fetal interface (Nitabuchs layer) in preeclamptic patients. STUDY DESIGN A prospective study of patients at Lehigh Valley Hospital was conducted between July 1993 and April 1994. Group 1 (study) consisted of 11 primigravid women meeting the criteria for the diagnosis of preeclampsia. Group 2 (control) consisted of 11 primigravid women who had an uncomplicated pregnancy. At delivery, basal plate placental specimens were obtained, fixed, and processed for study by a blinded observer utilizing IgG, IgA, IgM, IgE immunofluorescence techniques. The placenta was then sent to a gynecologic pathologist for blinded evaluation and measurement of Nitabuchs membrane by light microscopy. RESULTS Taking the average width of 3 measurements of Nitabuchs membrane by light microscopy revealed no significant difference (group 1, .1839 mm vs. group 2, .1555 mm). Immunofluorescence techniques revealed that the thickness of immunofluorescence of Nitabuchs membrane was significantly greater in the study group vs. the control group (157.48 pixels vs. 63.80 pixels, P = .006, respectively). CONCLUSION Evaluation of the maternal-fetal interface reveals the deposition of increased immunoglobulins, the physiology of which may be similar to nephropathies as seen in systemic disease processes. The deposition of immunoglobulins may be associated with a common antigen which may point to an immunologic etiology for preeclampsia in some women.

Obstetrical Factors Associated with Nuchal Cord in a High-Risk Population

The obstetrical factors associated with nuchal cord at birth were retrospectively studied in 520 high-risk patients with gestational ages ranging from 24 to 42 weeks. The overall frequency of nuchal cord at birth was 16.7% (87 of 520). The frequencies of nuchal cord in preterm and term gestations were 14.7 and 22%, respectively. Factors associated with increased incidence of nuchal cord at birth were vertex presentation, vaginal birth, and term gestation. When the data were analyzed according to route of delivery and gestational age, it was found that the group of neonates born vaginally at term had the highest incidence of nuchal cord (17 of 51 or 33.3%, P <. 05) as compared to infants born at term by cesarean section (14 of 90 or 15.5%), preterm born vaginally (24 of 140 or 17.1%), and preterm born by cesarean section (32 of 239 or 13.3%). These data suggest that vaginal birth at term is the most significant factor associated with increased frequency of nuchal cord. Although a lower mean cord artery pH ...