Jeffrey M. Barrett

Pregnancy-related Rupture of Arterial Aneurysms

Over 50 per cent of ruptured arterial aneurysms in women under the age of 40 are pregnancy-related. The hemodynamic and endocrine changes of pregnancy appear to be the cause of arterial alterations which may lead to new aneurysm formation and/or weakening of preexisting aneurysms. The most commonly reported arteries to have aneurysms rupture during pregnancy are the aorta, cerebral arteries, splenic artery, renal artery, coronary artery, and ovarian artery. In many instances, the rupture of an arterial aneurysm will initially simulate other less serious disease processes, thus delaying the correct diagnosis until a catastrophic event occurs. Early diagnosis and treatment of a ruptured arterial aneurysm are imperative in order to give optimal chances of survival to the mother and fetus.

The effect of type of delivery upon neonatal outcome in premature twins

A retrospective study from January 1, 1976, through July 31, 1981, was performed to evaluate the relationship between type of delivery and perinatal morbidity and mortality in twins of birth weight less than 2,000 gm. Vaginally delivered second twins who weighed 601 to 999 gm had increased risk of neonatal mortality when compared to their siblings. Among twins who weighed 1,000 to 1,499 gm, vaginally delivered second twins had significantly lower Apgar score and increased risks of neonatal morbidity in comparison to their siblings, whereas second twins who were delivered by cesarean section had no difference in Apgar score or neonatal morbidity from those of their siblings. In twins who weighed 1,500 to 1,999 gm, a significant increase in neonatal complications in vaginally delivered second twins was not found, although the majority of neonatal complications did occur in vaginally delivered second twins. Cesarean section is proposed as the optimal route of delivery for all twins expected to have a birth weight less than 1,500 gm.

Induced abortion: A risk factor for placenta previa

A threefold increase in the incidence of placenta previa, from one in 318 deliveries (0.3%) in 1972-1974 to one in 109 deliveries (0.9%) in the twelve-month period ending June 30, 1980, was noted at Vanderbilt University Hospital. Two large groups of patients not present in 1972-1974 were found to be responsible for this increased incidence of placenta previa: one-way maternal transports and women who had had induced first trimester abortions. The frequency of maternal transports having placenta previa was 3.3% (p less than 0.0001), and the frequency of placenta previa in women after an induced first trimester abortion was 3.8% (p less than 0.0001). When correction for maternal transports was made, the endogenous induced first trimester abortion population had a frequency of placenta previa of 2.1% (p less than 0.004), whereas the remainder of the endogenous population had an incidence of placenta previa similar to that found in the years 1972-1974. Induced first trimester abortion is seen as a significant factor predisposing to placenta previa.

The nonstress test: An evaluation of 1,000 patients

In November, 1978, the fetal heart rate nonstress test (NST) was instituted as the primary screening procedure for the evaluation of fetal well-being at Vanderbilt University Hospital. The results of the first 1,000 patients tested are presented. The stillborn rate within 8 days of a reactive NST was 6.4 per 1,000, with the stillbiths occurring either in patients with diabetes mellitus or with intrauterine growth retardation (IUGR). A review of other series in which both the total indications for nonstressed testing and the risk groups in which stillbirths occurred within 7 days of an NST reveals that patients with diabetes mellitus (p less than 0.025) and patients with IUGR (p less than 0.01) are at greater risk for stillbirth within 7 days of an NST. Weekly nonstress testing, effective in preventing stillbirths in most risk groups, is not adequate in patients with diabetes mellitus or IUGR.

Continuous or interrupted fascial closure: A prospective evaluation of No. 1 Maxon suture in 402 gynecologic procedures*

During a 14-month period of using a long-term absorbable suture (No. 1 Maxon), 402 patients were entered into a prospective, randomized trial of fascial closure. Patients were randomized between a continuous closure (201 patients) and an interrupted en bloc (201 patients) technique. Each patient was subjected to a preoperative and intraoperative protocol for wound management. There were no acute wound failures. Wound infection rates and risk of hernia were not apparently affected by closure technique.

The efficacy and safety of the cytobrush during pregnancy

The safety and efficacy of abrasive cytology, using the cytobrush, were evaluated in 300 pregnant patients. When compared to conventional cytology obtained with a cotton-tipped applicator there was no difference in adverse pregnancy events. Smear adequacy (containing endocervical cells) was statistically (P less than 0.01) and clinically increased from 21 to 86%. The use of abrasive cervical cytology was associated with a twofold increase in the incidence of abnormal smears.

Single-dose antibiotic prophylaxis for patients undergoing extended pelvic surgery for gynecologic malignancy

The comparative efficacy of single-dose antibiotic prophylaxis was retrospectively evaluated in 116 patients undergoing extended pelvic surgical procedures with curative intent. During the 24-month period, other important variables such as surgeons experience, duration of preoperative hospitalization, preoperative preparation, method of hair removal, suture type, suture size, use of drains, use of cautery, and abdominal closure were controlled. The overall surgical site infection rate was 4.3% after radical hysterectomy with lymphadenectomy and 4.5% after total hysterectomy with lymphadenectomy. In this clinical situation the use of a single dose of antibiotic prophylaxis theoretically decreases cost and patient exposure and appears to be as efficacious as a multiple-dose regimen.

Funic reduction for the management of umbilical cord prolapse

The current management of umbilical cord prolapse centers on attempts to alleviate the pressure of the presenting part on the cord while preparation for cesarean section is being made. A 10-year experience in which there were vigorous attempts to accomplish safe vaginal delivery after the diagnosis of umbilical cord prolapse is presented. Eight cases of umbilical cord prolapse occurred, a frequency of 1 in 277 deliveries (0.37%), all of which had a normal immediate neonatal outcome. Vaginal delivery was accomplished in seven patients (87.5%); diagnosis was made in two of them when delivery was imminent. Five patients were more remote from delivery and had successful funic reduction (manual replacement of the prolapsed cord). Funic reduction is proposed as a potentially beneficial initial step in the management of umbilical cord prolapse.

Single-center study results of cefotetan and cefoxitin prophylaxis for abdominal or vaginal hysterectomy.

A prospective randomized study of 90 patients undergoing hysterectomy who received a single 1 gm dose of cefotetan and multiple 2 gm doses of cefoxitin was completed. An overall infection rate of 1.2% was recorded. Bacteriologic and clinical success rates were not different between antibiotics.

Comparison of aggressive and conservative management of premature rupture of fetal membranes.

A 3-year prospective study was undertaken to compare two types of management of rupture of the fetal membranes between 26 and 34 weeks. Patients in whom amniotic fluid, obtained by amniocentesis, was shown to have no evidence of infection, and who had less than mature lecithin/sphingomyelin (L/S) ratios, were given steroids and, if needed, treated with tocolytic agents. Patients in whom no amniotic fluid could be obtained were not given steroids, but were managed expectantly. Only patients with rupture of membranes greater than or equal to 24 hours were included in the collection of data. Despite the aggressive treatment protocol of the steroid group, no significant difference was found between the two groups in the prevalence of respiratory distress, hyperbilirubinemia, patent ductus arteriosus, episodes of apnea and bradycardia, or necrotizing enterocolitis. Perinatal mortality rates were similar in the two groups, and no difference in the incidence of maternal or neonatal infectious complications was found.