John F. Huddleston

Fatal meconium aspiration syndrome occurring despite airway management considered appropriate

A combined obstetric-pediatric approach to tracheal toilet is said to prevent serious cases of the potentially fatal meconium aspiration syndrome. After delivery of the head a DeLee trap is used to suction the oropharynx and nasopharynx. Immediately following delivery, endotracheal suction is performed in an effort to remove any remaining meconium-stained amniotic fluid. Although routinely using this approach, we continue to have occasional cases of fatal meconium aspiration syndrome. Therefore, we reviewed the outcome of infants born through meconium-stained fluid. During a 5-year period, 1420 (15%) of 9299 live-born infants had meconium-stained fluid. Thirty (2.1%) of these 1420 developed meconium aspiration syndrome and 12 (40%) died; eight received a postmortem examination. Four had unequivocal evidence of meconium aspiration, two had large numbers of intra-alveolar squamous cells, and two had no evidence of aspiration. We conclude that aggressive airway management during and immediately after delivery does not always prevent fatal meconium aspiration syndrome.

Vaginal delivery following previous cesarean birth

Because of the rising cesarean birth rate in the United States, renewed interest in vaginal delivery after prior abdominal operation has been evident. In a prospective collaborative study 789 patients were evaluated for inclusion into this investigation. Of the 717 subjects who entered the study 162 chose to attempt vaginal birth and 101 were successful. Desire for tubal sterilization and the lack of prior vaginal delivery were significant correlates of the group selecting repeat abdominal birth and of those who were unsuccessful when vaginal delivery was attempted. There were eight dehiscences and three uterine ruptures among the 717 patients and none was related to catastrophic outcome for the mother or neonate. Perinatal losses (12) were not related to uterine rupture or method of delivery. There were no significant differences in uterine disruption between patients selecting either route of delivery. Likewise ancillary factors such as a prior febrile puerperium (endometritis), number of prior cesarean births, low-vertical uterine incisions, recurrent operative indications, the use of epidural anesthesia, or oxytocin administration were not discriminating factors in whether women chose to attempt or were successful in completing vaginal delivery after prior abdominal birth. From our data vaginal birth after cesarean section appears to be safe if conducted in a carefully selected population that is closely monitored in a prospective manner.

Apgar scores and umbilical arterial pH in preterm newborn infants

One- and five-minute Apgar scores and umbilical cord arterial pH values were compared in preterm newborn infants of various gestational ages. The more premature the infant, the more likely the Apgar score was low in the presence of a pH greater than or equal to 7.25. Conversely, the closer to term, the more frequently an infant with a pH of less than 7.25 had an Apgar score of greater than or equal to 7. Therefore, in preterm infants, there is little congruity between the Apgar score and umbilical cord pH. Based on these findings, it is not appropriate to label preterm newborn infants as asphyxiated based on a low Apgar score.

Management of prolonged pregnancy: Results of a prospective randomized trial

Prolonged pregnancy was rigorously defined in 180 gravid women without other complications. Patients were randomly assigned to be serially followed, either by amniocenteses or by oxytocin challenge tests (OCTs). Induction of labor, based upon only (1) a finding of meconium in the amniocentesis group or (2) a positive test in the OCT group, was nearly three times more frequent in the amniocentesis group. The incidence of meconium, which overall was 22% initially and 44% at delivery, as well as the frequencies of obstetric and perinatal complications, were similar in both management groups. Although meconium was significantly associated with abnormal labor progression, intrapartum fetal distress, and low 1 and 5 minute Apgar scores, induction of labor after discovery of meconium, when compared to nonintervention, did not improve perinatal outcome. It is concluded that a search for meconium is of little value in the management of prolonged pregnancy.

A search for antigen-antibody complexes in pre-eclampsia: Further evidence against immunologic pathogenesis☆

Circulating immune (antigen-antibody) complexes have been proposed as possible important in the pathogenesis of pre-eclampsia. Thirty-four serum samples from pre-eclamptic women were examined for the presence of antigen-antibody complexes by the C1q binding and Raji cell assays. Slightly abnormal C1q binding occurred in two serum samples, while all Raji cell determinations were found to be in the normal range for a healthy, nonpregnant population. It is concluded that circulating immune complexes do not occur regularly in pre-eclampsia.

Vaginal breech delivery of selected infants weighing more than 2000 grams

This retrospective study analyzes 580 term and near-term singleton pregnancies complicated by breech presentation from 1976 through 1982. Vaginal delivery was achieved in 174 patients (30%), 135 of which were selectively allowed a trial of labor. Six infant deaths occurred (1%); all were neonatal deaths directly related to lethal congenital anomalies, for a corrected neonatal mortality rate of 0%. No significant difference was found in the incidence of low Apgar scores, traumatic birth injury, or requirement for neonatal resuscitation between those infants delivered by cesarean section and those delivered vaginally. Although no maternal deaths occurred, cesarean section was associated with a 38-fold increase in significant maternal morbidity. These data suggest that with careful patient selection and fetal monitoring, vaginal delivery of the term or near-term breech infant remains a real alternative to routine cesarean delivery of all breech infants. A selection and management protocol is proposed.

Decreased levels of amniotic fluid α-fetoprotein associated with Down syndrome

Abstract Low maternal serum α-fetoprotein levels have been associated with fetal aneuploidies. Amniotic fluid α-fetoprotein levels have been reported to be low with Down syndrome (trisomy 21) but not with other fetal trisomies. We compared the amniotic fluid α-fetoprotein levels from 25 cases of autosomal trisomy (18 of trisomy 21, four of trisomy 13, three of trisomy 18) diagnosed by midtrimester fetal cytogenetic studies with those from matched, cytogenetically normal pregnancies. With these normal pregnancies used as controls, statistical analyses were performed on the data for all the trisomic fetuses, on the data for trisomy 21 only, and on the data for trisomies 13 and 18 combined. Amniotic fluid α-fetoprotein levels were significantly lower in the 25 trisomic cases compared with controls, 0.77 ± 0.34 versus 1.03 ± 0.34 mg/dl (p 0.40). These findings suggest that the low maternal serum levels of α-fetoprotein reported in cases of Down syndrome may be related to reduced amniotic fluid concentrations. However, the reduced maternal serum α-fetoprotein levels reportedly associated with trisomies 13 and 18 do not seem to be explained by low amniotic fluid concentrations.

A county-wide obstetrical automated medical record system

ConclusionOur strategy has been to achieve inexpensive and reliable data entry/data output while utilizing the functionality of a complex set of medical data previously developed by us. The front-end processor approach has achieved a 260-to-1 reduction in input/output channel calls on the IBM 370 for the OBAR system. The speed of data entry has doubled from the earlier mode of data entry through TSO during Phase I of the project. The Eclipse system has achieved a nearly consistent 24-hour availability independent of the state of the IBM 370/158. The system has excellent response time, and it is capable of growth in multiple physical locations. The system has met its functional goals at a reasonable cost.

Continued utility of the contraction stress test

Unhappily, some pregnancies do not produce the results desired by parents or physicians. Indeed, early pregnancy loss or perinatal mortality may occur and be devastating to the parties involved. The possibility of maximizing perinatal outcomes has led to the concept of high-risk pregnancy. Prospective designation as high risk and special surveillance with selective intervention are considered beneficial. Pregnancies may be designated as high risk for many reasons, and the particular risk factor may determine the type of surveillance indicated. For example, the pregnant woman whose only identifiable risk factor is a previous pregnancy with early, asymptomatic cervical dilatation is at risk for preterm delivery. Appropriate surveillance might include intensive patient education and frequent clinical and ultrasound evaluations of the cervix. In other pregnancies, the high-risk designation is applied because of concern for the insidious development of uteroplacental insufficiency (UPI). UPI may be considered inadequacy, sometimes progressing to frank failure, of uteroplacental exchange. In pregnancies at risk for UPI, appropriate surveillance should be directed toward the detection of this inadequacy. UPI may result in fetal growth restriction, fetal demise, or intrapartum fetal distress. For the detection of UPI to be clinically useful, periodic fetal testing must, in a timely manner, alert the obstetrician, who may then take measures to prevent or at least minimize any adverse effects on the fetus. Currently, most fetal surveillance for UPI is with antepartum fetal heart rate (FHR) testing, using external fetal monitoring equipment, complemented by assessments made by ultrasound. The two types of FHR tests are the nonstress test (NST), described in another chapter, and the contraction stress test (CST), to which this chapter is devoted.

A rationale for omitting two-hour postprandial glucose determinations in gestational diabetes

OBJECTIVE In making decisions regarding initiation of insulin therapy in gestational diabetes, most maternal-fetal obstetricians rely more on elevated fasting glucose values than on elevated 2-hour postprandial levels. We sought to determine whether the latter test is necessary. STUDY DESIGN From the patients with gestational diabetes mellitus managed over a 17-month period at Grady Memorial Hospital, we retrospectively analyzed data to determine whether normal (< 105 mg/dl) fasting plasma glucose values predict elevated 2-hour postprandial values and whether the latter predict adverse outcome. RESULTS From 194 patients with gestational diabetes mellitus, 546 paired fasting and 2-hour postprandial glucose values were recorded. Fasting levels were normal in 467 (85%); in those, 2-hour levels were < 120 mg/dl in 83% and < 140 in fully 96%. In 131 women with all fasting plasma glucose values normal, the birth weights and the rates of cesarean delivery, shoulder dystocia, and macrosomia were similar, regardless of whether 2-hour postprandial glucose values were > or = 120. The actual cost of the 546 2-hour postprandial glucose tests was nearly