John M. O'Brien

The impact of initiating a human immunodeficiency virus screening program in an urban obstetric population

OBJECTIVE Our purpose was to describe the incidence of human immunodeficiency virus infection and to assess the cost/benefit ratio of universal antenatal human immunodeficiency virus screening. STUDY DESIGN Medical records of women in this urban obstetrics population, from the years 1988 to 1993, were examined. The incidence of known human immunodeficiency virus seropositivity at delivery was determined. The costs of performing human immunodeficiency virus screening, evaluating the disease status, and administering therapy were calculated. These costs were compared with an averaged cost for care and follow-up of infants infected through vertical transmission. RESULTS The incidence of known human immunodeficiency virus seropositivity at delivery approximately doubled since the initiation of a human immunodeficiency virus screening program (0.26% to 0.48%). Obstetric screening added an approximate

Daily antenatal testing in women with severe preeclampsia

100,000 to medical costs. The calculated cost of pediatric follow-up of human immunodeficiency virus-seropositive infants for the first 18 months was estimated at

Early versus late amniotomy for labor induction: A randomized trial

344,355. In our population, with universal screening and zidovudine therapy, the medical costs could be reduced by

The use of a modified vaginal pouch for the diagnosis and management of premature rupture of the membranes

175,500 per year. CONCLUSION A program of voluntary human immunodeficiency virus screening increases the incidence of known human immunodeficiency virus infection. Offering screening and follow-up to all pregnant patients in an urban setting is both cost-effective and medically beneficial.

Vaginal Delivery of a Second, Nonvertex Twin by High Vacuum After Failed Breech Extraction and Successful External Version

OBJECTIVE Our purpose was to determine whether daily antenatal testing in the expectant management of severe preeclampsia remote from term prevents stillbirth or neonatal compromise at birth. STUDY DESIGN We reviewed the medical records of 68 women with severe preeclampsia remote from term who underwent expectant management with daily fetal testing until delivery. On admission each patient had reassuring nonstress testing (absence of persistent severe variable or late decelerations), biophysical profile (> or = 6), and amniotic fluid volume (> or = 2 cm maximal vertical pocket before 32 weeks or amniotic fluid index > or = 5 after 32 weeks). RESULTS There were no stillbirths. Twenty-one patients (31%) had nonreassuring testing necessitating delivery. Two neonatal deaths occurred as a result of complications of prematurity. There were no statistical differences in the cord arterial pH (p = 0.93) or in the 1- and 5-minute Apgar scores (p = 0.18 and p = 0.88, respectively) between those with normal and abnormal antenatal testing. CONCLUSIONS Because optimizing neonatal outcome is the only reason to prolong pregnancy in women with severe preeclampsia, confirmation of fetal well-being is mandatory. Because neither stillbirths nor fetal compromise at birth occurred in patients undergoing daily antenatal testing, we recommend daily testing in patients with severe preeclampsia managed expectantly.

Efficacy of outpatient induction with low-dose intravaginal prostaglandin E2 : a randomized, double-blind, placebo-controlled trial

OBJECTIVE Our purpose was to determine the impact of early and late amniotomy on labor induction with continuous oxytocin infusion at term. STUDY DESIGN A total of 209 women admitted for labor induction were randomized to early or late amniotomy. The early amniotomy group (n = 106) had membranes ruptured as soon as it was deemed safe and feasible. The late amniotomy group (n = 103) had membrane rupture performed at > or = 5 cm dilatation. The first 103 women received a continuous oxytocin infusion with incremental adjustments at 60-minute intervals as required. The next 106 women had adjustments every 30 minutes as required. Statistical analysis was confined to concurrent groups. RESULTS Early amniotomy was associated with shorter labor (13.3 vs 17.8 hours, p = 0.001), chorioamnionitis (22.6% vs 6.8%, p = 0.002), and significant fetal umbilical cord compression (12.3% vs 2.9%, p = 0.017). The benefit regarding shortening of labor was limited to women having oxytocin increments every 30 minutes as required (13.3 vs 17.8 hours, p = 0.001). Alternatively, the increase in chorioamnionitis was confined to the 60-minute group (39% vs 11%, p < 0.001), which also demonstrated a trend toward increased moderate and severe variable decelerations (19.6% vs 6.4%, p = 0.08). CONCLUSIONS When a protocol of 60-minute increments in oxytocin infusion rate is desired, amniotomy should be performed late in labor to reduce chorioamnionitis and significant umbilical cord compression. Alternatively, if early amniotomy is necessary, oxytocin should be adjusted every 30 minutes as tolerated.

Cervicovaginal prolactin: A marker for spontaneous preterm delivery

A modified Reality vaginal pouch (Wisconsin Pharmacal, Jackson, Wis.) was effective in assessing membrane integrity in patients evaluated for suspected premature rupture of the membranes and was useful for collecting fluid in patients requiring pulmonary maturity studies. This technique does not alter the incidence of infection and is beneficial in the management of selected patients.

Amniotic fluid index in hospitalized hypertensive patients managed expectantly

Several options exist to effect vaginal delivery of a second, nonvertex twin. In the case presented, breech extraction and external version with subsequent labor were both inadequate to achieve timely delivery before the onset of fetal distress. A case of vacuum extraction of an unengaged second twin converted to vertex is described and discussed.