John S. Sholl

Abruptio placentae: Clinical management in nonacute cases

One hundred thirty cases of clinically diagnosed abruptio placentae encompassing the wide range of acuity were grouped by gestational age at delivery into previable, preterm, and term divisions for comparison of demographic data, presenting symptoms, delay to delivery, mode of delivery, and delivery indications. Attention was focused on the preterm group of patients to assess the implications of presenting symptoms, the usefulness of ultrasonography, and the safety and efficacy of tocolysis. Cigarette smoking and a previous poor obstetric history were found to be more frequent in the preterm compared to the term abruptio placentae. Ultrasonic visualization of a clot was successful in 25% of the preterm patients but otherwise appeared to have little or no impact on course or management. Tocolysis for the preterm patients appeared to be beneficial in prolonging gestation and did not increase the likelihood of cesarean delivery, hemorrhage, or fetal distress. The cumulative rates of delivery following admission were compared with and without tocolysis, with and without sonographic visualization of a clot, and overall as a function of gestational age at initial hospitalization. Perinatal mortality was 17%. Inpatient management with frequent fetal heart rate monitoring, tocolysis if indicated, and timely use of cesarean delivery are advocated to promote prolongation of the pregnancy and minimized perinatal mortality.

Enhanced sensitization after cordocentesis in a rhesus-isoimmunized pregnancy

It has been suggested that the optical density at 450 nm may be an unreliable predictor of the severity of fetal anemia in the midtrimester of pregnancy; therefore fetal blood sampling, rather than amniotic fluid evaluation, should be performed in all isoimmunized pregnancies with elevated maternal antibody titers in the midtrimester. Potential complications of such an approach are discussed and an alternative plan of management is offered.

Prediction of hematocrit decline after intravascular fetal transfusion.

Fetal blood sampling and intravascular transfusion via cordocentesis allow more precise fetal evaluation and treatment in isoimmunized pregnancies. However, the timing of repeat transfusion has remained empiric. In this report we review our experience with fetal transfusions in isoimmunized pregnancies to evaluate the ability to predict fetal hematocrit decline and thereby determine the optimum timing for repeat transfusions. Between March 1986 and March 1988, 60 intravascular fetal transfusions were performed in 20 patients. Fetal transfusions were excluded from analysis if blood samples were unable to be obtained before and after transfusion, as well as at the beginning of the next transfusion or birth. Fifty-three procedures were analyzed. Two equations were used to predict the fetal hematocrit at the subsequent transfusion. The difference between observed and predicted hematocrits at the beginning of a subsequent transfusion or birth was -0.9% +/- 5.8% with equation 2, which was the more accurate formula in the majority of fetuses. Prediction of fetal hematocrit decline may be used to determine the optimum timing of repeat transfusion.

Cost savings and perinatal outcome associated with outpatient management of triplet pregnancy

OBJECTIVE Our goal was to compare the lengths of hospitalization and the perinatal outcomes of triplet pregnancies managed with either outpatient or inpatient third-trimester bed rest. STUDY DESIGN Thirty-two triplet pregnancies in which outpatient bed rest was prescribed (April 1993 to April 1996) were compared with a historic cohort of 34 triplets (January 1985 to March 1993) in which routine hospitalization was undertaken in the third trimester. Length of hospitalization and maternal and neonatal outcome parameters were compared between groups. RESULTS Maternal inpatient hospital days were significantly reduced for the group managed as outpatients, but combined maternal and neonatal hospitalization was similar between groups. The mean gestational age at delivery was 1 week greater in the hospitalized cohort (33.5+/-2.8 vs 32.5+/-2.8, respectively; p=0.16), and average birth weight was correspondingly greater in hospitalized cases (1942 gm vs 1718 gm, p < 0.005). Neonatal lengths of stay were similar between groups, reflecting earlier postnatal discharge in the outpatient era of this study. Preeclampsia occurred with greater frequency in the outpatient group (31.3% vs 8.8%, p=0.02), and the neonatal complication of intraventricular hemorrhage occurred more commonly in this cohort as well (10/96 vs 1/102, p=0.004). All other maternal and neonatal complications were similar between groups. CONCLUSION Reduction in the length of hospitalization attributable to outpatient management was limited to the maternal length of stay. It is possible that the observed maternal and neonatal complications in the outpatient group may have been related to less rigorous bed rest. We would suggest that the differences noted in preeclampsia, birth weight, and intraventricular hemorrhage support prospective evaluation of bed rest in triplet pregnancy.

Prediction of hematocrit decline after intravascular fetal transfusion

of normal fetuses (p < 0.01). The increase in deceleration time across both atrioventricular valves in normal fetuses may be related to heart rate, an increased rate of ventricular relaxation, or an increase in ventricular compliance. The fetuses with intrauterine growth retardation and the absence of end-diastolic velocities in the umbilical artery have abnormally increased deceleration times; in the abnormal fetus this may be a result of impaired ventricular relaxation or decreased ventricular compliance.