José A. Miranda

Amnioinfusion in term labor with low amniotic fluid due to rupture of membranes: a new indication.

OBJECTIVE The null hypothesis was that the use of intrapartum amnioinfusion to induce term labor because of premature rupture of membranes when labor was complicated by low amniotic fluid volume due to vaginal loss would not improve fetal heart rate patterns, decrease the incidence of operative delivery, or improve neonatal acid-base status. STUDY DESIGN 200 term pregnancies with low amniotic fluid due to vaginal loss were randomly chosen to receive intrapartum amnioinfusion or standard obstetric care without amnioinfusion. Fetal heart rate pattern, method of delivery and neonatal acid-base status were compared with Students t test, chi-squared analysis, Mann-Whitney U- or Fishers exact test. RESULTS When amnioinfusion was used, the fetuses had lower rates of variable (74 vs. 91%, P<0.01) or late (26 vs. 58%, P<0.001) decelerations. Spontaneous deliveries were more frequent (77 vs. 59%, P<0.01) and cesarean sections less frequent (3 vs. 10%, P<0.05). Mean umbilical arterial (7.24+/-0.07 vs. 7.21+/-0.08, P<0.01) and venous (7.31+/-0.06 vs. 7.28+/-0.08, P<0.01) pH were significantly higher in newborns with amnioinfusion, and babies in this group had lower rates of neonatal acidemia of arterial (22 vs. 36%, P<0.005) or venous (13 vs. 26%, P<0.005) origin. CONCLUSIONS Amnioinfusion improved fetal heart rate pattern, lowered the incidence of operative delivery, and improved neonatal acid-base status in term labor complicated by low amniotic fluid due to vaginal loss.

Transcervical intrapartum amnioinfusion for preterm premature rupture of the membranes

OBJECTIVES To investigate the effect of transcervical amnioinfusion on the management of labour and neonatal outcomes in preterm premature rupture of the membranes. STUDY DESIGN This clinical trial included 86 patients with premature rupture of the membranes between weeks 27 and 35 of gestation. Patients were randomly assigned to receive amnioinfusion via a two-way catheter or to the control group. Clinical management was otherwise the same in both groups. RESULTS Amnioinfusion decreased the frequency of variable decelerations in fetal heart rate (27.9% versus 53.5%, p<0.05) and the rate of obstetric interventions motivated by nonreassuring fetal status (13.6% versus 52.4%, p<0.05). At delivery, pH values were significantly higher in the treatment group than in the conventionally managed control group (median 7.29 versus 7.27). CONCLUSIONS Intrapartum transcervical amnioinfusion for preterm premature rupture of the membranes reduced the number of interventions needed because of nonreassuring fetal status, and improved neonatal gasometric values without increasing maternal or fetal morbidity.

Meconium-stained amniotic fluid in labor: a randomized trial of prophylactic amniofusion

OBJECTIVES To investigate the effect of amnioinfusion in women with meconium-stained amniotic fluid on the rate of cesarian sections and on neonatal morbidity. STUDY DESIGN A randomized controlled trial. A total of 206 women with meconium-stained amniotic fluid were assigned to receive amnioinfusion via two-way catheter or no amnioinfusion (control group). The catheter was inserted and other treatment was the same in both groups. RESULTS Amnioinfusion decreased the rate of cesarian sections for fetal distress (RR 0.23, 95% CI 0.07-0.79) and increased mean pH at birth (7.24+/-0.1 versus 7.21+/-0.1, P<0.05). It also decreased the frequency of variable fetal heart rate decelerations (RR 0.74, 95% CI 0.59-0.92), and of meconium below the vocal cords in neonates (RR 0.37, 95% CI 0.19-0.69). CONCLUSIONS Amnioinfusion improves the neonatal outcome and reduces the frequency of cesarian sections.

Posthysterectomy wound infection: A review

We reviewed the microorganisms isolated from gynecologic surgery wounds showing signs of infection, from January to December 1990. A total of 88 samples of abdominal wall exudates from as many patients who had undergone abdominal hysterectomy were studied. In 54 women (61.3%), cultures were positive and, in 26 specimens (48.1%), mixed aerobic-anaerobic flora were isolated. In 28 cases (51.9%), a single microorganism was isolated, the most frequent being Staphylococcus aureus, followed by Mycoplasma hominis and Escherichia coli. Mycoplasma hominis was unexpectedly frequent, appearing in five women with wall abscess and fever.

Nonpuerperal Breast Infection

Objective: We undertook a microbiological study of purulent specimens from women with symptomatic breast abscesses. Methods: Fifty-one purulent samples were collected in 2 periods (December 1991–April 1992 and January 1994–June 1994) from nonpuerperal breast abscesses in 44 patients attending our hospital. Results: One of the most frequently isolated microorganisms was Proteus mirabilis (9 patients, 20.4%), present as a pure culture in all but 1 specimen (isolated together with Peptostreptococcus spp.). Staphylococcus aureus was isolated in 10 specimens, 6 of which were post-tumorectomy abscesses. Polymicrobial anaerobic flora were isolated in 11 specimens (21.5%); Staphylococcus epidermidis in 4 (8%); and Streptococcus milleri, Alcaligenes sp., and mixed aerobic-anaerobic flora in 1 specimen each. The 7 remaining samples (13.7%) were negative bacteriological cultures. Conclusions: We draw attention to the frequent isolation of P. mirabilis in recurrent and torpid breast abscesses in 4 women in whom surgery was necessary in addition to antibiotic treatment.

Meconium-Stained Amniotic Fluid in Labor: A Randomized Trial of Prophylactic Amnioinfusion

Meconium in the amniotic fluid, found in as many as 22% of deliveries, has been associated with increased perinatal morbidity and mortality, meconium aspiration syndrome, and an increased need for cesarean delivery because of fetal distress. Amnioinfusion may lower the cesarean delivery rate and the risk of meconium aspiration by lessening compression of the umbilical cord and diluting meconium. This randomized, controlled trial, enrolling 206 women with meconium-stained amniotic fluid, examined the effectiveness of amnioinfusion using a two-way catheter in reducing the cesarean delivery rate and improving the neonatal acid-base status. All participants had moderate to thick meconium in the amniotic fluid. Pregnancies were at term and uncomplicated, and there always was a single fetus in vertex presentation. Half of the women were assigned to receive amnioinfusion after manual examination and removal of 10 ml of amniotic fluid via the vagina. Physiological saline was given by infusion pump until full cervical dilation or until the uterine pressure rose to 20 mm Hg. The amniotic fluid index (AFI) was determined before and after an hour of amnioinfusion. In other respects, treatment in the two groups was identical. Meconium concentrations were similar in the two groups at the outset. In 17 cases amnioinfusion was stopped because of uterine hypertonia, but intervention was not necessary. There were no alterations in fetal heart rate. Amnioinfusion lowered the rate of cesarean delivery for fetal distress (relative risk, 0.23) and increased the mean pH of umbilical arterial blood at birth from 7.21 to 7.24. Variable fetal heart rate decelerations decreased with amnioinfusion (relative risk, 0.74). The presence of meconium below the vocal cords decreased with active treatment (relative risk, 0.37). Amnioinfusion promoted spontaneous vaginal delivery in this study of women having moderately to severely meconium-stained amniotic fluid. The need for cesarean delivery, especially for fetal distress, was reduced. The investigators believe that complications can be minimized by continually monitoring intrauterine pressure.

Changes in the rate of tubal ligation done after cesarean section.

OBJECTIVE We studied tubal ligations done after cesarean section in a Spanish hospital during a 20-year period, in order to analyze changes in patient characteristics and indications for cesarean delivery. STUDY DESIGN We reviewed the clinical records, for the period from 1978 to 1997, of 1996 cases of cesarean section followed by tubal ligation in 108776 births in which the fetus weighed 1000 g or more. RESULTS During the 20-year period of study, the proportion of cesarean sections relative to vaginal deliveries increased, as did the frequency of cesarean section followed by tubal ligation relative to cesarean and vaginal deliveries. The proportion of women who underwent tubal ligation after a second cesarean section decreased from 60% during 1978-1982 to 5.6% during 1993-1997. The most frequent maternal pathology associated with gestation was previous cesarean section (60.5%), although 50% of the women had no underlying pathology. CONCLUSIONS In our setting, the rate of cesarean section followed by tubal ligation has been increasing steadily since the early 1980s. The proportion of women who requested tubal sterilization and who had only one living child, or who had had a previous cesarean birth, also increased.