Joseph J. Apuzzio

Mode of term singleton breech delivery

We disagree with the conclusion expressed in the ACOG Committee on Obstetric Practice Opinion No. 265. The opinion was based essentially on the results of a randomized, noncontrolled, multicenter clinical trial, by Hannah et al. In the United States, the standard criteria for singleton vaginal breech delivery at term include a clinically adequate pelvis, normal circumference of a well-flexed head, an estimated fetal weight not exceeding 3500 g, an obstetrician skilled in conducting vaginal breech delivery, progressive labor at an acceptable rate with the breech well applied to the cervix, appropriate descent, a normal second stage, and double setup with available anesthesia. We find it a matter of concern that the above-mentioned criteria were not among the requirements in the Hannah et al study. According to their protocol, fetal weight could be as high as 4000 g. Augmentation of protracted labor was permissible. Most American physicians experienced in breech delivery would not agree that a 0.5-cm per hour cervical dilatation rate in active labor and a 2-hour second stage of the labor are acceptable. The experience and competence of the obstetricians participating in the quoted study is another open question. The standards of obstetric training vary from country to country, and some of them may fall short of those prevailing in North America. The Committee Opinion also failed to consider the adverse effect of cesarean delivery on future gestations. A complete evaluation of the complications should have included both early and remote consequences of abdominal breech deliveries. We believe that the Committee Opinion may dissuade obstetricians from attempting vaginal breech delivery even in a frank breech, secundagravida with an estimated fetal weight of 7 lb, whose first infant weighed 9 lb, who presents at 7-cm dilatation and 1 station. The practice of obstetrics is an art, which requires broad knowledge, the development and maintenance of specific skills, as well as good clinical judgment. We believe that by ignoring this fact, the Committee did disservice to our specialty and to our patients.

Septic Pelvic Thrombophlebitis: Diagnosis and Management

Septic pelvic thrombophlebitis (SPT) was initially diagnosed and described in the late 1800s. The entity had a high incidence and mortality during this period of time, and a surgical therapeutic approach was the treatment of choice. Since then, the diagnosis, incidence, and management of the entity evolved. This evolution followed the development of newer diagnostic tools such as computed tomography (CT), magnetic resonance imaging (MRI), and a better understanding of the pathophysiology of the disease. The treatment of SPT has had significant changes as well, from a surgical approach at the end of the 19th century to a medical approach after the 1960s. By using an adequate broad-spectrum antibiotic therapy, mortality has decreased. However, controversy in the management of this entity remains even till today.

Prenatal diagnosis of fetal renal mesoblastic nephroma

A rare case of fetal renal mesoblastic nephroma diagnosed prenatally by ultrasonography is presented.

Asymptomatic Bacteriuria in Pregestational Diabetic Pregnancies and the Role of Group B Streptococcus

We sought to determine if gravidas with pregestational diabetes mellitus (DM) are at increased risk for asymptomatic bacteriuria (ASB) compared with nondiabetic gravidas. This is a retrospective case-control study of 150 pregnant patients with pregestational DM and 294 nondiabetic controls. Rates of ASB and any colony count of group B streptococcus (GBS) bacteriuria were reviewed. The incidence of ASB among pregestational diabetics was higher compared with nondiabetic gravidas (18% versus 8.2%, odds ratio [OR] 2.47, 95% confidence interval [CI] 1.37 to 4.45). GBS was the most common organism in diabetic gravidas (26%). There was no difference in incidence of ASB recurrence (OR 1.26, 95% CI 0.37 to 4.36), but antibiotic resistance was higher in the control group (OR 0.28, 95% CI 0.09 to 0.91). Diabetic gravidas with ASB or any level of GBS bacteriuria had higher hemoglobin A (1c) values compared with diabetics without ASB (8.31 +/- 1.89 versus 7.31 +/- 1.84, P = 0.0035). Our results demonstrate that gravidas with DM are at increased risk of ASB including GBS bacteriuria compared with non-diabetic gravidas.

Post-cesarean section endometritis: causative organisms and risk factors.

THE CLINICAL DIAGNOSIS of post-cesarean section endometritis is based on the presence of fever and uterine tenderness, but there are no uniformly satisfactory microbiologic methods for confirming the clinical impression. Therefore, we undertook a prospective stud) by means of a culturing technique previously described to determine the clinical significance of isolates from amniotic fluid and the lower uterine segment.’ We also examined the risk factors for the development of endometritis. Patients undergoing cesarean section at the Martland Hospital, Newark, New Jersey, were studied according to the previously described technique.’ The following data were collected for each patient: age, history of prior cesarean section, duration of ruptured membranes, number of vaginal examinations, hematocrit, peripheral leukocyte count, indication for cesarean section. type of anesthesia, duration of anesthesia, and history of prior amniocentesis. Patients who developed fever greater than 100” F determined orally in two separate 24-hour periods with uterine tenderness and who had no other source of fever were classified as demonstrating clinical evidence of endometritis. We defined laboratory evidence of infection as growth fi-om either the amniotic fluid or lower uterine segment specimens. Thirty-six of 105 patients in ;I G-month period developed clinical and laboratory evidence of infection (Table I). In an additional 43 patients there was neither clinical nor laboratory data indicating infection. Twelve patients developed clinical but nor laboratory evidence of endometritis and in 14 cases cultures were positive (three of the amniotic fluid and 1 1 of the lower uterine segment) but the patients did not develop clinical manifestations of infection.

Comparison of parenteral ciprofloxacin with clindamycin-gentamicin in the treatment of pelvic infection

A prospective, randomized study of intravenous followed by oral ciprofloxacin compared with the combination of intravenous clindamycin and gentamicin was conducted in 122 women hospitalized with pelvic infections. Clinical diagnoses included endometritis (97 patients) and uncomplicated pelvic inflammatory disease (25 patients). Treatment successes for endometritis included 42 of 50 (84 percent) patients treated with ciprofloxacin compared with 35 of 47 (75 percent) treated with the clindamycin-gentamicin combination. Treatment successes for acute salpingitis included 10 of 10 (100 percent) treated with ciprofloxacin and 13 of 15 (87 percent) treated with clindamycin-gentamicin. Ciprofloxacin successfully eradicated Chlamydia trachomatis in 11 of 12 patients as did clindamycin-gentamicin in six of seven patients. In this study of pelvic infection, ciprofloxacin demonstrated efficacy comparable with the combination of clindamycin and gentamicin, and is effective against C. trachomatis.

Difficulties in the prenatal diagnosis of Jarcho-Levin syndrome

Prenatal diagnosis of Jarcho-Levin syndrome early in pregnancy has not been previously reported. We present a case in which ultrasound examination resulted in a tentative diagnosis at 22 weeks of pregnancy. The difficulties in arriving at a definite diagnosis are presented.

Abdominal rescue after entrapment of the aftercoming head

Entrapment of the aftercoming head during breech delivery is generally perceived as a complication that must be resolved by a vaginal extraction procedure. The successful rescue by classical cesarean section described in this report was performed for entrapment of the deflexed fetal head following delivery of the body and the arms.

Effect of maternal cocaine abuse on renal arterial flow and urine output of the fetus

OBJECTIVE Our purpose was to study the short-term effect of maternal cocaine abuse on blood flow of the fetal kidney and the fetal hourly urine output. STUDY DESIGN Thirty-three pregnant patients of various gestational ages with a history of cocaine abuse were studied. Patients were included if the urine specimen was positive for cocaine on the day of study. Patients were excluded if the urine specimen was positive for any other vasoactive substances or medications. Color and pulsed wave Doppler studies were used to obtain the flow velocity waveform of the fetal renal artery. The resistance index was calculated from systolic and diastolic values of flow velocity waveforms, Longitudinal, transverse, and anteroposterior diameters of the fetal urinary bladder were measured from transverse and coronal images at their maximum diameters, and the bladder volume was calculated. The hourly urine output of the fetus was measured from the difference in the bladder volume at half-hour intervals. As controls, 110 normal pregnancies between 19 and 40 weeks were similarly studied for normal values. The resistance index of the fetal renal artery and the hourly fetal urine output of the two groups were compared. RESULTS The resistance index of the fetal renal artery of normal pregnancies had a negative association with gestational age (p < 0.05). Cocaine-exposed fetuses had a significantly higher resistance index of the renal artery (p < 0.01) than did normal fetuses of corresponding gestational ages. A decrease in the hourly urine output of cocaine-exposed fetuses was observed, compared with normal controls of corresponding gestational ages (p < 0.001). CONCLUSION The resistance index values of fetal renal artery and fetal urine output were affected by maternal cocaine abuse.

Prenatal diagnosis of dicephalous conjoined twins in a triplet pregnancy

Abstract Prenatal diagnosis of dicephalous conjoined twins in a triplet pregnancy and their management are presented.