Michael P. Nageotte

Management of the nonvertex second twin: Primary cesarean section, external version, or primary breech extraction

Six hundred eighty-two consecutive twin deliveries were reviewed. Included in the study were 136 sets of vertex-nonvertex twins with birth weights greater than 1500 gm. A primary attempt at delivery of the second twin by external version was performed on 41 twins, 55 twins underwent attempted breech extraction, and 40 patients had a primary cesarean section solely because of physician preference. There were no differences in the incidence of neonatal morbidity or mortality among the modes of delivery. External version was associated with a higher failure rate than primary breech extraction (p less than 0.01). External version was associated with complications (fetal distress, cord prolapse, and compound presentation) that were not seen in the other two groups. Primary breech extraction of the second nonvertex twin weighing greater than 1500 gm appears to be a reasonable alternative to either cesarean section or external version.

A randomized trial of ritodrine tocolysis versus expectant management in patients with premature rupture of membranes at 25 to 30 weeks of gestation

Expectant management was compared with similar management plus ritodrine tocolysis in a randomized controlled trial in patients with premature rupture of membranes at 25 to 30 weeks of gestation. In the tocolysis group intravenously administered ritodrine was instituted at the onset of labor and then changed to the oral form if successful. Tocolysis was discontinued or not instituted after 31 weeks of gestation. Seventy-nine patients were randomized over a 4-year period, 39 in the tocolysis group and 40 in the expectant group. Twenty-three patients in the tocolysis group actually received ritodrine. No difference between the two groups was demonstrated in the interval between premature rupture of membranes and delivery or in reaching 32 weeks of gestation. No statistical difference was seen in maternal morbidity. Birth weights and gestational ages at delivery were similar between the two groups as were the incidences of neonatal morbidities caused by prematurity and infection and in the duration of neonatal hospital stays. Despite being conducted in those gestational ages in which prolongation of pregnancy might be expected to be of most benefit, no difference could be demonstrated with the addition of tocolytic therapy over expectant management alone.

Prophylactic intrapartum amnioinfusion in patients with preterm premature rupture of membranes

Patients with preterm premature rupture of the membranes are at increased risk to develop intrapartum variable decelerations and fetal distress. Short-term saline solution amnioinfusion may be of benefit in the treatment of variable or prolonged decelerations once they appear. In an effort to assess the benefit of prophylactic amnioinfusion, patients with preterm premature rupture of the membranes were studied during a 1-year period in a prospective randomized manner. Patients receiving prophylactic amnioinfusion had significantly decreased incidence and severity of variable decelerations in the first stage of labor (p less than 0.005). In the second stage of labor, the incidence of severe (p less than 0.005) and total (p less than 0.001) decelerations was also decreased in the treatment group. The umbilical arterial pH at delivery was significantly lower (p less than 0.001) as was the umbilical venous pH (p less than 0.005) in the newborn infants of control patients compared with those of patients receiving amnioinfusion. This suggests that prophylactic intrapartum amnioinfusion is of significant benefit in reducing the incidence of variable decelerations and improving the metabolic state in newborn infants born to women with preterm premature rupture of the membranes.

Fetal gastroschisis and omphalocele: Is cesarean section the best mode of delivery?

There has always been controversy regarding the mode of delivery of fetuses with abdominal wall defects. Prior studies may have been biased in this evaluation as a result of the effects of delay in repair, transport of the fetus to level III facilities, and antenatal diagnosis compared with an unsuspected diagnosis. The purpose of this study was to evaluate mode of delivery at level III institutions with access to complete care to determine if cesarean section improved outcome. One hundred eight infants were treated in the study period for abdominal wall defects. Fifty-six infants met all criteria for admission to the study. No difference in neonatal morbidity or mortality was identified. No difference was found in infants who were born by elective cesarean section compared with infants delivered after labor ensued. In conclusion, we found no evidence that cesarean section or avoidance of labor improved outcome in fetuses with uncomplicated abdominal wall defects.

Quantitation of uterine activity preceding preterm, term, and postterm labor

To assess uterine activity before labor in patients delivering preterm, at term, and postterm, the maximum spontaneous contraction frequency per 10-minute window during the initial portion of antepartum fetal heart rate monitoring was analyzed. Patients with multiple gestation, third trimester bleeding, polyhydramnios, or premature rupture of membranes and those already diagnosed with preterm labor were eliminated from the study. Of the 2446 remaining patients (7247 antepartum fetal heart rate tests) who went into spontaneous labor, 237 did so before 37 completed weeks of gestation, 1077 entered labor at term (38 to 42 completed weeks), and 1132 did so after 42 weeks. There was a significant increase in maximum uterine activity per 10-minute window from 30 to 44 weeks of gestation (average 4.7% per week; r = 0.97, p less than 0.0001). When compared with patients delivering spontaneously at term, average maximum uterine activity per 10-minute window was greatest in the preterm labor group (p less than 0.05) and least in the postterm labor group (p less than 0.05). These differences were present for several weeks preceding the onset of spontaneous labor. All three groups showed a surge of uterine activity during the 3 days before the onset of spontaneous labor.

Rate of recurrence of preterm premature rupture of membranes in consecutive pregnancies

The reported incidence of preterm premature rupture of membranes ranges between 1% and 2% of all pregnancies. The rate of recurrence is poorly defined. The goal of this study was to establish the frequency of recurrence in a high-risk referral practice. Over a 5-year period we identified 121 patients with preterm premature rupture of membranes who had a minimum of two consecutive pregnancies under our care, resulting in a total of 255 pregnancies for analysis. Recurrent preterm premature rupture of membranes occurred in 39 of 121 patients, for a rate of 32.2% (95% confidence interval, 23.9 +/- 40.5). We were unable to demonstrate an association between the estimated gestational age at the time of rupture in the index pregnancy, latency period, interval between pregnancies, and the probability of repeat preterm premature rupture of membranes in the next pregnancy. We conclude that patients with preterm premature rupture of membranes should be counseled regarding the significant risk of recurrence and need to have close follow-up in their subsequent pregnancies.

Antepartum surveillance for a history of stillbirth: When to begin?

OBJECTIVEnA history of stillbirth is universally accepted as an indication for antepartum fetal heart rate testing. Our goal was to examine when fetal testing should begin in an otherwise healthy patient with a history of stillbirth.nnnSTUDY DESIGNnThis is a nonconcurrent cohort study of patients who were seen for antepartum surveillance from January 1979 to December 1991 with a history of stillbirth as the only indication for testing. Subsequent pregnancies were evaluated for adverse outcomes and abnormal antepartum test results.nnnRESULTSnThere was one case of recurrent stillbirth among the 300 study patients. Nineteen patients (6.4%) had one or more positive antepartum surveillance tests (positive contraction stress test or biophysical profile < or = 4). Three patients (1%) had positive tests before 32 weeks, all of whom were subsequently delivered without incident at term. Three patients were delivered for positive tests at < 36 weeks, one by cesarean section for fetal distress. We could not detect a relationship between the gestational age of the previous stillborn and the incidence of abnormal tests or fetal distress in subsequent pregnancies.nnnCONCLUSIONnAntepartum surveillance should begin at > or = 32 weeks in the healthy pregnant woman with a history of stillbirth.

How frequently should the amniotic fluid index be repeated

OBJECTIVEnOur objective was to determine the most appropriate interval for assessing amniotic fluid volume with amniotic fluid index.nnnSTUDY DESIGNnIn a retrospective analysis amniotic fluid indexes performed every 3 to 4 days in antepartum testing patients were compared with their follow-up values. Of 10,742 amniotic fluid indexes there were 7393 with follow-up values within 4 days. The results were stratified by current amniotic fluid index, gestational age, and concurrent nonstress test results. The groups were compared with chi 2 analysis.nnnRESULTSnPatients with normal amniotic fluid index (> or = 8 cm) had a 0.54% chance of oligohydramnios developing in the next 4 days. Those patients with low normal amniotic fluid indexes (5 to 8 cm) had a 5% chance of oligohydramnios developing within the next 4 days, and patients with low amniotic fluid indexes (< or = 5 cm) had a 59% chance of persistent oligohydramnios 4 days after the index examination. Subdividing by gestational age demonstrated that patients > or = 41 weeks gestation had a 2.6% chance of oligohydramnios developing within 4 days if current amniotic fluid index was between 8 and 15 cm. Results of concurrent fetal heart rate findings did not appear to change the risk for development of oligohydramnios.nnnCONCLUSIONnIn patients < 41 weeks gestation with normal amniotic fluid indexes, a repeat amniotic fluid index is not necessary for 7 days.

Gram stain results from amniocentesis in patients with preterm premature rupture of membranes—Comparison of maternal and fetal characteristics

A total of 108 patients with preterm premature rupture of membranes who had undergone amniocentesis were retrospectively analyzed. Seventy-seven patients had negative amniotic fluid Gram stains and were managed expectantly. Thirty-one patients had positive amniotic fluid Gram stains confirmed by subsequent cultures and were delivered of infants on that basis. A univariate comparison of various parameters revealed significant differences in maternal temperature, pulse, and white blood cell count. Patients with positive Gram stains had lower mean gestational age, higher baseline fetal heart rate, and nonreactive fetal heart rate tracings. On the basis of a multivariate stepwise discriminate analysis, fetal heart rate greater than 150 beats/min or nonreactive nonstress test were the best predictors of the Gram stain findings, with a sensitivity of 71%, specificity of 76%, and negative predictive value of 87%. These data suggest that in patients with preterm premature rupture of membranes and fetal tachycardia or nonreactive nonstress test, amniocentesis should be performed in the initial evaluation.

Achievement of the 30-minute standard in obstetrics-can it be done?

One standard by which obstetrical practice is measured is the ability to achieve a time line of ≤ 30 minutes from decision for surgery to time of surgical incision for women in labor for whom a cesarean delivery is indicated due to fetal intolerance to labor. We reviewed our institutions performance regarding this standard and identified an initial rate of 25% of cases actually meeting this standard. Using a program of continuous quality improvement, various systematic and individual barriers were identified and overcome resulting in a significant change in performance. This is a report of the various processes and identified areas of challenge encountered to improve on the ability to achieve this important standard of care.