Paul G. Tomich

The maternal and neonatal outcome of triplet gestations

OBJECTIVE Our purpose was to determine the contemporary maternal and neonatal outcome of triplet gestations. STUDY DESIGN A retrospective review of 57 triplet deliveries between April 1, 1989, and July 31, 1994, was performed. RESULTS The mean gestational age at delivery was 33.0 +/- 2.7 weeks, and the mean birth weight was 1820 +/- 513 gm. The most common maternal complications were preterm labor (86.0%), anemia (58.1%), preeclampsia (33.3%), preterm premature rupture of the membranes (17.5%), postpartum hemorrhage (12.3%), and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (10.5%). Neonatal complications included hyaline membrane disease (29.6%), transient tachypnea of the newborn (20.1%), intraventricular hemorrhage (7.7%), and major congenital anomalies (7.1%). The perinatal mortality was 41 per 1000. Birth order had no significant effect on the incidence of neonatal complications. CONCLUSION Perinatal mortality rates have improved in recent years but remain higher than for singleton gestations. Despite increasing experience with triplets, the rate of maternal complications is high.

The effect of tocolytic use in the management of symptomatic placenta previa

OBJECTIVE The null hypothesis is that tocolysis has no effect on pregnancy prolongation in the aggressive expectant management of symptomatic preterm placenta previa. STUDY DESIGN One hundred twelve preterm pregnancies with confirmed placenta previa and an initial episode of acute vaginal bleeding were selected for this retrospective analysis. Exclusion criteria included gestational age > or = 35 weeks, delivery within 24 hours of admission, prior treatment for bleeding or preterm labor, and contraindications to tocolytic use. Tocolysis was prescribed, at the discretion of the treating clinical staff, in selected pregnancies with significant uterine contractions after admission of the patient. The majority of treated patients (85%) received intravenous magnesium sulfate and/or oral or subcutaneous beta-sympathomimetics within 24 hours of admission. Most patients remained hospitalized until delivery under this aggressive expectant management protocol. Both treated and untreated control study groups were similar at inclusion with regard to parity, gestational age, contraction frequency, and degree of initial bleeding. Outcome variables for each treatment group were obtained from final chart review. Continuous and categoric variables were compared with Student t test or chi 2 analysis-Fishers exact test, respectively. RESULTS The clinical use of tocolysis in symptomatic placenta previa was associated with a clinically significant delay of preterm delivery. Significant improvement in clinical parameters such as interval from admission to delivery (39.2 vs 26.9 days, p < 0.02) and birth weight (2520 vs 2124 gm, p < 0.03) was observed in the tocolysis group. There was no observed statistical difference between the two treatment groups with regard to incidence of recurrent bleeding, interval from admission to first recurrent bleeding, and need for transfusion. There was a trend for patients with multiple bleeding episodes to have been receiving tocolytic therapy (p < 0.10). A trend for requiring a postpartum transfusion was also noted in the tocolysis group (p < 0.09). Treated pregnancies receiving long-term maintenance tocolysis with oral or subcutaneous terbutaline exhibited a greater degree of pregnancy prolongation than those treated with short-term intravenous magnesium alone (43.7 vs 15.3 days, p < 0.02). CONCLUSIONS This retrospective analysis suggests that tocolytic intervention in cases of symptomatic preterm previa may be associated with clinically significant prolongation of pregnancy and increased birth weight. Tocolytic therapy in these cases does not appear to have an impact on frequency or severity of recurrent vaginal bleeding. Further prospective analysis may delineate the role of tocolysis in the aggressive expectant management of symptomatic placenta previa.

Neonatal viability in the 1990s: Held hostage by technology

The emergence of new obstetrical and neonatal technologies, as well as more aggressive clinical management, has significantly improved the survival of extremely low birth weight (ELBW) infants. This development has heightened concerns about the limits of viability. ELBW infants, weighing less than 1,000 grams and no larger than the palm of ones hand, are often described as “miracles” of late twentieth century technology. Improved survivability of ELBW infants has provided opportunities for long-term follow-up. Information on their physical and emotional development contributes to developing standards of practice regarding their care.

Etiology and outcome of extremely low-birth-weight infants

OBJECTIVE Our purpose was to determine whether the reason for delivery of extremely low-birth-weight infants influenced the immediate neonatal outcome. STUDY DESIGN At a regional perinatal center a retrospective analysis of 111 neonates with birth weights between 500 and 800 gm and their respective mothers was performed. The mother-infant pairs were grouped according to the reason for delivery. Group 1 included those with idiopathic preterm labor. Group 2 included mothers with preterm rupture of membranes. Group 3 included those delivered for maternal or fetal indications. Group 4 included all multiple gestations. Maternal, intrapartum, and neonatal outcome variables were then evaluated for statistical significance by analysis of variance and chi2 methods and a p value of 0.05. RESULTS The neonatal outcome variables (survival and incidence of major intraventricular hemorrhage, hyaline membrane disease, and fetal sepsis) were not found to be significantly different among the four groups tested. CONCLUSION The reason for the delivery of extremely low-birth-weight infants does not have an impact on the immediate neonatal outcome in these neonates.

The ethics of caring for conjoined twins. The Lakeberg twins.

In June 1993, conjoined twin Amy and Angela Lakeberg became the focus of national attention. They shared a complex six-chambered heart and one liver; only one could survive separation surgery; and even her chances were slim. The medical challenge was great and the ethical challenges were even greater.

Effect of dual tocolysis on the incidence of severe intraventricular hemorrhage among extremely low-birth-weight infants

OBJECTIVE Our purpose was to evaluate the null hypothesis that dual tocolysis with magnesium sulfate and indomethacin does not alter the rate of grade III or IV intraventricular hemorrhage. STUDY DESIGN Fifty-six neonates weighing 500 to 800 gm from mothers who received tocolytic therapy with magnesium sulfate alone or in combination with indomethacin were the subjects of this retrospective study. Demographic variables were evaluated with a Student t test, chi(2) analysis, Fisher exact test, or Mantel-Haenszel chi(2) as appropriate. RESULTS There was an increased incidence of grade III to IV intraventricular hemorrhage among patients treated with dual therapy (p = 0.02). Logistic regression showed that fetal age and dual tocolysis with indomethacin were the only independent prognostic factors for severe intraventricular hemorrhage. CONCLUSION The results indicate that dual tocolysis with indomethacin may place extremely low-birth-weight infants at increased risk for grade III to IV intraventricular hemorrhage.

Effect of chronic tocolytic therapy on maternal ventricular function in pregnant rabbits

OBJECTIVE Our purpose was to determine whether peripartum cardiomyopathy may be associated with chronic beta-mimetic tocolytic therapy. STUDY DESIGN On gestational day 20 (term 31 days), two 200 microliter Alzet miniosmotic pumps were implanted in the subcutaneous tissue of pregnant New Zealand White rabbits. Each pump was filled with terbutaline (20 micrograms/microliter, n = 7) or saline solution (0.9%, n = 7) and infused continuously for 7 days. The rabbits were killed on the twenty-eighth gestational day. Maternal hearts were placed on a Langendorff (nonejecting) perfusion apparatus for assessment of cardiac function. At a constant perfusion pressure and heart rate left ventricular diastolic pressure was varied while left ventricular developed pressure and left ventricular +/- rate of pressure rise, index values of left ventricular contractility and relaxation, were continuously recorded. Comparisons between groups at each preload were made by analysis of variance. RESULTS Hearts taken from terbutaline-treated rabbits exhibited periodic arrhythmias and mechanical alternans in five of seven hearts versus one of seven in the saline solution group. At a preload of 0 mm Hg both left ventricular developed pressure (88.0 vs 48.4 mm Hg, p < 0.001) and left ventricular rate of pressure rise (1406 vs 653 mm Hg/sec, p < 0.001) were less in terbutaline-treated rabbits. At a preload of 10 mm Hg left ventricular developed pressure (104.4 vs 56.7 mm Hg, p < 0.01) and rate of pressure rise (1424 vs 694 mm Hg/sec, p < 0.001) were also significantly less in terbutaline-treated rabbits. Left ventricular relaxation was also impaired at all preloads. CONCLUSIONS In this model chronic administration of terbutaline during late pregnancy significantly depresses global maternal cardiac function.