Rani Lewis

PRETERM LABOR AND PRETERM PREMATURE RUPTURE OF THE MEMBRANES Diagnosis and Management

Preterm delivery due to preterm labor and pPROM is responsible for most infant morbidity and mortality in the United States. The patient who presents with suspicious symptoms should undergo a thorough evaluation to confirm the diagnosis of either entity and identify a treatable cause. Determination of gestational age, fetal well-being, and the presence of intrauterine infection is a crucial step in subsequent management. Corticosteroid therapy has been demonstrated to be one of the most effective antenatal interventions to reduce infant morbidity and should be administered to patients with preterm labor, if feasible, when fetal pulmonary maturity is absent or undocumented. We recommend a similar protocol regarding gravidas with pPROM remote from term but recognize the need for further study in this area. Acute tocolytic therapy has been demonstrated to offer short-term benefit to enhance corticosteroid effect. However, all of the available tocolytic agents carry significant risks to the mother and fetus. As such, administration of these agents should be given only when the potential benefits outweigh the risks of administration. Evaluation for fetal pulmonary maturity and intrauterine infection, in concert with evaluation of gestational age-dependent risks of prematurity, may be helpful in determining whether tocolysis should be attempted. Adjunctive antibiotic administration has not been shown to reduce maternal or infant morbidity in the face of preterm labor. However, such treatment offers a reduction of chorioamnionitis, prolongation of latency, and a possible reduction of neonatal infectious and gestational age-dependent morbidity in the setting of pPROM remote from term. Finally, current guidelines recommend the administration of intrapartum GBS prophylaxis when preterm birth or prolonged membrane rupture is anticipated if GBS carrier status is unknown or positive. Intrapartum treatment with intravenous penicillin or ampicillin is appropriate.

Serial amniotic fluid index in severe preeclampsia: A poor predictor of adverse outcome☆☆☆★

OBJECTIVE The purpose of the study was to determine the relationship between low amniotic fluid index and intrauterine growth restriction and nonreassuring fetal testing in patients with severe preeclampsia. STUDY DESIGN We reviewed the medical records of 136 women with severe preeclampsia managed conservatively for at least 48 hours. Patients were followed up with a daily nonstress test and amniotic fluid index. We evaluated amniotic fluid index < or = 5 cm and < or = 7 cm, measured on admission or just before delivery (i.e., final), and attempted to correlate these findings with the incidence of nonreassuring fetal testing necessitating cesarean section or the incidence of intrauterine growth restriction (birth weight < or = 10th percentile). RESULTS One hundred seven patients had a cesarean section, but only 42 (39%) of these were for a nonreassuring fetal heart rate tracing or a persistent biophysical profile of < or = 4, and 38 (36%) of the pregnancies resulted in infants with intrauterine growth restriction. During expectant management, the amniotic fluid index worsened for 61 (45%) patients and improved or remained the same for 75 (55%). For those with an amniotic fluid index of < or = 5 cm both on admission and at delivery, there was a significantly higher incidence of intrauterine growth restriction compared with those with an amniotic fluid index > 5 cm (p = 0.007 and p = 0.029, respectively). However, there was no association between intrauterine growth restriction and an amniotic fluid index < or = 7 cm. Moreover, there was no difference in the frequency of nonreassuring fetal heart rate testing on the basis of amniotic fluid volume (p = 0.59) or intrauterine growth restriction (p = 0.4). CONCLUSIONS For women with severe preeclampsia remote from term, an amniotic fluid index < or = 5 cm is predictive of intrauterine growth restriction but lacks sensitivity. There is no association between the amniotic fluid index status and frequency of cesarean section for fetal distress or nonreassuring fetal testing.

The impact of initiating a human immunodeficiency virus screening program in an urban obstetric population

OBJECTIVE Our purpose was to describe the incidence of human immunodeficiency virus infection and to assess the cost/benefit ratio of universal antenatal human immunodeficiency virus screening. STUDY DESIGN Medical records of women in this urban obstetrics population, from the years 1988 to 1993, were examined. The incidence of known human immunodeficiency virus seropositivity at delivery was determined. The costs of performing human immunodeficiency virus screening, evaluating the disease status, and administering therapy were calculated. These costs were compared with an averaged cost for care and follow-up of infants infected through vertical transmission. RESULTS The incidence of known human immunodeficiency virus seropositivity at delivery approximately doubled since the initiation of a human immunodeficiency virus screening program (0.26% to 0.48%). Obstetric screening added an approximate

The evaluation of infection and pulmonary maturity in women with premature rupture of the membranes

100,000 to medical costs. The calculated cost of pediatric follow-up of human immunodeficiency virus-seropositive infants for the first 18 months was estimated at

Selected issues in premature rupture of the membranes: herpes, cerclage, twins, tocolysis, and hospitalization.

344,355. In our population, with universal screening and zidovudine therapy, the medical costs could be reduced by

Oral terbutaline after parenteral tocolysis: A randomized, double-blind, placebo-controlled trial ☆ ☆☆ ★

175,500 per year. CONCLUSION A program of voluntary human immunodeficiency virus screening increases the incidence of known human immunodeficiency virus infection. Offering screening and follow-up to all pregnant patients in an urban setting is both cost-effective and medically beneficial.

Biventricular assist device as a bridge to cardiac transplantation in the treatment of peripartum cardiomyopathy.

Although the etiology of PROM is multifactorial, increasing evidence regarding clinical risk factors, membrane histology, membrane culture, and amniotic fluid microbiology shows a strong association with infection. Recent studies suggest an association between genital tract infection, preterm labor (PTL), and preterm premature rupture of the membranes (pPROM). If correct, this information may be used to target areas for prevention, as well as to develop management protocols. This article reviews both the diagnostic tests for the causes associated with pPROM and the evaluation of intraamniotic infection and pulmonary maturity in patients with pPROM.

Recent advances in the management of preeclampsia

A number of issues related to premature rupture of the membranes (PROM) are less common or have not been thoroughly evaluated. Genital herpes simplex colonization carries the potential for significant perinatal morbidity, particularly with primary infection and membrane rupture. Cervical cerclage is both a risk factor for preterm PROM (pPROM) and confounds the management of women with PROM. Twin gestations carry an increased risk of pPROM and earlier membrane rupture. Membrane rupture can involve the presenting or nonpresenting sac. In each case, the fetus with intact membranes is at risk due to brief latency or intrauterine infection after membrane rupture of its sibling. Prophylactic and therapeutic tocolysis remains controversial because of the high risk of intrauterine infection after PROM, and the lack of data demonstrating long-term efficacy. With increased attention to health care costs, home management of pPROM has recently been suggested as an alternative to hospitalization after pPROM. This article reviews the clinical course and management options regarding these issues. Also discussed are those issues for which there is controversy but little available data. Each of these issues offers fruitful ground for discussion and further study.