Richard E. Besinger

Randomized comparative trial of indomethacin and ritodrine for the long-term treatment of preterm labor.

A randomized prospective trial was performed to compare the efficacy and safety of ritodrine and indomethacin in the long-term treatment of preterm labor. Forty patients with intact membranes in preterm labor at 23 to 34 weeks gestation were randomized to receive either intravenous ritodrine or oral indomethacin as the first-line tocolytic agent. Successful intravenous ritodrine therapy was followed by oral terbutaline therapy, and indomethacin-treated patients continued to receive oral indomethacin. Treatment failures were defined as progressive preterm labor or patient intolerance, and these patients were treated with intravenous magnesium sulfate. Ritodrine and indomethacin were equally successful in delaying preterm birth as defined by interval to delivery, gestational age at delivery, delivery delayed greater than 7 days, attainment of 35 weeks of gestation, percentage of patients who required magnesium sulfate therapy, percentage of patients who were readmitted with premature rupture of membranes, absence of recurrent preterm labor, and infant birth weight. More than 80% of mothers who received ritodrine voiced complaints of beta-sympathomimetic side effects, and one patient discontinued treatment as the result of intolerance. There were minimal patient complaints with indomethacin use. No statistically significant differences were noted in neonatal outcome as defined by Apgar scores, umbilical cord pH, intensive care days, ventilator days, or neonatal deaths. However, three cases of primary pulmonary hypertension were observed in the indomethacin group. We had not previously observed this problem with short-term (24 to 48 hours) indomethacin therapy.

The safety and efficacy of tocolytic agents for the treatment of preterm labor.

Pharmacologic inhibition of uterine contractions remains the mainstay of treatment for preterm labor despite the ongoing controversy regarding its effectiveness. A diverse variety of tocolytic medications have been proposed for clinical use, with betamimetics and magnesium sulfate being the common therapeutic agents of choice in the United States today. The clinician using these agents should be aware of the significant maternal and fetal side-effects associated with these particular medications. New classes of pharmacologic agents, including prostaglandin synthetase inhibitors, calcium channel blockers and phosphodiesterase inhibitors, have been proposed as tocolytic agents and are currently undergoing critical clinical evaluation. The purpose of this review is to provide a compilation of the available clinical studies that document the safety and efficacy of these various tocolytic agents.

Preterm and term fetal cardiac and movement responses to vibratory acoustic stimulation

To assess fetal response to vibratory acoustic stimulation, 24 preterm (group A; less than 36 weeks gestation) and 30 term (group B; greater than or equal to 36 weeks gestation) pregnancies were studied. Study variables were perceived fetal movement, fetal heart rate, and fetal heart rate pattern. Observer- and patient-perceived fetal movement responses were noted in most cases but were slightly more common in term patients (group A: + fetal movement, patient 87.5%/observer 87.5%) group B: + fetal movement, patient 96.7%/observer 90%). Baseline changes in fetal heart rate (greater than or equal to 10 beats/min) were observed in 46% of preterm fetuses and 70% of term fetuses. Tachycardia (fetal heart rate greater than 160 beats/min) was a common finding in both groups. In group A, tachycardia after vibratory acoustic stimulation persisted more than 1 minute in 29.2% and more than 5 minutes in 12.5% of patients. In group B tachycardia beyond 1 and 5 minutes was noted in 73.3% and 50% of patients, respectively. A significant shift to awake fetal heart rate patterns occurred in both groups; 29% to 79% was noted in group A (p less than 0.001) and 46.7% to 90% in group B (p less than 0.001). When vibratory acoustic stimulation was used, the high occurrence of increased baseline, tachycardia, and emergence of unusual fetal heart rate patterns must be recognized to adequately interpret fetal heart rate tracings.

A Girl with a Birth Weight of 280 g, Now 14 Years Old

To the Editor: One of us and several colleagues previously reported in the Journal the survival, at 18 months of age, of a girl with extreme symmetrical intrauterine growth restriction; she had a birth weight of 280 g and a length of 25 cm at a gestational age of 26 weeks and 6 days.1 To our knowledge, her birth weight remains the lowest in the world literature. We now report her growth and development at 14 years of age, as she enters high school (Figure 1). At two years of age, our patient had a Mental Development Index score of .xa0.xa0.

Quantitative and qualitative relationships between fetal heart rate accelerations and fetal movement

We measured duration, amplitude, and duration at peak amplitude of 117 heart rate accelerations of 12 normal fetuses greater than 36 weeks gestation. Fetal movement measured by Doppler was analyzed for duration of movement; number of limb, spine, and rolling movements; and total movements per epoch of movement. Of 117 accelerations, only five were not associated with recorded movement and all of these had amplitude less than 12 bpm and duration less than 16 seconds. Only four (3%) accelerations occurred before fetal movement was detected, 23 (20%) began after onset of movement, and the large majority (77%) of fetal heart rate (FHR) accelerations occurred synchronously with fetal movement. In addition to an obvious correlation between number of movements and time spent in movement, a relationship exists between movements and duration of accelerations. Movements do not correlate with amplitude of accelerations. Fetal movement and heart rate acceleration relate temporally, but the strength or type of movemen...

Sonographic detection of an unsuspected intra-abdominal surgical sponge in a pregnant patient.

The diagnosis of foreign bodies by sonography has been well documented. Many reports describe the successful localization of foreign bodies in the superficial soft tissues. 1-8 However, there are few case reports describing sonographic detection of intra-abdominal surgical sponges 9-11 and, to our knowledge, none in a pregnant patient. Most cases were not accurately identified preoperatively, and most patients were explored with a presumptive diagnosis of an ovarian neoplasm. 10,11 Sonography is usually the first imaging modality used in the pregnant patient population, and familiarity with the sonographic appearance of intra-abdominal surgical sponges allows a diagnosis to be reached and appropriate management to be instituted. We report a case of a retained surgical sponge adherent to the uterus in an asymptomatic pregnant patient accurately diagnosed with sonography.

EFFECT OF AMNIOINFUSION ON THE INCIDENCE OF POSTPARTUM ENDOMETRITIS IN PATIENTS UNDERGOING CESAREAN DELIVERY

We reviewed records from 251 consecutive cesarean deliveries performed over a six-month period to evaluate the effect of amnioinfusion during labor on the incidence of postpartum endometritis in patients who delivered by cesarean section. One hundred fifty-four patients were excluded because they were not in labor, were at less than 35 weeks gestation or received antibiotics during labor. Twenty-three of the remaining 97 patients received amnioinfusion during labor and represented the study group. Seventy-four patients did not receive amnioinfusion during labor and were used as controls. The incidence of postpartum endometritis in the amnioinfusion group was 13%, while the incidence in the group not receiving amnioinfusion was 38% (relative risk, 0.34; 95% confidence interval, 0.13-0.88; P = .026). Amnioinfusion during labor appears to significantly decrease the incidence of postpartum endometritis in patients subsequently undergoing cesarean delivery.