Richard I. Lowensohn

Lecithin/sphingomyelin ratio in pregnancies complicated by diabetes mellitus

The amniotic fluid lecithin/sphingomyelin (L/S) ratio was determined in 182 pregnancies complicated by Classes B and C diabetes and in 28 patients with Classes D, F, and R diabetes. These data were retrospectively correlated with the occurrence of the respiratory distress syndrome (RDS) or hyaline membrane disease (HMD). Only four cases of RDS and two cases of HMD were observed in 200 patients with an L/S ratio of 2.0 or greater prior to delivery. This 3 per cent incidence of complications is no higher than that of the nondiabetic population in our institution. Seven of 10 neonates with an antenatal L/S ratio of 1.5 to 1.9 developed RDS. An L/S ratio of 2.0 or more appears to be reliable predictor of fetal pulmonary maturity even in pregnancies complicated by diabetes mellitus.

Cervicovaginal fistula: An apparent increased incidence with prostaglandin F2α

A rare but difficult to treat complication of midtrimester abortion is cervicovaginal fistula. It has been reported as a consequence of criminal, spontaneous, and induced abortions with either laminaria, Hegar dilatation, puncture of the ovum, or by injection of soap. This condition was recently reported as a consequence of intraamniotic hypertonic saline or prostaglandin (PG) instillation. At the Womens Hospital in Los Angeles, 5291 midtrimester abortions with intraamniotic instillation of hypertonic saline had been performed since the advent of elective abortion. There were 4 cases of central cervical rupture (cervicovaginal fistula) for a net incidence of 1:1000. 3 out of 373 intraamniotic PGF2alpha-treated patients developed cervical fistula for an incidence 10 times higher than saline abortion. Other studies confirm this finding. If all such studies are combined, the net incidence is 9 in 678 cases or 1.3%. High risk patients include those who are pregnant for the 1st time, are less than 21 years old, and are treated with hypertonic saline augmented by oxytocin. The fistula may occur with intraamniotic PGF2alpha alone, but the incidence is greater in patients receiving PGs and oxytocin together. A recurring feature is a moderate to severe cramping pain without cervical response even before oxytocin is started. The use of mechanical dilatation of the cervix with the introduction of either laminaria tents or Foley catheters is suggested for primigravid patients receiving hypertonic saline and intravenous oxytocin augmentation. If cervical spasm is the mechanism of action of PGF2alpha, initial insertion of laminaria should be considered with all primigravid patients. Further study of a larger series should be done to elucidate the role of PGs in the development of cervicovaginal fistula. 7 case reports are presented.

Estriol in pregnancy: VI. Experience with unconjugated plasma estriol assays and antepartum fetal heart rate testing in diabetic pregnancies☆☆☆

Abstract The reliability of daily unconjugated plasma estriol (E3) as a first-line test for fetal surveillance in the management of diabetic pregnancies was assessed. Seventy consecutive insulin-dependent diabetic women admitted in late pregnancy were followed up with daily 8 am unconjugated plasma E3 assays and weekly antepartum fetal heart rate testing (AFHRT). There were no perinatal deaths, and only two neonates developed the respiratory distress syndrome. The mean gestational age at delivery was 38 weeks. Pregnancies continued until elective delivery at 38 weeks and development of a mature amniotic fluid lecithin/sphingomyelin (L/S) ratio (n = 40) unless spontaneous labor began earlier (n = 20) or early delivery was indicated for either maternal reasons (n = 3) or presumed fetal distress (n = 7). Intervention for fetal distress took place when plasma E3 levels had fallen by 40% or more from the highest mean of three consecutive preceding values (significant drop) and both a nonstress test (NST) and a contraction stress test (CST) were abnormal irrespective of the L/S ratio (n = 2) or, in the presence of a mature L/S ratio, when either plasma E3 levels had fallen significantly or AFHRT was abnormal (n = 5). Five patients without a mature L/S ratio and a significant fall in plasma E3 with a reactive NST were not delivered. Only 14 (1.2%) of the 1,180 plasma E3 assays in 12 (17%) of the 70 patients represented a significant drop and fetal distress was documented in two of these 12 pregnancies, the only two in which both NST and CST were abnormal. In 18 of the 70 patients in whom 317 NSTs were performed, 26 NSTs (8.2%) were nonreactive initially, but 18 of these 26 NSTs were either reactive when repeated within hours or followed by negative CSTs. Documented fetal distress was found to occur 1 day after a reactive NST and a normal plasma E3 but was indicated in time for successful intervention by both tests. These data indicate that: (1) daily unconjugated plasma E3 assays constitute a reliable first-line test of fetal status in diabetic pregnancies, (2) a single daily plasma E3 at 8 a.m. suffices, (3) the 40% limit for a significant drop appears to be sensitive enough to detect fetal distress, (4) AFHRT, if done daily, may be used in lieu of daily plasma E3 determinations, and (5) both plasma E3 assays and AFHRT render false abnormal results. By combining both biophysical and biochemical testing, it is possible to virtually eliminate the need for unwarranted intervention and unnecessary prematurity.

Current Patterns of Neonatal Morbidity and Mortality in Infants of Diabetic Mothers

Recent advances in antepartum fetal evaluation have contributed to a marked reduction in fetal deaths in pregnancies complicated by overt diabetes mellitus. To determine the effect of these changes on neonatal morbidity and mortality, a retrospective analysis of complications in 322 infants of diabetic mothers (IDM) in White classes B–R was undertaken. The majority (89 per cent) of the IDM were delivered at term with a mean gestational age of 38 weeks. Neonatal morbidity correlated significantly with gestational age, occurring in 80 per cent of the preterm and 40 per cent of the term infants. The overall incidence of complications was: hyperbilirubinemia 37 per cent, hypoglycemia 31 per cent, hypocalcemia 13 per cent, polycythemia 8 per cent, and necrotizing enterocolitis 2 per cent. Respiratory distress syndrome (RDS) occurred in 9 per cent and congenital malformations in 6 per cent of the infants. Nine infants died, and four of these deaths were due to anomalies. These data indicate that (1) a reduction in fetal mortality has been accompanied by a reduction in neonatal mortality; (2) neonatal morbidity has been decreased but remains significant in the IDM; and (3) congenital anomalies have replaced RDS as a major cause of neonatal death for the IDM.

The value of lecithin/sphingomyelin ratios in diabetes: A critical review

Abstract The value of the lecithin/sphingomyelin (L/S) ratio in the management of high-risk pregnancies has been widely accepted. A group for which major controversy still exists is the pregnancy complicated by diabetes mellitus. Some studies, such as our own, report great success with the use of the test in this disorder, while others have been unable to rely upon it. This problem prompted a closer look at our own data, with a specific analysis of the factors which may explain the discrepancies. Specifically, a subgroup of our population was selected by limiting the study to 93 patients in White Classes B through R whoseL/S ratio determinations were 2.0 or above within three days of delivery. A comparison was made of this group of patients with those of the most recent conflicting report, that of Mueller-Heubach and co-workers 8 at the Magee-Womens Hospital in Pittsburgh. The study populations appeared similar in the distribution of disease severity and gestational ages of those patients withL/S ratios over 2.0. The incidence of respiratory distress syndrome (RDS) in those infants withL/S ratios over 2.0 was compared. The group in Pittsburgh reported an 18% incidence, while we have observed a 5% incidence in this population. The factors which may explain this difference include the definition of RDS, the inclusion of Class A patients in a series, and methodologic differences in the preparation of specimens for the determination of theL/S ratio. None of these factors can conclusively explain the disparity in these studies. However, when taken together they do appear to offer a plausible explanation for such differences. It appears essential to standardize both laboratory procedures and criteria for evaluation of neonatal outcome before comparing results.

Laceration of the ascending branch of the uterine artery: A complication of therapeutic abortion

Perforation of the uterine cervix combined with laceration of the ascending branch of the uterine artery is one of the potential complications of therapeutic abortion. The evidence suggests that the injury occurs during the course of serial dilatation of the cervix, is easily overlooked, and may be accompanied by either internal or external hemorrhage which is often intermittent, delayed, and temporarily controlled by measures that ultimately are proved ineffective.

Abdominal hysterectomy for abortion-sterilization. A report of 500 consecutive cases.

This report is a retrospective study of 500 consecutive abdominal hysterectomies performed on the Therapeutic Abortion Service at the Los Angeles County-University of Southern California Medical Center from 1968 to 1974. The cases have been examined as to the patients profile of age, religion, ethnic group, marital status, gravidity, parity, and abortion history; the coexisting medical problems; the types of associated surgeries performed; complications and morbidity, including blood loss, febrile episodes, and length of hospitalization. This patient population was predominantly 26 to 35 years of age, Catholic, Spanish-surname, married, and in their third to eighth pregnancy. Over 30% of our patients had some relatively severe medical or social problem contributing to their selection of this procedure. In over 80% of patients, hysterectomy was the only surgical procedure performed. Average blood loss was less than 400 cc, and 6.8% of patients had transfusion. In about 32% of patients a significant febrile episode was recorded. The average postoperative stay in hospital was about 5 days. No death was encountered. In view of these findings and the apparent benefits of a combined procedure, it is suggested that this surgical approach is a safe and effective method of simultaneous termination of unwanted pregnancy and childbearing capacity in selected cases in which hysterectomy would be medically indicated.

A study of the relationship between Goodwin's high-risk score and fetal outcome☆

Correlation between Goodwins high-risk score and Apgar score was studied in 266 pregnancies managed with the use of the information from clinical monitoring. The correlation coefficients between Goodwins score and Apgar scores were -0.3178 for one-minute Apgar scores and -0.2668 for five-minute Apgar scores. Both are significant at the level of p less than 0.001. When the patients were divided into two groups by Goodwins score, fetuses of the group with the higher score (greater than or equal to 4) were significantly more acidotic than those of the group with the lower score. Therefore, Goodwins high-risk scoring system is simple and useful in the selection of potential risk patients.

Face Presentation at Term

A retrosepective study was conducted of 50,300 conseutive deliveries between July of 1973 and January of 1978. There were 40 instances of face presentation with gestational age greater than 36 weeks and fetal weight greater than 25000 g for an incidence of 1 per 1250 deliveries. Cesarean section was performed in 50% of cases. Spontaneous vaginal delivery occurred with mentum anterior presentation 88% of the time, with mentum transverse presentation 45% of the time, and with mentum posterior presentation 25% of the time. Fetal heart rate (FHR) monitoring was available for review in 29 of the 38 (76%) live births. Internal techniques were used in 79% and external techniques in 21% of the cases. The FHR patterns were classified according to the predominant pattern seen in the first stage of labor. In 59% (17 of 29), variable decelerations were noted, and severe variable decelerations were present in 29% (8 of 29). Late decelerations were noted in 24% (7 of 29) of cases. Only 4 patients completed labor without variable or late decelerations. There were 38 live births and 2 stillbirths. Both of the stillborns were noted to have tight nuchal cords which were believed to be the cause of death. One death occurred intrapartum. Of the 38 live births, there were 14 (37%) with 1-minute Apgar scores of 6 or less and 5 (13%) with 5-minute Apgar scores less than 7. Four of the 5 low 5-minute Apgar scores occurred in babies with mentum posterior position. Of the 23 patients monitored by internal electrodes, no serious trauma was noted as a result of the electrode placement.