Robert D. Eden

Intra-amniotic bacterial colonization in premature labor

Bacterial culturing was performed on amniotic fluid obtained by transabdominal amniocentesis from 33 patients with singleton pregnancies who were in idiopathic premature labor with intact membranes prior to the thirty-fifth week of gestation. Bacteria were isolated in seven patients (21.2%). The patients who were at highest risk for intra-amniotic colonization were those who had two or more clinical parameters suspicious for intra-amniotic infection in a pregnancy prior to the thirtieth week. Anaerobic bacteria were isolated from all seven patients. Only one patient had mixed aerotolerance isolates. Anaerobic that were classified as significant pathogens were isolated in four patients. Three patients had isolates that grew on primary plates, and the rest were recovered only from broth. The greatest impact of intra-amniotic bacterial colonization in premature labor with intact membranes on perinatal outcome is expressed in extreme prematurity and appears to be a function of the pathogenicity and concentration of the offending organism(s).

Myasthenia gravis and pregnancy: a reappraisal of thymectomy.

A retrospective review of pregnancy in patients with myasthenia gravis at Duke University was conducted. Twelve new cases of pregnancy in eight myasthenic mothers are reported. In general, thymectomy was the primary treatment modality in these patients and preceded the gestational period in all cases. The clinical course of myasthenia gravis in these pregnancies prompted a literature review of previous case reports. Comparison of clinical symptomatology, course of disease, and maternal and perinatal morbidity and mortality revealed that the incidence of clinical exacerbation was less in the thymectomy than in the nonthymectomy group. The role of the thymus in the pathogenesis of myasthenia gravis is reviewed. The rationale for the use and timing of thymectomy in the treatment of the myasthenic patient is presented. This review supports the continued use of thymectomy for the initial treatment of the young, nonpregnant myasthenic female patient.

Accuracy of ultrasonic fetal weight prediction in preterm infants.

We analyzed the accuracy of four previously reported ultrasound formulas by means of abdominal circumference and/or biparietal diameter measurement for the prediction of fetal weight in the preterm infant (less than 2,000 gm). The birth weights of 25 preterm infants delivered within 72 hours of ultrasound measurement were compared to the weights calculated by formulas derived from the ultrasound measurements, and the accuracy of each formula was determined. A high degree of correlation was found or the logarithmic formulas with the use of both biparietal diameter and abdominal circumference measurement. Our data suggest that the present ultrasound methodology is of sufficient accuracy to warrant the use of ultrasonic measurement to predict fetal weight prospectively before delivery of the very low-birth weight infant. We also retrospectively reviewed the previous 4-year neonatal mortality rate for infant weighing between 500 and 2,000 gm at birth at Duke University.

Nephelometric urinary protein profile as an index of renal involvement in hypertensive disorders of pregnancy

Protein analysis was performed on the urine of 62 pregnant women with the use of a nephelometric technique. Thirty-seven women were classified as having mild or severe pregnancy-induced hypertension and/or chronic hypertension. The protein analysis was performed on urine samples obtained prior to delivery and was compared to the degree of proteinuria as determined by the dipstick technique. The degree of immunoglobulinuria increases with increasing severity of pregnancy-induced hypertension while the urine concentration of albumin and transferrin becomes nondetectable. The urinary protein profile appears to be extremely sensitive and accurate in predicting severity of disease.

Serial nephelometric urine IgG measurement and the management of pregnancy-induced hypertension

Serial IgG analysis was performed on the urine and serum of 16 patients with pregnancy-induced hypertension. Significant immunoglobulinuria developed prior to the development of azotemia, significantly decreased creatinine clearance, significant proteinuria (greater than or equal to 3+ dipstick or greater than or equal to 5 gm per 24-hour urine collection), or oliguria. Nephelometric measurement of urine IgG concentrations appears to be a rapid and accurate method for confirming the severity of clinical disease, the degree of renal involvement, the benefit of treatment modalities on renal function, and the likelihood of postpartum maternal morbidity.

Reengineering Electronic Fetal Monitoring Interpretation: Using the Fetal Reserve Index to Anticipate the Need for Emergent Operative Delivery:

Objective: The near-ubiquitous use of electronic fetal monitoring has failed to lower the rates of both cerebral palsy and emergency operative deliveries (EODs). Its performance metrics have low sensitivity, specificity, and predictive values for both. There are many EODs, but the vast majority have normal outcomes. The EODs, however, cause serious disruption in the delivery suite routine with increased complications, anxiety, and concern for all. Methods: We developed the fetal reserve index (FRI) as multicomponent algorithm including 4 FHR components (analyzed individually), uterine activity, and maternal, obstetrical, and fetal risk factors to assess risk of cerebral palsy and EOD. Scores were categorized into green, yellow, and red zones. Here, we studied 300 patients by the FRI, all of whom had normal neonatal outcomes. We attempted to distinguish the clinical course of those cases which required an EOD versus controls which did not. Results: 51 cases with EOD had FRIs much lower than 249 non-EOD cases. The red zone was reached more frequently (P < .001) and lasted longer (1.06 vs 0.05 hours; P < .001). Reaching the red zone had a sensitivity of 92% for EOD, with a positive predictive value of 64% and a false positive rate of 10.4%. Conclusions: Our data suggest the FRI can significantly lower the incidence of EODs by identifying the opportunity for intrauterine resuscitation. Our approach can reduce the disruptive effects of EODs and their concomitant increased risks of complications. The FRI may provide a metric that can refine labor management to reduce CP and EODs.