Shlomo Arieli

A Comparison of Clinical and Ultrasonic Estimation of Fetal Weight

Objective To compare the accuracy of routine ultrasonic and clinical birth weight estimation. Methods The study sample included 1717 women with singleton pregnancies, admitted in early labor with an ultrasonic estimated fetal weight (EFW) performed during the preceding week. Clinical EFW was obtained before rupture of the membranes by the attending senior resident, who was unaware of the ultrasonic EFW. Accuracy was determined by the percentage error, the absolute percentage error, and the proportion of estimates within 10% of the actual birth weight (birth weight ± 10%). Statistical analysis was done by the paired t test, the comparison of correlated variances, the Wilcoxon sign test, and the χ2 test. Actual birth weight in the study sample averaged 3334 ± 607 g (± standard deviation, [SD]) and ranged between 690 and 5320 g. Results The means of all error terms of the clinical EFW were significantly smaller than those of the ultrasonic EFW. However, the rates of estimates within 10% of birth weight were not significantly different (72 and 69%, respectively). In birth weights less than 2500 g, both methods overestimated the birth weight, but the mean errors of the ultrasonic EFW were significantly smaller than those of the clinical EFW. The ultrasonic EFW had significantly higher rates of birth weight ± 10% than the clinical EFW (63 compared to 49%, respectively). In the 2500–4000 g birth weight, only the clinical EFW had no systematic error, whereas the ultrasonic EFW underestimated the birth weight. The mean errors of the clinical EFW were significantly smaller and the rate of birth weight ± 10% significantly higher than those of the ultrasonic EFW. In the birth weight greater than 4000 g, both methods underestimated the birth weight, and the mean errors and the rate of estimates within 10% of birth weight were similar for both methods. Conclusion Clinical estimation of birth weight in early labor is as accurate as routine ultrasonic estimation obtained in the preceding week. In the lower range of birth weight (less than 2500 g), ultrasonic estimation is more accurate; in the 2500–4000 g range, clinical estimation is more accurate. In the higher range of birth weight (greater than 4000 g), both methods have similar accuracy.

Ripening of the unfavorable cervix with extraamniotic catheter balloon : Clinical experience and review

The use of an extraamniotic catheter balloon, inflated above the internal cervical os, has been advocated as a nonpharmacological, mechanical method of cervical ripening before induction of labor. Additional measures may include applying traction on the catheter, or the infusion of normal saline (1 ml/min) via the catheters port into the extraamniotic space. The results of catheter balloon cervical ripening are reviewed from 13 published reports and a departmental series of 190 pregnancies with unfavorable cervix, encompassing nearly 1000 patients. A mean change in cervical score of at least 3 points, was noted in most studies after balloon expulsion or removal. The present series and other studies suggest that oxytocin use for induction and/or augmentation of labor is increased after balloon ripening, compared with its use in spontaneous labor or after cervical ripening by prostaglandins. In 11 studies, catheter balloon ripening was compared with cervical ripening by other mechanical, or pharmacological (i.e., oxytocin or prostaglandins) methods. Of these, eight were prospective and randomized-controlled and three were case-controlled studies. It is suggested that ripening efficacy by catheter balloon is similar, or better, than other methods; but there is no significant difference in the mode of delivery or perinatal outcome. This review also suggests that cervical ripening with extraamniotic catheter balloon has the advantages of simplicity, low cost, reversibility, and lack of systemic or serious side effects.

Investigation of the uterine cavity in recurrent aborters

To prospectively compare the diagnostic ability of both HSG and diagnostic hysteroscopy in recurrent aborters, an HSG followed by a diagnostic hysteroscopy was performed in 106 patients during an investigation into recurrent abortions. The uterine cavity findings on HSG and at hysteroscopy were compared. Among the 60 abnormal HSG patients, intrauterine pathology was demonstrated in 37 (34.9%). Among the 46 normal HSG patients, a normal uterine cavity was found in 33 (31.3%). The sensitivity of the HSG in revealing intrauterine abnormalities was therefore 79% and its specificity 60%. In 23 pathologic HSG, no abnormalities were seen by hysteroscopy. In 13 cases, hysteroscopy demonstrated mild intrauterine findings overlooked by HSG. The false-positive rate was 38% and the false-negative rate was 28%. Hysterosalpingography showed a high false-positive rate, especially in the intrauterine adhesions group. In view of the low specificity and high false-positive and false-negative rates, we believe that hysteroscopic evaluation of the uterine cavity is superior to HSG in recurrent abortions.

Local methotrexate injection: A nonsurgical treatment of ectopic pregnancy

Twenty seven patients with unruptured tubal pregnancy were selected for nonsurgical treatment with the use of one injection of 12.5 mg of methotrexate into the ectopic site at laparoscopy. No adverse reactions were observed. In three patients (11%), a laparotomy was performed because of rising beta-human chorionic gonadotropin titers. In the other patients, serum beta-human chorionic gonadotropin levels decreased to the nonpregnant range with no further intervention, and the patients recovered uneventfully. This method is suggested as an alternative to surgery in selected cases of early unruptured tubal pregnancy.

Dynamic ultrasonographic imaging of the third stage of labor: New perspectives into third-stage mechanisms

OBJECTIVE Dynamic ultrasonographic imaging of the third stage of labor was performed to document ultrasonographic findings and to present new perspectives into third-stage mechanisms. STUDY DESIGN Twenty-five normal deliveries and five with prolonged third-stage labor were studied. RESULTS Normal third-stage labor could be divided into four phases: (1) latent phase, characterized by thick, placenta-free wall and thin, placenta-site wall; (2) contraction phase, with thickening of placenta-site wall (from < 1 cm to > 2 cm); (3) detachment phase, in which the placenta completes its separation and detaches; and (4) expulsion phase, with a sliding movement of the placenta. Although oxytocic agents were routinely used, they do not seem to influence the findings. In five cases with retained placenta the placenta-site wall was initially thin. In four of them it became thick, and the placenta was removed by traction of the cord, whereas in the fifth case the placenta-site wall remained thin and the placenta had to be removed manually. CONCLUSION Shearing forces seem to tear the decidual septae and thereby separate the placenta. This process is completed only when the placenta-site wall attains full thickness. In cases of prolonged third-stage labor, traction of the cord should be applied only when this phase is completed and the actual sliding movement of the placenta is observed.

Characteristics of maternal heart rate patterns during labor and delivery.

OBJECTIVE To find patterns characteristic of maternal heart rates recorded by an electronic fetal monitor and compare them with concomitant fetal heart rate (FHR) patterns. METHODS Maternal heart rates and FHRs during active labor and delivery were simultaneously recorded in 26 parturients with singleton pregnancies in vertex presentation. The FHRs were obtained by an external ultrasound transducer or via a spiral scalp electrode and maternal heart rates by a triple‐wire cable with electrocardiographic electrodes attached to the chest. Representative tracings of 30–60 minutes duration were selected from all stages of labor and after delivery of the placenta. Quantitative assessments were carried out under guidelines from the National Institute of Child Health and Human Development after blinding the source of these tracings. Patterns were compared by appropriate statistical analyses. RESULTS Baseline maternal heart rates were significantly lower and their variability significantly higher than FHRs during all stages of labor. Maternal heart rates showed no decelerations; the proportion of tracings with accelerations increased as labor advanced, most of them coinciding with uterine contractions or bearing down efforts. The FHRs had both decelerations and accelerations. However, tracings with only accelerations (and no decelerations) were observed in decreasing frequency as labor advanced. Maternal accelerations had higher amplitudes and longer durations than fetal accelerations, especially in the second stage of labor. CONCLUSION Maternal heart rate patterns recorded by electronic fetal monitors closely resemble fetal patterns. Baseline “fetal bradycardia,” the absence of decelerations in the second stage of labor, and marked accelerations coinciding with uterine contractions may suggest a maternal heart rate rather than an FHR recording.

Oligohydramnios: Maternal Complications and Fetal Outcome in 145 Cases

One hundred and forty-five cases of oligohydramnios in the second and third trimester were diagnosed by ultrasonography out of 25,000 obstetrics patients (0.58%). In this group, pregnancy complications included hypertension (22.1%) and bleeding in the second trimester (4.1%). We found a high incidence of meconium-stained amniotic fluid (29.1%), fetal distress (7.9%) and premature placental separation (4.2%). IUGR occurred in 24.5% of cases. Asphyxia during labor occurred in 11.5% and different other perinatal problems in 23.5%. Cesarean section was performed in 35.2% of these pregnancies. Seventeen percent of the cases presented as breech. Intrauterine fetal death occurred in 5.5% of these pregnancies. The gross perinatal mortality was 16% and the corrected perinatal mortality was 10.7%. The overall rate of fetal malformations was 11% and that of lethal malformations 4.8%. The skeletal (7.6%) and urinary system (4.1%) were the predominant systems affected. Oligohydramnios is associated with a higher rate of pregnancy complications and increased fetal morbidity and mortality, and thus termination should be considered when pulmonary maturity is present or in cases of fetal distress.

TUBAL PATENCY AFTER LOCAL METHOTREXATE INJECTION FOR TUBAL PREGNANCY

Tubal patency was investigated by hysterosalpingography in 21 of 37 patients with unruptured tubal pregnancy treated by local methotrexate injection at laparoscopy. 18 of the 21 patients had bilateral tubal patency, and the only tube of a patient with a single fallopian tube was also patent. 6 subsequent intrauterine pregnancies have so far been recorded. Local methotrexate injection into the tubal pregnancy may provide an efficient and safe alternative to surgery in early unruptured ectopic pregnancy.

Current management of ruptured corpus luteum

The objectives of the study are to assess current management of the rather frequent event of ruptured corpus luteum. Special emphasis is made on the value of ultrasonography, laparoscopy and culdocentesis in deciding appropriate treatment. A series of 70 patients with ruptured corpus luteum diagnosed and treated during a period of 6 years in one institution in Israel is reported. Eighteen patients with concurrent ruptured corpus luteum and ectopic pregnancy are included. Abdominal pain, the most prevalent presenting symptom, has no typical characteristics. The correlation between large amount of fluid as observed by ultrasound and the finding of > 250 ml of blood at laparotomy is very high. Culdocentesis was performed in only 21 patients. Surgical intervention (laparoscopy, laparotomy following laparoscopy or direct laparotomy) was carried out in 58 patients (83%). The remaining 12 cases were handled by observation only. Forty patients required laparotomy in whom 17 underwent wedge resection. We conclude that observation is sufficient treatment in hemodynamically stable patients, without severe abdominal pain and in the presence of a small amount of pelvic fluid demonstrated by ultrasound. When a large amount of fluid is observed and/or in the presence of severe abdominal pain laparoscopy should be performed on admission. Direct laparotomy is mandatory in case of circulatory collapse.

Uterine flora at cesarean and its relationship to postpartum endometritis

OBJECTIVE To evaluate the relationship between the presence of microorganisms at the time of cesarean at different sites of the genital tract and the development of postpartum endometritus. METHODS One-hundred thirty-three healthy women who delivered by cesarean were enrolled in this prospective study. Cultures were obtained during the surgery and on days 3-5 postoperatively. Gram staining of uterine cavity fluid was done on days 3-5. Gram stains were examined under a high-power microscope for the presence of polymorphonuclear leukocytes. RESULTS Twenty patients (15.0%) met the criteria for postpartum endometritis. Forty-five patients (33.8%) had one or more positive cultures (n = 133) at the time of surgery, resulting in 93 positive cultures and 123 bacterial isolates. Forty-four patients had positive postoperative uterine cavity cultures at days 3-5 postpartum, resulting in 65 isolates. Of 44 patients with a positive postoperative culture, 26 (59.1%) also had Gram stain positive for polymorphonuclear leukocytes in the uterine cavity fluid, whereas only six of 89 patients (6.7%) with negative postoperative culture had a positive Gram stain (P < .05). The relative risk of having a positive culture on postoperative day 3-5 if the culture at surgery was positive at any site was 15.6 (95% confidence interval [CI] 5.9, 42.2), and it was 19.5 (95% CI 6.8, 57.8) if the culture was positive at the lower uterine segment. CONCLUSION The presence of bacteria in the lower uterine segment at the time of the surgery predicts their presence in the uterine cavity during puerperium. The Gram stain of uterine cavity fluid on postcesarean days 3-5 is another quick tool that can expedite the diagnosis of postpartum endometritis.