Wendy Dorchester

Advanced maternal age: the mature gravida.

A 3-year study of women ages 35 years and older who were delivered at Womens Hospital of Long Beach from January 1, 1981, to December 31, 1983, was performed to study the risks involved with advanced maternal age. The study group included 1023 women who were 35 years and older, and they were divided into parous and nulliparous groups. A control group consisting of 5343 women aged 20 to 25 years was used for comparison. Each group was analyzed for the following parameters: pregnancy complications, labor complications, delivery factors, and neonatal outcome. The results show very few statistical differences in the factors analyzed. On the basis of this 3-year study it appears that pregnancies in women of advanced maternal age in the 1980s who are delivered in a modern tertiary care center may be of no higher risk for adverse outcome than pregnancies in younger parturients.

A prospective multi-institutional study of antepartum fetal heart rate monitoring

Abstract A total of 18,517 antepartum fetal heart rate (AFHR) monitoring studies were conducted on 7,448 high-risk patients in 18 institutions in the United States between 1976 and 1980. Data were gathered prospectively. A perinatal mortality rate of 12.9/1,000 (5.5/1,000 corrected) with a fetal death rate of 3.2/1,000 (1.9/1,000 corrected) was found. Nonreactive nonstress tests and nonreactive positive contraction stress tests were associated with significantly increased morbidity and mortality. When patients were ranked by “worst test result,” the presence of persistent late decelerations (positive contraction stress test) appeared to be an earlier warning sign of fetal deterioration than did the loss of reactivity.

A prospective multi-institutional study of antepartum fetal heart rate monitoring: II. Contraction stress test versus nonstress test for primary surveillance☆

This study includes, 1,542 patients who underwent nonstress tests (NSTs) for primary fetal surveillance and 4,626 patients who underwent contraction stress tests (CSTs) for primary fetal surveillance. All pregnancies were at increased risk for uteroplacental insufficiency. The results showed that the two groups were comparable according to maternal diagnostic criteria for testing. Those patients who underwent NSTs as primary surveillance had a 2.9% incidence of intervention because of abnormal test results while the CST group had a 4.5% incidence of intervention because of abnormal test results ( p less than 0.05). The NST group had significantly more respiratory distress syndrome, intrauterine growth retardation, birth weight less than 2,500 gm, and 5-minute Apgar scores less than 7. The antenatal death rate was nearly eight times higher in the NST group (7.8/1,000 versus 1.1/1,000 in the CST group) (p less than 0.05). After correction for congenital anomalies and unrelated causes, the NST group had an antenatal death rate of 3.2/1,000 versus 0.4/1,000 in the CST group (p less than 0.05); there was still an antenatal death ratio of 8:1.

Prophylactic intrapartum amnioinfusion in patients with preterm premature rupture of membranes

Patients with preterm premature rupture of the membranes are at increased risk to develop intrapartum variable decelerations and fetal distress. Short-term saline solution amnioinfusion may be of benefit in the treatment of variable or prolonged decelerations once they appear. In an effort to assess the benefit of prophylactic amnioinfusion, patients with preterm premature rupture of the membranes were studied during a 1-year period in a prospective randomized manner. Patients receiving prophylactic amnioinfusion had significantly decreased incidence and severity of variable decelerations in the first stage of labor (p less than 0.005). In the second stage of labor, the incidence of severe (p less than 0.005) and total (p less than 0.001) decelerations was also decreased in the treatment group. The umbilical arterial pH at delivery was significantly lower (p less than 0.001) as was the umbilical venous pH (p less than 0.005) in the newborn infants of control patients compared with those of patients receiving amnioinfusion. This suggests that prophylactic intrapartum amnioinfusion is of significant benefit in reducing the incidence of variable decelerations and improving the metabolic state in newborn infants born to women with preterm premature rupture of the membranes.

Quantitation of uterine activity preceding preterm, term, and postterm labor

To assess uterine activity before labor in patients delivering preterm, at term, and postterm, the maximum spontaneous contraction frequency per 10-minute window during the initial portion of antepartum fetal heart rate monitoring was analyzed. Patients with multiple gestation, third trimester bleeding, polyhydramnios, or premature rupture of membranes and those already diagnosed with preterm labor were eliminated from the study. Of the 2446 remaining patients (7247 antepartum fetal heart rate tests) who went into spontaneous labor, 237 did so before 37 completed weeks of gestation, 1077 entered labor at term (38 to 42 completed weeks), and 1132 did so after 42 weeks. There was a significant increase in maximum uterine activity per 10-minute window from 30 to 44 weeks of gestation (average 4.7% per week; r = 0.97, p less than 0.0001). When compared with patients delivering spontaneously at term, average maximum uterine activity per 10-minute window was greatest in the preterm labor group (p less than 0.05) and least in the postterm labor group (p less than 0.05). These differences were present for several weeks preceding the onset of spontaneous labor. All three groups showed a surge of uterine activity during the 3 days before the onset of spontaneous labor.

Pulmonary injury associated with antepartum pyelonephritis: Can patients at risk be identified?*

The development of pulmonary injury in cases of antepartum pyelonephritis is rare but serious. To date, factors that might identify patients at risk have not been determined. We compared 11 patients with pyelonephritis and pulmonary injury with 119 patients with pyelonephritis only. Pulmonary injury was more likely to occur in the more severe cases; however, the presence of a maternal heart rate greater than 110 beats/min and a fever to 103 degrees F 12 to 24 hours before the occurrence of respiratory symptoms in a gestation greater than 20 weeks was highly predictive of pulmonary injury. The most significant predictive factors associated with pulmonary injury were elements of treatment such as fluid overload, use of tocolytic agents, and, to a lesser extent, choice of antibiotic. Therefore, if tocolytic agents are considered at all in the management of acute pyelonephritis in pregnancy, they should be used only in patients with documented cervical change. In addition, urinary output should be monitored very closely. These data also may suggest a cause of the pulmonary edema that is occasionally seen in the management of premature labor with the use of tocolytic agents and fluids in the presence of a possible occult infection.

The significance of a previous stillbirth

Among 7052 patients studied between 1976 and 1982 in a collaborative project on antepartum fetal heart rate monitoring, 337 patients had a previous stillbirth as a reason for testing. Overall a previous stillbirth history significantly increased the risk of having a positive result on a contraction stress test, primarily among hypertensive patients. Patients with a previous stillbirth also had a significantly higher incidence of respiratory distress syndrome in their neonates attributable to premature intervention for maternal indications (primarily among hypertensive women and patients with clinical intrauterine growth retardation). Low Apgar scores were found to be significantly increased in diabetics with previous stillbirths primarily due to neonates with congenital malformations. Premature intervention by labor induction or cesarean section was more common among patients with a previous stillbirth for both maternal indications and abnormal antepartum fetal heart rate studies. Previous stillbirth would appear therefore to be a significant risk factor primarily when associated with a diagnosis of hypertension or clinical intrauterine growth retardation.

Gram stain results from amniocentesis in patients with preterm premature rupture of membranes—Comparison of maternal and fetal characteristics

A total of 108 patients with preterm premature rupture of membranes who had undergone amniocentesis were retrospectively analyzed. Seventy-seven patients had negative amniotic fluid Gram stains and were managed expectantly. Thirty-one patients had positive amniotic fluid Gram stains confirmed by subsequent cultures and were delivered of infants on that basis. A univariate comparison of various parameters revealed significant differences in maternal temperature, pulse, and white blood cell count. Patients with positive Gram stains had lower mean gestational age, higher baseline fetal heart rate, and nonreactive fetal heart rate tracings. On the basis of a multivariate stepwise discriminate analysis, fetal heart rate greater than 150 beats/min or nonreactive nonstress test were the best predictors of the Gram stain findings, with a sensitivity of 71%, specificity of 76%, and negative predictive value of 87%. These data suggest that in patients with preterm premature rupture of membranes and fetal tachycardia or nonreactive nonstress test, amniocentesis should be performed in the initial evaluation.

Short versus long course of prophylactic antibiotics in cesarean section

Abstract The use of prophylactic antibiotics to reduce post-cesarean section febrile morbidity has been advocated since 1968. Although this approach has theoretical and actual disadvantages, all but one study found a reduction in febrile morbidity when prophylactic antibiotics were used. An unresolved question was the duration of antibiotic therapy. A double-blind randomized study compared a long course of ampicillin (3 days) to a short course of ampicillin (three doses) to placebo. The long course of prophylactic antibiotics reduced febrile morbidity significantly better (p

The risks of amniocentesis in the management of premature rupture of the membranes

Amniocentesis has proved to be a useful tool in the management of preterm gestation with premature rupture of the membranes. Concern has been expressed, however, regarding possible risks of amniocentesis to mother or fetus. A retrospective review was made of 137 patients referred to us because of premature rupture of the membranes between 28 and 34 weeks of gestation. Amniocentesis was successfully performed in 91 patients. A statistical analysis of the time interval from amniocentesis to labor failed to show any evidence that amniocentesis might induce labor. In addition, no maternal or neonatal morbidity could be attributed to amniocentesis.