Search

Our purpose was to compare the accuracy of ultrasonographic and manual cervical examinations for the prediction of preterm delivery.One hundred two singleton pregnancies at high risk for preterm delivery were followed up prospectively from 14 to 30 weeks with both serial cervical ultrasonography measurements and manual examinations of the length of the cervix. The primary outcome studied was preterm (35 weeks) delivery.Excluding six induced preterm deliveries, 96 pregnancies were analyzed. The mean cervical length measured by ultrasonography was 20.6 mm in pregnancies delivered preterm (n = 17) and 31.3 mm in pregnancies delivered at term (n = 79) (p = 0.003); the mean cervical lengths measured by manual examination were 16.1 mm and 18.6 mm in the same preterm and term pregnancies, respectively (not significant). The sixteenth- and twentieth-week ultrasonographic cervical lengths predicted preterm delivery most accurately (p0.0005). The 25th percentiles of ultrasonographic (25 mm) and manual (16 mm) cervical lengths showed relative risks for preterm delivery of 4.8 (95% confidence interval 2.1 to 11.1, p = 0.0004) and 2.0 (95% confidence interval 0.5 to 4.7, p = 0.1), respectively; sensitivity, specificity, and positive and negative predictive values were 59%, 85%, 45%, 91%, and 41%, 77%, 28%, and 86%, respectively.Cervical length measured by ultrasonography is a better predictor of preterm delivery than is cervical length measured by manual examination. Cervical ultrasonography in patients at high risk for preterm birth seems to be most predictive of preterm delivery when it is performed between 14 and 22 weeks' gestation.

The efficacy of prostaglandin E 2 (PGE 2 ) vaginal suppositories as an abortifacient was evaluated in 40 women between 16 and 20 weeks' gestation. All pregnancies were successfully terminated with a mean time of 12.7 hours (S.D. 5.7). Eight patients (20 per cent) were treated with oxytocin augmentation after spontaneous rupture of the membranes during PGE 2 vaginal suppository therapy. Gastrointestinal side effects and drug fever were frequent but self-limiting. The success of this approach eliminates amniocentesis for drug instillation as well as the supplementary use of intravenous oxytocin in high concentrations and/or intracervical laminaria.

A total of 176 lecithin/sphingomyelin ( L/S ) ratio determinations and 92 rapid "shake tests" (ST) were carried out on amniotic fluid specimens from 146 patients between 26 and 43 weeks' gestation. Mean L/S ratios increased from less than 1.0:1 at 26 weeks' to 2.0:1 at 34 weeks' gestation, and were thereafter unassociated with the respiratory distress syndrome (RDS) in normal pregnancies. RDS was found after maximum L/S determinations of 1.9:1 and 2.1:1 in patients with Rh isoimmunization and Class B diabetes mellitus, respectively. Less mature values were followed by no RDS in several patients, particularly where gestational and intrapartum stress was involved. The ST at the highest dilution (1/2) in 51 patients was associated with no gestation of less than 34 weeks, no L/S of less than 2.3:1, and proved to be a reliable guide to neonatal pulmonary maturity. Caution should be exercised when interpreting tests of fetal pulmonary maturity in problem pregnancies.

Review of the sonographic findings of 1000 pregnancies with viable gestations in the first trimester revealed a minimum incidence of twinning of 3.29%. Of these, 21.2% demonstrated the "vanishing twin" phenomenon, often with associated bleeding, but with a good prognosis for the remaining fetus. Ovulation induction did not appear to alter these data. The sonographic criteria for "vanishing twin" are discussed. The incidence of multiple gestation is 3.29% to 5.39%, higher than previously believed.

This study was undertaken to help formulate standardized dosage schedules of intraamniotic prostaglandin F2alpha (PGF2alpha) with respect to time to abort, completeness of abortion, and incidence and severity of side effects. The subjects were 100 healthy volunteer pregnant women (aged 14 to 42, gestational age 16 to 22 weeks) seeking abortion. 52 were nulliparous. There were 67 black patients and 33 whites. Blood studies and treatment urinalysis were performed. A test dose of 5 mg PGF2alpha (THAM salt) was given followed by saline to clear the catheter of the drug. Different protocols were formulated with respect to subsequent dosage. Oxytocics and laminaria were used where necessary. The first 10 patients (Group 1) were given a loading dose of 20 mg PGF2alpha and subsequent doses. There were 6 complete abortions and 4 incomplete abortions. Average time to abortion was 26 hours. Group 2 (n=10) was treated with an initial dose of 30 mg and another dose of 25 mg at 12 hours. There were 6 complete, 1 incomplete, and 3 failed abortions; average time to abortion was 25 hours. Group 3 (n=40) was given an initial dose of 30 mg, followed by 25 mg at hour 6, 30 mg at hours 18-24 and 25 mg at hours 24-30. There were 28 complete, 11 incomplete, and 1 failed abortion; average time to abortion was 21 hours. Group 4 (n=20) was given a large loading dose of 40 mg with no further therapy for 18-24 hours. There were 11 complete and 9 incomplete abortions; average time to abortion was 21 hours. Group 5 (n=20 gravidas) was treated with a loading dose of 40 mg followed by 20 mg in 6 hours and 40 mg after 24 hours. There were 14 complete, 5 incomplete, and 1 failed abortion. Overall, 65 patients aborted completely and 30 incompletely, giving a total of 95 successes in 100 patients. 40 had diarrhea and 8 had vomiting. There were no statistically significant linear regression between time to abort and patient age, parity, or gestational age. A comparison of nulliparous and parous patients in Group 5 showed a near significant difference in mean interval time to abort at p 0.05 level. A comparison of PGF2alpha with hypertonic saline shows little difference between the 2 methods with respect to proportion of complete abortion. 15-methyl analogues may reduce the high incidence of vomiting and diarrhea in the PGF2alpha method.

Analysis of amniotic fluid protein electrophoretic patterns in 60 patients studied showed 6 discrete protein bands. The pre-albumin fraction increased with gestational age with a peak at 38 weeks followed by a sharp decline after the fortieth week. Correlation of gestational age with this finding is possible.

The results of 24 hour urinary estriol determinations in 47 prolonged gestations, 25 pre-eclamptic or chronically hypertensive gravidas, and 9 diabetic pregnancies are presented. The use of urinary estriol levels in determining the method and timing of delivery in these 81 complicated pregnancies is discussed. The fetal outcome, including case reports of 4 perinatal deaths, is provided. A brief critical evaluation of the usefulness of urinary estriols is included. "Serial urinary estriol determinations … offer promise of a useful laboratory aid and the only objective method thus far available to supplement clinical judgment." 1

In order to evaluate luteolytic activity, prostaglandin F2alpha (PGF2alpha) was administered intravaginally to 7 women in doses ranging from 125 to 400 mg during the late luteal phase of the cycle. The women ranged in age from 22-28 years. The women, with a history of regular menstrual cycles, were studied during 3 menstrual cycles (2 control and 1 treatment). Cycles were monitored by basal body temperature and daily blood samples from day 10 of the cycle to the day of menses. 24 and 48 hours following treatment with prostaglandin F2alpha, each woman received 3000 and 6000 I.U. of human gonadotropin (HCG) intramuscularly. Although there was a transient decrease in 5 subjects, progesterone levels increased after the HCG. The length of the cycle was prolonged significantly in 5 of 7 subjects. Slight vaginal bleeding was noted in 2 subjects immediately following treatment. 2 women experienced severe vomiting and diarrhea. The chemical profile in all 7 patients was unaffected by PGF2alpha administration.

In a previous report, Cendehill strain attenuated rebella virus failed to demonstrate transplacental passage as judged by infection of placental or fetal tissue. This study was continued in seronegative patients undergoing abortion. In 3 cases, rubella virus was cultured in the products of conception obtained by dilatation and evacuation. An attempt was made to verify that the virus recovered was vaccine virus by inoculation into New Zealand white rabbits. These findings are presented along with a possible hypothesis.

To determine the susceptibility of the postpartum and postabortal genital tract to infection with attenuated rubella virus, 30 patients with negative hemagglutination inhibition (HI) titers were studied. Following inoculation with Cendehill or RA 27/3 vaccine, viral cultures of the cervix and uterine cavity were obtained with blood specimens to evaluate serologic conversion. Attenuated rubella virus was not isolated in any patient; seropositive conversion was achieved in 24 women. The significance of these findings related to wild rubella virus infection is discussed.

2 cases of undiagnosed abdominal pregnancy observed in a 1-year period are reported. Both were complications of 2nd-trimester induced abortion. In case 1, a 25-year old black woman (gravida 5, para 2), multiple attempts at amniocentesis resulted only in bloody fluid. Intramuscular methyl-prostaglandin F2alpha (PGF2alpha) was administered and hypertonic saline was infused, but neither uterine cramping nor rupture of the membranes followed. PGE2 vaginal suppositories produced no change. Laparotomy revealed a large abdominal mass superimposed on the fundus, extending posterior to the uterus in the cul-de-sac. The amniotic sac contained a 15 ounce stillborn fetus. In case 2, a 33-year old black woman (gravida 2, para 1), bloody fluid was again obtained on amniocentesis. Intravaginal PGE2 suppositories and oxytocin were given, but dilation did not proceed despite uterine cramping. Examination revealed a cystic mass to the right of the uterus and fixed to the cul-de-sac. Laparotomy resulted in removal of a 45 gm macerated fetus. There appeared to be a rent in the right tube from which the gestation had been extruded with secondary implantation upon the abdominal viscera. A 3rd abdominal pregnancy observed in that time period resulted in a live birth at 41.5 weeks of gestation. Clinically, the diagnosis of abdominal pregnancy can be made by sounding the uterus. Laparoscopy will differentiate between abdominal and cornual pregnancy. Sonography is an additional diagnostic aid. When 2nd trimester abortion patients are given PGE2 as a vaginal suppository, 97% abort within 36 hours. Side effects such as vomiting, diarrhea, temperature elevation, and facial flush indicate adequate absorption. When these signs are present but expulsion of fetal tissue or membrane rupture do not occur, extrauterine gestation should be considered.

Forty-five of 49 patients were aborted successfully with 15(S)-15-Me-PGF 2α after previous techniques to induce abortion had met with failure in 39. Nine patients had spontaneous premature rupture of membranes without onset of labor. The majority of patients aborted within 7 hours following initiation of this method of treatment.

A pilot study was conducted to ascertain the feasibility of using PG (prostaglandin) F2alpha as an intravaginal abortifacient at early gestations. 12 healthy women 7-17 days beyond their expected menstrual period were used as subjects. 4 were given a 50 mg/ml solution of PGF2alpha as an aqueous Tham salt solution every 2 hours for an 8-12 hour period. The other 8 received a 200 mg/ml solution at a dose of 50 mg every 2-3 hours for a 10-16 hour period. The 4 who received the weaker solution did not abort. 6 of the 8 who received the more concentrated solution aborted successfully. Gastrointestinal side effects were common but unrelated to the total dose of the drug received. This study proves the success of drug-induced abortion with PGs early in pregnancy. Further research is being done with PG administration through vaginal suppository. If this is successful, this type of abortion might be self-produced in the future.

In their article "Posterior cervical rupture following prostaglandin-induced mid-trimester abortion," Wentz and associates (American Journal of Obstetrics and Gynecology 115: 1107, 1973) described 2 patients with this complication who had received intraamniotic prostaglandin F2a (PGF2a). We have observed 2 similar cases occurring in the first 100 patients given this medication (American Journal of Obstetrics and Gynecology, in press). In both instances, the cervix completely effaced but remained as a relatively inelastic band never dilating more than 2 cm. Since that time, when faced with the similar situation, we have inserted a thick laminaria tent with good results. We offer this as a possible form of therapy to be followed by others who have been confronted with this difficulty. In addition, we have also seen this situation occur during hypertonic saline-induced abortion and suggest that this is not peculiar to PGF2a or, indeed, even increased by this particular drug.

Cendehill strain attenuated rubella virus was administered to 34 patients scheduled for termination of pregnancy by suction dilatation and evacuation or hysterotomy/hysterectomy. Eight patients were seronegative initially, and 7 of these converted by the time of or following an abortion as determined by hemagglutination-inhibition titers. Two pregnancies (in seropositive patients) were allowed to go to term. In no case was virus isolated from placental or fetal tissue. The implications of these findings are discussed.

This brief case history documents the usefulness of administering prostaglandins (PGs) postpartum for treating uterine atony after cesarean section. The patient was a 29-year-old gravida 2, para 0. After cesarian section, the atony of the uterus was noted, and the patient did not respond to intravenous ergotrate or brisk uterine massage with warm sponges. PGF2 alpha was injected superficially into the myometrium; about 1 mg of a 5 mg/ml solution was administered. Uterine contraction began almost immediately. However it was limited to the local area of injection and sustained for less than 2 minutes. After 6 such injections failed to produce the desired effect, the patient was given 250 mcg of PGF2 alpha 15-methyl ester Tham salt intramuscularly. After 8 minutes, the uterus increased tone in a tetanic-like contraction which sustained. No further atony occurred. Nor did side effects present a problem. Estimated blood loss during this time was 850 ml, and the postoperative hemoglobin was 8.5 gm/100 ml.