Search

Preterm small-for-gestational-age (SGA) infants with abnormal values of umbilical artery Doppler velocimetry may be more likely to experience longer hospitalization than SGA infants with normal velocimetry. Doppler velocimetry measures blood flow rates. Of 100 infants in a study who were thought to be clinically growth retarded, 38 were SGA. Neither gestational age nor birth weight among the SGA infants correlated with adverse outcome. Ten infants in the study died, and seven of these had abnormal Doppler results. Normal Doppler results were noted in 39% of the SGA infants. Abnormal velocimetry in the umbilical artery may reflect increased resistance to blood flow from the uterus to the placenta, which may in turn compromise maternal-fetal oxygen and nutrient exchange throughout the pregnancy. Infants at risk for growth retardation may need to be assessed carefully throughout pregnancy to lessen the need for intervention and the rate of adverse outcome.

Doppler velocimetry is a technique that is used to measure blood flow, and it has been used to identify abnormalities in blood flow in the umbilical cord. Previous studies have reported that some infants who are small for their gestational age (SGA) at birth have abnormal Doppler velocimetry test results, indicating that blood flow in the umbilical cord is abnormal. Other studies have reported that this technique does not predict abnormal outcome in twin pregnancies that involve the twin transfusion syndrome. This syndrome occurs when one fetus receives less blood and amniotic fluid (the fluid that surrounds the developing fetus) than the other, which can cause the fetus to be SGA at birth. To determine if Doppler velocimetry can be used in multiple-gestation pregnancies (pregnancies involving two or more fetuses) to identify fetuses at risk for low-birth-weight and birth defects, 94 pairs of twin fetuses and seven sets of triplets were examined. Doppler velocimetry was performed during pregnancy and these test results were compared with the outcome of each pregnancy. Eight percent of the fetuses examined had abnormal Doppler test results, and all of them were born prematurely. Of the infants with abnormal Doppler test results, 77 percent weighed less than 3.3 pounds at birth, 12 percent had birth defects, and 12 percent were stillbirths. There were six cases of twin transfusion syndrome resulting in fetal growth retardation, and Doppler test results were abnormal in four of the cases. It is concluded that fetuses with abnormal Doppler velocimetry test results have higher rates of infant morbidity and mortality. (Consumer Summary produced by Reliance Medical Information, Inc.)

Developmental studies were done at 3 and 4 years of age in a series of 656 children and the results were correlated with the preceding labor pattern and the type of delivery. It was determined that there were significant adverse effects among offspring delivered by midforceps procedures or born following labors characterized by prolonged deceleration, secondary arrest of dilatation, or arrest of descent.

Prenatal factors known to be associated with delivery of an infant with low birth weight (LBW) were studied in 165 women who were delivered of infants of 2,500 gm or less, as well as 154 women who were delivered of term infants with normal birth weights (greater than 2,500 gm). Data included information related to the clinical course of the pregnancy through 24 weeks' gestation. Of 25 characteristics measured prenatally, 10 variables were identified which indicated differences between the LBW and normal birth weight groups sufficient to make them suitable for a discriminant analysis. Following further analysis and attribute reduction, eight variables were selected as the final set of discriminating attributes. These are: maternal age, height, and weight, the patient's perception of her own parental treatment as a child, presence of uterine anomalies, bleeding during pregnancy, suspected multiple gestation, and number of previous pregnancies ending with a gestational age of 13 through 36 weeks. On the basis of coefficients derived for each of these variables, an equation was developed to derive a discriminant score for each patient. With the use of such equations, 73.5% of the known cases were correctly classified into groups with low and high birth weight. A similar high correct classification of cases was made when suspected multiple gestation was excluded as a variable.

Appearance of a repetitive late deceleration pattern following oxytocin-induced uterine contractions in the prepartum patient may indicate fetal compromise, while absence of this finding may reflect fetal well-being. In this study, 72 patients at risk for intrauterine asphyxia underwent 81 satisfactory oxytocin challenge tests. Eight tests in seven patients were interpreted as positive; 72, as negative; and one, as suspicious. In 64 patients with negative tests, no fetal deaths or neonatal asphyxial depressions were observed. One patient developed intrapartum fetal distress with late decelerations 8 days after a negative test and was delivered by cesarean section. The positive test appears to correlate meaningfully with other clinical parameters reflecting intrauterine compromise.

Aortic node biopsies performed in 26 patients with Stage I ovarian cancer revealed 5 with metastases. All were associated with virulent tumors of the undifferentiated anaplastic or embryonal cell type. The 19 per cent incidence of lymphatic metastasis in this area stresses the need for evaluation of the aortic node chain in patients with early delimited ovarian cancer.

The incidence of uterine contractility and of abnormalities of fetal heart rate (FHR) pattern was determined in a series of 2,834 monitored gravid women with singleton pregnancies producing mature infants in vertex presentation. Those subjected to uterotonic agents for induction or augmentation of labor had significantly more tetanic contractions, baseline hypertonus, and coupling of contractions. Similarly, significantly more variable and late FHR decelerations occurred in stimulated labors, and these were concentrated primarily in those receiving oxytocin. The overall incidence of FHR decelerations associated with the use of prostaglandin E2(PGE2) was comparable to that encountered in unstimulated labor. The similarity between the contractions of spontaneous labor and those labors produced by PGE2is noted.

A study was made of the relationship between electronic fetal heart monitoring and the Apgar score in 14,350 babies delivered between 1970 and 1975 at Beth Israel Hospital, Boston. Simple comparison of Apgar scores in monitored and unmonitored babies showed no difference at 5 minutes. When we controlled for gestational age and other potential confounders, a different pattern emerged. In a group of obviously high-risk pregnancies, monitored babies had a more favorable distribution of 5-minute Apgar scores (3.8% instead of 7.2% with a score below 6, P = 0.020). This group contained the 7.4% of all babies who were ≥36 weeks of gestational age at highest risk (with problems such as hydramnios, multiple pregnancy, placental complication, or malpresentation). A similar trend for babies less than 36 weeks' gestational age with the same obstetric complications did not achieve statistical significance. There was no evidence for benefit in the other risk categories.

Prostaglandin E2was administered orally for induction of labor in 100 normal term gravidas with two dosage regimens. The data derived were compared with comparable data from gravidas matched with study patients according to prelabor cervical preparation and other relevant obstetric and actuarial features. Analysis of patterns of cervical dilatation and station vs. time was carried out. A dose of 0.5 mg. hourly was found to be effective in inducing labor of good quality with minimal side effects, providing a better balance between efficacy and adverse reactions than the higher dosage level.

A matched control study was undertaken in which 156 children were examined between ages 23 and 62 months after births associated with spontaneous labor, oxytocin-induced labor, or prostaglandin E 2(PGE 2)-induced labor. Physical development was not adversely affected by labor induction based on heigh and weight percentiles. The frequency of neurologic or developmental abnormalities not attributable to postdelivery events was the same overall in induced and spontaneous labors (19.2 per 1,000), but those abnormalities occurring after labor induction all followed use of oxytocin. None followed PGE 2despite case-selection criteria which specifically chose PGE 2cases from among those with documented adverse drug-related reactions.

The Panel on Review of Obstetrical and Gynecological Devices of the Food and Drug Administration has tentatively recommended that all diagnostic, surgical, monitoring, therapeutic, and prosthetic devices in current use in the discipline be designated according to perceived need for scientific review, specific standards, and/or general controls for purposes of regulatory classification. Feedback is solicited from all obstetrician-gynecologists and other concerned citizens.

A review of 1,011 consecutive intrapartum heart rate tracings yielded 37.3% with some degree of variable deceleration pattern. No differences in Apgar score distribution were observed in the presence of uncomplicated variable deceleration pattern when compared to those tracings marked normal. However, the presence of variable decelerations in association with other heart rate patterns resulted in lower mean Apgar scores at 1 and 5 minutes, which were significantly different from those of the fetal heart rate (FHR) normal group. Mean Apgar scores at 1 and 5 minutes were significantly different from normal when variable decelerations were noted in the presence of tachycardia and loss of variability. Mean Apgar scores were lower when bradycardia (prolonged episodes of heart rate <120 bpm) was present in the record when compared to normal, but the presence of variable decelerations with bradycardia did not result in different mean scores. The presence of baseline changes with loss of variability and variable decelerations appeared to result in the lowest mean scores. When bradycardia or tachycardia occurred in exclusive association with variable decelerations, the percentage of depressed newborn infants was relatively high.

A new balloon-type cervical dilating device (CDD) was inserted just after intra-amniotic infusion of a combination of prostaglandin F2αand hypertonic saline in an effort to shorten the interval from infusion to abortion. The CDD has both dilator and anchor balloons which are inflated with normal saline after insertion into the cervical canal. The infusion-to-abortion interval was shorter in patients with the CDD dilator inflated (14.6 ± 2.1 hours) than in those with both dilating and anchor balloons inflated or in those aborting without the device in place at all (23.0 ± 1.7 and 18.8 ± 1.0 hours, respectively).

There was a marked regression of structural abnormalities associated with in utero exposure to diethylstilbestrol (DES) among 173 women observed for up to 5 years. Cervical ectopy, present in 121 women at initial examination, decreased in extent in 91 women (75.2%) and disappeared completely in 38 (31.4%). The cervicovaginal hood (CVH), present initially in 123 women, diminished in 65 patients (52.8%) and disappeared completely in 35 (28.4%). The longer the follow-up period, the greater the extent of resolution of these lesions. Patients with both findings at entry into the study showed parallel diminution of ectopy and CVH. This investigation documents that DES-associated ectopy and CVH are labile lesions which tend to decrease in extent with time and may eventually disappear.

Placental oxygen consumption was studied by Warburg respirometric techniques in 617 placentas obtained at delivery. Correlations between Apgar score, gestational age, and infant weight were analyzed. Elevated oxygen consumption was encountered among placentas from infants with low Apgar scores, short gestational age, and low birth weight when these factors were examined separately. When corrections were applied for fetal size, the correlation between placental oxygen consumption and Apgar score disappeared.

The exchange of carbon dioxide between fetal and maternal blood has been investigated by means of radioactive and stable tracers. Pregnant rhesus monkeys were used for this purpose because the fetal blood compartment in this animal is accessible and samples of fetal blood can be obtained without interrupting or terminating the pregnancy. The operative technique is described in detail.

Placental oxygen utilization was studied by respirometric techniques to determine the effect of varying substrate concentrations of oxytocin. It was found that oxygen uptake was depressed significantly at levels of natural and synthetic oxytocin exceeding 10 mU. per milliliter, well above that usually reached in clinical usage. Vasopressin suppressed metabolic activity somewhat also. The preservative agent, chlorobutanol, was shown to act similarly, accounting for all the effect seen with vasopressin, but only part of that encountered with oxytocin. Preservative-free, high concentration, synthetic oxytocin was free of depressive effect, on the other hand. The implications are discussed.

1.1. Tritium labeled D-histidine has been synthesized by a series of known reactions. The radiochemically and optically pure material was subjected to degradation procedures, which indicated that most of the activity was in the β-hydrogen atoms rather than the imidazole ring.2.2. The isolation of labeled histidine from blood filtrates by the carrier dilution method was investigated. A procedure is described whereby a quantitative recovery can be obtained.3.3. A mixture of tritium labeled D-histidine and carbon-14 labeled L-histidine was injected intravenously into pregnant rhesus monkeys. The tritium and carbon-14 (histidine) activity in maternal and fetal blood samples collected over a period of several hours was determined by isolation and analyses of the pure D- and L-carrier mixtures.4.4. L-histidine was found to disappear from the maternal bloodstream about two and one half times faster than the D-isomer. Both enantiomorphs crossed the placenta rapidly. The ratio of the transfer rates for D- and L-histidine was found to be 1:1.40.5.5. During the passage through the placenta, tritium labeled D-histidine does not undergo inversion as shown by enzymatic degradation of carrier mixtures isolated from fetal blood.6.6. The ratio of D- to L-histidine in maternal urine secreted during this period of observation was 25 and 28:1. The faster urinary secretion of the D-isomer is best explained as a stereospecific renal mechanism in addition to a preferential metabolism of the L-form.

A group of 218 gynecological patients presenting various lesions of the pelvic organs has been studied to determine the relationship between gynecological conditions and ureterohydronephrosis. The frequency of occurrence of urinary tract dilatation with prolapse, cystocele, tumors of the uterus and ovaries, and pelvic inflammatory disease has been noted. The importance of prompt treatment of the conditions has been emphasized.

A series of 1,194 patients were studied in labor by means of clinical observations and separately by cervical dilatation time and descent time function curves. Clinical diagnostic criteria of abnormalities were found to be discrepant from the more objective graphic criteria. Delivery outcome was determined on the basis of clinical and graphic diagnoses of abnormality, respectively. From the prognostic point of view, the diagnosis arrived at by cervimetric means was shown to be more likely to be correct, and therefore more useful, than the diagnosis made clinically.

Reconstituted collagen mesh fabric has been used in gynecological surgery as a substitute for endopelvic fascia in colporrhaphy, and for ligamentous support in posthysterectomy vaginal vault prolapse. The 4 cases are detailed. Absence of complications in this small preliminary series is noted. There were good functional and anatomic results seen in follow-up intervals of up to 49 months.

The relationship between maternal age and labor has been examined in as objective a manner as is available to us in clinical terms, using graphicostatistical techniques. No really important differences in the course of labor that could be ascribed to advancing age were found. The single exception was a progressive increase in second stage, which in itself was a relatively small matter in the total picture of the course of labor. The factors contributing to a widely held clinical impression that older patients have long labors are discussed.

1. The efficacy of plotting cervical dilatation against time as a method of graphically analyzing labor is demonstrated.2. The sigmoid characteristics of the curves thus obtained in primiparas at term are illustrated.3. The first stage of labor is divided into four phases based on the graphic alterations noted. Their respective limits are defined.4. Primary and secondary inertia are redefined in terms of deviation from the “normal.”5. The application of this method to the study of the effects of sedation, stimulation, anesthesia, etc., upon the course of labor is indicated.6. The value of this method for the study of individual labors, in progress, is stressed.

1. A tapering-off of the process of parturition occurs during the postplacental hour; this decrudescence should be recognized as the “fourth stage of labor.”2. The fourth stage of labor is a physiologic and clinical entity.3. The physiology of the fourth stage of labor is postulated, the two main physiologic phases being:I.The Contractile PhaseA. Stage of“Uterine myotamponade”(immediate uterine contraction).B. Stage of“uterine thrombotamponade”(Secondary relaxation with formation of placental site sinusoidal and intrauterine hematomas).C. Stage of“Myouterine indifference.”D. Stage of“Fixed myouterine contraction.”II.The Hemorrhagic PhaseA.Traumatic hemorrhage1. Uterovaginal tract laceration bleeding. (Component One.)B.Atonic Hemorrhage1. The clotting hemorrhagic component associated with placental separation. (Component Two.)2. The nonclotting hemorrhagic component probably arising from denuded myometrium.16(Component Three.)4. Both the contractile and hemorrhagic phases are simultaneous and interrelated.5. The official recognition and physiologic appreciation of the fourth stage of labor would result in a reduction of mortality from postpartum hemorrhage, which is assuming first place among the causes of maternal mortality.6. A questionnaire concerning the fourth stage of labor should be part of every labor record.7. The normal“nonclotting component”16of postpartum blood may be analogous with the nonclotting component of menstrual blood which this author believes also consists of two components, a clotting and a nonclotting. The same uterine enzyme17which may be responsible for the failure of one of the postpartum blood components to clot may be responsible for the failure of one of the menstrual components to clot.8. Postpartum hemorrhage, when not due to uterovaginal tract trauma, may consist of a hemorrhage of (a) one of the clotting components, (b) the nonclotting component, or (c) a combination of any two, or all three. “Shock bleeding”18may be a superimposed late complication.

1.1. A critical quantitative in vivo evaluation of synthetic oxytocin has been undertaken and is herein reported.2.2. Effective action as a postpartum uterotonic agent is demonstrated.3.3. When used to induce labor, a failure rate of 13.5 per cent is encountered.4.4. In dysfunctional labors, 97.3 per cent effectiveness is noted.5.5. The effect of synthetic oxytocin upon the progress of cervical dilatation is determined by graphicostatistical cervimetric analysis.6.6. In primiparas, all phases of the first stage of labor are significantly shortened and the maximum slope steepened, the pattern approaching a theoretical ideal.7.7. The same changes are seen when the drug is used in multiparas, except for the deceleration phase.8.8. No untoward effects are evidenced either in labor or post partum, to mother or infant, when utilized in the cautious manner described.

A group of 163 multiparas with secondary arrest of dilatation in the active phase, arrest of descent in the second stage, or prolonged deceleration phase was studied. They were found to have distinctive characteristics with respect to age, obstetric history, fetopelvic relationships, and fetal size and position. More than 40 per cent required operative delivery. Aggressive obstetric practices, many potentially or actually traumatic, were encountered. Fetal morbidity and mortality were significantly high. The value of the labor pattern as a prognostic index was duly noted.

We have reviewed the experience at the Sloane Hospital for Women comprising 69 patients with ruptured uterus. The interrelationships of time of rupture (with regard to labor), site, degree, and symptoms have been detailed, and the relative significance of each weighed. It has been shown that the risk of uterine rupture in subsequent pregnancy after uterine operation in any given patient, although influenced in some measure, cannot be predicted on the basis of any of these factors. Similarly, accurate prognostication cannot be made with reference to the type and technique of the previous uterine incision, the reason for its having been performed, and the postoperative course that ensued.

A schema is offered which divides clinical labor into three functional divisions—preparatory, dilatational, and pelvic. They are defined on the basis of cervical dilatation-time and descent-time patterns. Distinctive characteristics of each are discussed in terms of functional objectives, techniques of assessment, effects of adverse factors, manifestations of pathology, and therapy.

Study of the relationship between station and elapsed time in labor has permitted construction of the station-time patterns of 202 nulliparas and 242 multiparas. Analysis of the slope of descent provided data for determining distribution characteristics and establishing tentative 5 and 95 percentile confidence limits. The critical lower limit of normal for nulliparas was found to be 0.96 cm. per hour and for multiparas 2.11 cm. per hour, data which define protraction of second stage descent, an aberration of labor previously not described.

The course of premature labor has been studied in 1,000 preterm patients by graphicostatistical analytical means. We have verified the correlation between prolongation of active phase and slowing of maximum rate of dilatation with increasing fetal weight. In nulliparas, comparable progressive protraction in latent and deceleration phases and second stage are also encountered. Two separate varieties of labor processes appear to exist among premature labors as determined by distribution patterns of active phase durations. These findings are felt to be significant with reference to factors dealing with onset of premature labor and with outcome for the fetus.

Twenty cases of sigmoidovaginal fistula have been reviewed from the recent literature. In 50 per cent of the cases, the fistula was due to prior diverticulitis. A review of 327 reported cases of sigmoidal fistulas due to diverticulitis disclosed that 2.6 per cent of such fistulas were sigmoidovaginal. An additional case is presented of a sigmoidovaginal fistula due to diverticulitis and irradiation approximately 12 months following treatment for cervical carcinoma.