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Objective: Our aim was to describe the treatment of iatrogenic previable premature rupture of membranes with the intra-amniotic injection of platelets and cryoprecipitate (amniopatch).Study Design: Patients with iatrogenic previable premature rupture of membranes and without evidence of intra-amniotic infection underwent transabdominal intra-amniotic injection of platelets and cryoprecipitate through a 22-gauge needle. The study was approved by the Institutional Review Board of St Joseph's Hospital in Tampa, Florida, and all patients gave written informed consent.Results: Seven patients with iatrogenic preterm premature rupture of membranes underwent placement of an amniopatch. Membrane sealing was verifiable in 6 of 7 patients. Three patients had iatrogenic preterm premature rupture of membranes after operative fetoscopy, 3 cases were after genetic amniocentesis, and 1 was after diagnostic fetoscopy. Three pregnancies progressed well, with restoration of the amniotic fluid volume and no further leakage. Two patients had unexplained fetal death despite successful sealing. One case of bladder outlet obstruction had no further leakage, but oligohydramnios persisted and did not allow unequivocal documentation of sealing. One patient miscarried from twin-twin transfusion, but the amniotic cavity was sealed.Conclusions: Iatrogenic preterm premature rupture of membranes can be treated effectively with an amniopatch. The technique is simple and does not require knowledge of the exact location of the defect. Unexpected fetal death from the procedure may be attributable to vasoactive effects of platelets or indigo carmine. Although the appropriate dose of platelets and cryoprecipitate needs to be established, the amniopatch may mean that iatrogenic preterm premature rupture of membranes no longer needs to be considered a devastating complication of pregnancy. [ABSTRACT FROM AUTHOR]

Objective: Intrapartum chemoprophylaxis has resulted in a significant reduction of group B Streptococcus neonatal infection. For penicillin-allergic patients, clindamycin or erythromycin is the recommended antibiotic. The purpose of this study was to establish any pattern of antibiotic resistance of group B streptococcal clinical isolates over the past 15 years.Study Design: Group B streptococcal isolates obtained from the lower genital tract were tested for sensitivity to ampicillin, penicillin, clindamycin, and erythromycin. The sensitivity of 100 group B streptococcal isolates retrieved in the period 1997-1998 was compared with that of 85 group B streptococcal isolates from 1980-1993.Results: From 1980-1993 group B streptococcal isolates were available for testing for antibiotic resistance along with 100 isolates from a second study period 1997-1998. Of the 100 group B streptococcal isolates from 1997-1998, 18 were resistant to erythromycin, of which 5 were also resistant to clindamycin, as compared with 1 of the 85 isolates from 1980-1993 that was resistant to erythromycin (P <.001). All the isolates were sensitive to ampicillin and penicillin. All 18 resistant strains from 1997-1998 were found to be sensitive to cephalothin.Conclusion: Over the past 18 years there has been increased in vitro resistance of group B streptococci to both clindamycin and erythromycin. If other studies confirm these findings, modifications to the current Centers for Disease Control and Prevention recommendations may be necessary. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to determine the factors that must be considered for appropriate counseling of patients with high-order multiple gestations.Study Design: A retrospective chart review was carried out from all high-order multiple gestations that were managed by a single perinatology group from February 1993-June 1998. Twin pregnancies that did not result from fetal reduction procedures were used as a control group.Results: Clinical outcome data were analyzed from 9 quadruplet, 25 triplet, 19 reduced twin, and 24 nonreduced twin pregnancies. Women with quadruplet pregnancies were admitted more frequently at an early gestational age, the infants were delivered earlier, and the maternal and neonatal hospital days were longer than for triplet and reduced and nonreduced twin gestations. Triplet pregnancies had an earlier gestational age at delivery (32.3 vs 34.2 weeks), a higher incidence of preterm labor (87% vs 68%), and a higher percentage of neonatal intensive care unit admissions (94% vs 59%) than reduced twin gestations. Reduced twins were hospitalized longer (16.4 vs 9.8 days), were delivered earlier (34.2 vs 36.2 weeks), had a higher incidence of preterm labor (68% vs 29%), and had a greater percentage of neonatal intensive care unit admissions (59% vs 21%), a greater percentage of birth weight <1500 g, and a greater frequency of respiratory distress syndrome (16% vs 2%) than nonreduced twins. There was no difference in neonatal survival and neurologic morbidity when all groups were compared.Conclusion: Although early delivery and prolonged (maternal and neonatal) hospitalization were common with quadruplets and triplets, maternal and neonatal outcomes were excellent. The decision for reduction from triplets to twins may not necessarily change pregnancy outcome but should still be discussed as an option for the parents. Continued efforts need to be made to reduce the overall number of iatrogenic high-order multiple gestations. [ABSTRACT FROM AUTHOR]

Objective: Our purpose was to describe the endoscopic characteristics of the site of rupture in vivo in patients with spontaneous premature rupture of membranes.Study Design: Patients with preterm premature rupture of membranes between 16 and 26 weeks of gestation, without evidence of intra-amniotic infection, and with a normal karyotype underwent transabdominal endoscopic examination of the amniotic cavity. Subsequently, an amniopatch of a combination of platelets and cryoprecipitate to seal the membrane defect was administered. The study was approved by the Institutional Review Board of St. Joseph's Hospital in Tampa, Florida, and all patients gave written informed consent.Results: Four patients underwent endoscopic examination and amniopatch administration; three had spontaneous preterm premature rupture of membranes, and in the other the membranes ruptured after an early amniocentesis. The location of the site of rupture was over the internal os in the 3 cases with spontaneous preterm premature rupture of membranes. This area was normal in the patient with iatrogenic preterm premature rupture of membranes. The longer the time between preterm premature rupture of membranes and fetoscopy, the larger and less defined was the site of rupture. The amniopatch restored amniotic integrity for a maximum of 72 hours.Conclusions: This is the first in vivo endoscopic visualization of the site of spontaneous rupture of membranes from within the uterine cavity. The defect is located over the internal cervical os in patients with spontaneous preterm premature rupture of membranes. There appear to be time-related changes in the morphologic characteristics of the site of rupture. Endoscopic visualization of the site of rupture has the potential for improving our understanding of spontaneous preterm premature rupture of membranes and in the development of possible therapeutic alternatives. [ABSTRACT FROM AUTHOR]

Objective: Current treatment of patients with selective intrauterine growth retardation in monochorionic twins includes expectant management, termination of pregnancy, or umbilical-cord occlusion. The purpose of this study was to assess the outcome of monochorionic twins with selective intrauterine growth retardation who were treated with selective laser photocoagulation of the communicating vessels., Study Design: Monochorionic twin pregnancies with selective intrauterine growth retardation at less than 26 weeks were eligible for the study. Selective intrauterine growth retardation was defined as <10th percentile for gestational age. Absent or reverse end-diastolic velocity in the umbilical artery of the twin with selective intrauterine growth retardation was required for eligibility after January 2000., Results: Thirty patients met the criteria for the study: 17 patients were treated expectantly (group I); 2 patients underwent umbilical-cord ligation of the twin with selective intrauterine growth retardation, and 11 patients underwent selective laser photocoagulation of the communicating vessels (group II). Survival rates for at least 1 fetus were no different between groups I and II (14/17 [82.3%] vs 8/11 [72.3%]; P = .4). However, concomitant demise of the co-twin occurred in 4 of 7 patients, and iatrogenic premature delivery for deterioration of the twin with selective intrauterine growth retardation was necessary in 2 patients in group I, which resulted in significant neonatal morbidity. Of the live-born babies, neurologic handicap was present in 3 of 22 babies (13.6%) versus 0 of 12 in groups I and II, respectively (P < .0001)., Conclusion: Selective intrauterine growth retardation in monochorionic twins can be effectively treated with selective laser photocoagulation of the communicating vessels. By unlinking the circulations between the fetuses, the pregnancy is rendered "functionally" dichorionic, which improves pregnancy treatment and results in decreased neonatal morbidity. This approach constitutes a new valuable alternative in the treatment of monochorionic twin pregnancies with selective intrauterine growth retardation. A randomized clinical trial of expectant treatment versus selective laser photocoagulation of the communicating vessels for monochorionic selective intrauterine growth retardation can be considered.

Objective: Vesicoamniotic shunting may be difficult or impossible in selected cases of fetal lower obstructive uropathy. The purpose of this article is to describe the performance of fetal hydrolaparoscopy and endoscopic fetal cystotomy in two fetuses with complicated lower obstructive uropathy., Study Design: Fetal hydrolaparoscopy-endoscopic fetal cystotomy was performed in a patient with a markedly thickened bladder that could not be entered percutaneously. A peritoneoamniotic (bridge) shunt was also placed. Fetal hydrolaparoscopy-endoscopic fetal cystotomy was performed in a second patient with a collapsed bladder from a previous vesicocentesis, because vesicoinfusion resulted in further ascites. Fetal cystoscopy was performed after endoscopic fetal cystotomy, and posterior urethral valves were ablated with neodymium:yttrium-aluminum-garnet laser energy. A vesicoamniotic shunt was left in place., Results: Adequate bladder drainage was obtained in both cases. The first baby required bilateral nephrotomy and a permanent cystotomy at birth and is scheduled for a bladder expansion procedure at the age of year. The second patient had premature rupture of membranes and fetal death from treatment of this complication 5 days after the original procedure., Conclusion: Fetal hydrolaparoscopy-endoscopic fetal cystotomy can be performed in complicated cases of lower obstructive uropathy. The procedure involves the creation of a defect in the bladder dome under direct endoscopic visualization within a spontaneous or intentional hydroperitoneum. Peritoneoamniotic shunting, vesicoamniotic shunting, or ablation of posterior urethral valves may then be performed. Fetal hydrolaparoscopy-endoscopic fetal cystotomy should be reserved only for complicated cases of lower obstructive uropathy in which conventional vesicoamniotic shunting is not safely possible. Further experience with fetal hydrolaparoscopy-endoscopic fetal cystotomy is necessary to establish its risks and benefits.

Objective: The purpose of this study was to evaluate the prognostic value of sonographic and clinical parameters to develop a staging classification of twin-twin transfusion syndrome (TTTS)., Study Design: Severe TTTS was defined as the presence of polyhydramnios (maximum vertical pocket of > or = 8 cm) and oligohydramnios (maximum vertical pocket of < or = 2 cm). Nonvisualization of the bladder in the donor twin (-BDT) and absence of presence of hydrops was also noted. The middle cerebral artery, umbilical artery, ductus venosus, and umbilical vein in both fetuses were assessed with pulsed Doppler. Critically abnormal Doppler studies (CADs) were defined as absent/reverse end-diastolic velocity in the umbilical artery, reverse flow in the ductus venosus, or pulsatile flow in the umbilical vein. TTTS was staged as follows: stage I, BDT still visible; stage II, BDT no longer visible, no CADs; stage III, CADs; stage IV, hydrops; stage V, demise of one or both twins. Laser photocoagulation of communicating vessels (LPCV) or umbilical cord ligation was performed depending on the severity of the condition. The study was approved by the Institutional Review Board of St. Joseph's Hospital in Tampa and by the Fetal Therapy Board at Hutzel Hospital, Detroit, and all patients gave informed consent., Results: A total of 80 of 108 referred patients met criteria for surgery, but only 65 were treated surgically: 48 with LPCV and 17 with umbilical cord ligation. Complete Doppler data were obtainable in 41 of 48 LPCV patients. Survival rates by stage for one or two fetuses were statistically different (chi-squared analysis = 12.9, df = 6, p = 0.044). Neither percent size discordance nor gestational age at diagnosis were predictive of outcome., Conclusion: Staging of TTTS using the proposed criteria has prognostic significance. This staging system may allow comparison of outcome data of TTTS with different treatment modalities.

Objective: To evaluate the effect of emergency cerclage on perinatal outcome in patients with incompetent cervix., Study Design: In this descriptive retrospective study, the charts of all patients admitted from 1985 to 1992 with a diagnosis of incompetent cervix and cervical dilatation > or = 2 cm were reviewed. Cervical dilatation at the time of cerclage placement, subsequent pregnancy duration and neonatal outcome were analyzed. Statistical analysis was performed using the paired Student t test., Results: During the eight-year period, 42 patients were admitted with a diagnosis of incompetent cervix, cervical dilatation > or = 2 cm, and underwent emergency cerclage. Cerclage resulted in a median (range) continuation of pregnancy of 30 (2-102) days. In 20 of these patients the membranes were not bulging through the external cervical os, and pregnancy was extended a median of 50 (30-102) days. The remaining 22 patients presented with membranes bulging into the vagina, and emergency cervical cerclage resulted in a median pregnancy extension of 16 (2-98) days. Parturients with bulging membranes were then analyzed according to cervical dilatation. Cerclage success was significantly lower when attempted at a cervical dilation > or = 4 cm. Median pregnancy duration was 6 (2-15) versus 21 (5-98) days in patients with cervical dilatation < 4 cm., Conclusion: The results of this study support emergency cerclage in patients without bulging membranes. The data do not support the use of emergency cervical cerclage in patients with bulging membranes and dilatation > or = 4 cm. In those patients, the use of cerclage should be individualized.

Objective: Our purpose was to determine whether treatment of bacterial vaginosis with metronidazole in patients with preterm delivery in the penultimate pregnancy from preterm labor or premature rupture of membranes reduces the risk of subsequent preterm birth., Study Design: From January 1989 to June 1992 patients with a singleton gestation between 13 and 20 weeks and a history of preterm birth in the preceding pregnancy from either idiopathic preterm labor or premature rupture of membranes were screened for bacterial vaginosis. Those with a positive screen were randomized to receive 250 mg of metronidazole three times a day for 7 days or placebo in a double-blind design. Data were analyzed with Student t and chi 2 tests, and differences considered significant at p < 0.05., Results: Of 94 eligible patients, 80 were enrolled and completed the study, of which 44 received metronidazole. Both groups were comparable in number of entry variables. Compared with the placebo group, patients in the metronidazole group had significantly fewer hospital admissions for preterm labor, 12 (27%) versus 28 (78%); preterm births, eight (18%) versus 16 (39%); births of infants weighing < 2500 gm, six (14%) versus 12 (33%); and premature rupture of membranes, two (5%) versus 12 (33%)., Conclusion: Treatment of bacterial vaginosis with metronidazole was effective in reducing preterm births in patients with a history of prematurity in the preceding pregnancy.

Objective: Our purpose was to establish the efficacy and safety of nifedipine versus magnesium sulfate in arresting preterm labor and the efficacy of nifedipine versus terbutaline in preventing recurrent labor., Study Design: Singleton pregnancies at < 34 weeks in preterm labor were randomized to either oral nifedipine or intravenous magnesium sulfate. In case of tocolysis failure ritodrine was added. After labor was arrested, the patients in the nifedipine group were maintained on oral nifedipine, and those in the magnesium sulfate group were treated with oral terbutaline until completing 34 weeks., Results: Of 100 patients 80 were considered eligible, of whom 39 were randomized to the nifedipine group. Both groups were comparable in terms of a number of entry variables, including cervical examination, contraction frequency, and gestational age. Both drugs were equally effective in arresting labor and delaying delivery > 48 hours, 92% versus 93%. Both study groups had a similar incidence of side effects, although four (10%) of magnesium sulfate-treated patients required drug discontinuation because of severe symptoms. Nifedipine was as effective as terbutaline in preventing recurrent labor, 26% versus 24%, and in achieving a gestation > 34 weeks, 62% versus 68%., Conclusions: Oral nifedipine is as effective as magnesium sulfate and terbutaline in arresting and preventing idiopathic preterm labor.

Optimum perinatal outcome is only achieved by the prevention of premature birth. When preterm delivery is unavoidable, antenatal pharmacologic therapy will result in a reduction in the leading causes of neonatal morbidity and mortality, mainly respiratory distress syndrome (RDS), BPD, intraventricular haemorrhage (IVH) and sepsis. These treatments combined with meticulous intrapartum management will result in significant improvements in the neonatal and long-term outcome in the premature baby.

Objective: Our purpose was to evaluate the relative efficacy and safety of indomethacin versus magnesium sulfate in the management of preterm labor in pregnancies < 32 weeks of gestation., Study Design: Eligible patients admitted with singleton pregnancies and idiopathic preterm labor between August 1988 and October 1989 were randomized by sealed envelopes to receive either indomethacin or intravenous magnesium sulfate., Results: Of 101 eligible patients 49 were randomized to receive indomethacin. The two study groups were similar in regard to a number of entry variables, including gestational age, cervical examination, and contraction frequency. Indomethacin was as effective as magnesium sulfate in delaying delivery > 48 hours, 90% versus 85%, and together with oral terbutaline in extending the gestation, 22.9 versus 22.7 days. Tocolysis with magnesium sulfate was discontinued in eight (15%) patients because of maternal side effects, in contrast to none in the indomethacin group, p < 0.05., Conclusion: For gestations < 32 weeks indomethacin may be considered an appropriate alternative to magnesium sulfate as a first-time tocolytic agent.

Objective: A retrospective study was conducted to establish the perinatal and long-term neonatal outcome at 1 year of life (corrected) of pregnancies complicated by premature rupture of membranes before fetal viability., Study Design: The outcome of 94 singleton pregnancies admitted from June 1982 to June 1991 with premature rupture of membranes at < 25 weeks' gestation that were managed expectantly were studied. To establish the effect of rupture of membranes, the neonatal outcomes of babies born with birth weights > 500 gm and gestational ages > 24 weeks were compared with those of a similar group of neonates from patients without preterm rupture of membranes and matched by gestational age, birth weight, race, sex, and mode of delivery. The outcome of the surviving neonates at 1 year of life (corrected) was established on the basis of their Bailey mental and psychomotor scores and on the results of neurologic, ophthalmologic, and hearing examinations., Results: The overall incidence of amnionitis was 24%. The median latency period was 10.5 days; in 26% of patients delivery was delayed > 2 weeks. Pulmonary hypoplasia was detected in 5% of patients, and there was no evidence of orthopedic deformities. Survival was achieved in 39 (40%) of neonates; 63% of these survivors were considered to have had normal development at 1 year of life (corrected)., Conclusion: Premature rupture of membranes at < 25 weeks is associated with a relatively high risk of perinatal mortality and neonatal and long-term morbidity, but a successful outcome can be achieved in about 60% of survivors.

Periventricular-intraventricular hemorrhage is an important problem, resulting in significant mortality and morbidity. Attempts to reduce this complication require an understanding of its pathogenesis. In this chapter a model was proposed, consisting of a series of events resulting in rapid changes of cerebral blood flow and intracranial pressure and leading to rupture of the unique fragile vessels of the germinal matrix and intraventricular regions. Understanding the beneficial physiologic changes induced by such agents such as phenobarbital and vitamin K and that such pharmacologic therapy must be started during the antenatal period has resulted in significant reductions of severe grades of IVH. Further prospective studies are needed to confirm these results using these two drugs alone and in combination. Other potentially beneficial drugs such as indomethacin should be investigated. Although the benefits of such therapy may improve perinatal outcome, the emphasis in our discipline should be the continued attempt to prevent the delivery of these VLBW infants.

Ninety pregnant women admitted to the high-risk pregnancy unit with a diagnosis of acute pyelonephritis were randomized to receive either oral (cephalexin 500 mg every 6 hours) or intravenous (IV) (cephalothin 1 g every 6 hours) antibiotic therapy. All patients were initially hydrated with 1 L of normal saline IV over 4 hours. Neither parenteral analgesics nor antiemetics were used. Bacteremia was noted in 13 (14.4%) of the 90 patients and mandated IV therapy. There was no difference between the oral and IV groups concerning predefined criteria for successful therapy (91.4 versus 92.9% successful therapy, respectively). No characteristic available at presentation predicted bacteremia or ultimate failure of therapy. Two patients (2.2%) experienced significant complications. These data suggest that in nonbacteremic patients, oral antibiotics are both safe and effective for the treatment of acute pyelonephritis in pregnancy.

Premature rupture of the membranes is probably a result of a loss in amniotic membrane collagen. A recent report that the concentration of alpha 1-antitrypsin was decreased in patients with premature rupture of the membranes suggested a generalized defect in such pregnancies. In this study we compared the concentration of alpha 1-antitrypsin in samples from pregnancies with premature rupture of the membranes and from pregnancies with preterm labor at similar gestational age. No difference in alpha 1-antitrypsin concentration was noted between these groups or between samples with or without intrauterine infection. These results support a localized inflammation and necrosis of the membranes at the site of rupture.

Severe symptomatic aortic stenosis in pregnancy carries a poor prognosis. Although cardiopulmonary bypass and surgical repair has been reported to have a low maternal mortality, the fetal risk remains substantial. We report a case in which percutaneous balloon valvuloplasty was performed successfully at 19 weeks' gestation. The procedure restored physiologic left ventricular outflow and improved the aortic valve peak systolic pressure gradient. This allowed progression of the pregnancy to term and an uneventful delivery of a healthy infant, with no maternal complications. Although the long-term efficacy of percutaneous balloon aortic valvuloplasty has not been established, this case report has shown it to be useful as a palliative procedure.

A study was conducted to determine the effect of obstetric management on the incidence of intraventricular hemorrhage in the very-low-birth-weight infant. The study covered four years and involved 488 live-born viable infants weighing between 500 and 1500 g, electronically monitored during labor and with echoencephalograms performed within the first three days of life. The overall incidence of intraventricular hemorrhage and mortality was 43 and 21%, respectively. However, both intraventricular hemorrhage and mortality, 72 and 44%, respectively, were increased for gestations less than 1000 g when compared with those between 1000 and 1500 g, 28 and 8%, respectively. Furthermore, the proportion of severe intraventricular hemorrhage (grade III or IV) was increased for gestations less than 1000 g, 32 versus 9%. The incidence of intraventricular hemorrhage and mortality, 57 and 26%, respectively, in the breech presenting infant over 1000 g delivered vaginally, was decreased by cesarean section, 27 and 9%, respectively, P less than .05. The incidence and the severity of intraventricular hemorrhage were not affected by the status of membranes or length of labor. Neonatal asphyxia as defined by a cord pH of less than 7.20 and severe respiratory distress syndrome as defined by duration of intermittent positive pressure ventilation over 72 hours resulted in a statistically significant increase of severe cases of intraventricular hemorrhage.

The thirty-third instance of pregnancy and Cushing's syndrome is presented and the literature is reviewed. There is a poor fetal prognosis without definitive treatment of Cushing's syndrome during pregnancy. Maternal complications are common with adrenal adenomas, 44% developing pulmonary edema and 100% developing hypertension. Prompt diagnosis and early treatment are necessary.

To establish the effect of antenatal vitamin K on the incidence and severity of intraventricular hemorrhage, 92 patients destined to deliver infants less than 32 weeks' gestation were, in a prospective fashion, randomly assigned to two groups. Group I received 10 mg of vitamin K1 intramuscularly every 5 days until delivery. Group II received no antenatal vitamin K1 therapy. There were 100 neonates less than 1500 gm, equally divided between groups I and II with respect to gestational age, birth weight, race, sex, presentation, route of delivery, duration of labor, Apgar scores, and arterial umbilical cord acid-base balance. The antenatal use of vitamin K resulted in significant reduction in the prothrombin time (12.7 versus 15.2 seconds) and partial thromboplastin time (42.6 versus 58.9 seconds; p less than 0.05). Furthermore, group I experienced a lower incidence of total (16% versus 36%) and severe (0% versus 11%) grades of intraventricular hemorrhage (p less than 0.05). This study suggests that the antenatal use of vitamin K may result in a reduction and severity of intraventricular hemorrhage in the neonate less than 1500 gm.

To evaluate the safety and efficacy of an abbreviated course of antibiotic therapy in postpartum endomyometritis, 109 patients with endomyometritis were randomized to three study groups. All were treated with clindamycin and tobramycin until afebrility and clinical signs of disease were absent. Patients in group I received antibiotics for greater than or equal to 24 hours, group II received therapy for greater than or equal to 48 hours, and group III received antibiotic therapy for greater than or equal to 48 hours that preceded a 7-day course of oral Augmentin. The groups were similar in size and in demographic and clinical parameters. Two patients from each group required a third antibiotic, and no patient required rehospitalization. Group III required more days of antibiotic therapy than did group I, 2.9 versus 2.1 days (p less than 0.01), and cost $412.00 more per patient. This data strongly suggest that a short course of antibiotic therapy is efficacious and safe and would result in substantial monetary savings.

One hundred six patients in preterm labor with intact amniotic membranes and gestational age less than or equal to 32 weeks were randomized to receive either ritodrine hydrochloride or a 48-hour course of indomethacin for tocolysis. The relative efficacy, maternal and neonatal safety, and costs were evaluated to determine which may be the more appropriate first-line pharmacologic agent used to manage preterm labor. Fifty-four patients and 52 patients were randomized to receive ritodrine hydrochloride or indomethacin, respectively. Ritodrine hydrochloride and indomethacin were equally effective in inhibiting uterine contractions and delaying delivery. Delivery was delayed for at least 48 hours in 83 and 94%, and for at least 7 days in 70 and 75% of patients receiving ritodrine or indomethacin, respectively. Tocolysis with indomethacin was associated with no maternal side effects, whereas tocolysis with ritodrine hydrochloride was associated with a 24% incidence of serious cardiovascular and metabolic adverse effects prompting discontinuation of the drug. There were no differences in outcome between the infants exposed to indomethacin versus ritodrine hydrochloride when delivered either remote from therapy or during therapy, except for a statistically higher serum glucose in the infants exposed to ritodrine hydrochloride when delivered during tocolytic therapy. There were no cases of premature closure of the ductus arteriosus or pulmonary hypertension. Tocolysis with indomethacin was 17 times less costly than tocolysis with ritodrine hydrochloride. For gestations less than or equal to 32 weeks complicated by preterm labor, indomethacin may be an appropriate alternative as a first-line tocolytic agent.

A randomized 18-month study was conducted to determine the effect of intrapartum chemotherapy in the prevention of neonatal group B streptococcal disease. Twelve hundred seven indigent patients at term were screened weekly for group B streptococci antenatally with a rapid test based on coagglutination methods and at the time of admission in labor, 263 (22%) were confirmed to have colonization, 67 of which had heavy colonization. One hundred thirty-five of these mothers were randomized to a group treated with 1 gm of ampicillin intravenously every 6 hours until delivery. The remaining 128 mothers were not treated. None of the infants born to the treated mothers had colonization with group B streptococci at surface culture sites. Fifty-nine (46%) of the infants born to untreated mothers, including 24 of 30 (80%) from mothers with heavy colonization, had colonization. Ampicillin treatment administered during labor to pregnant patients with heavy colonization significantly reduced vertical transmission of group B streptococci.

Six hundred ninety-eight patients with premature rupture of the membranes between 26 and 34 weeks were managed expectantly without the use of tocolytics or corticosteroids. Of these, 92 (13 per cent) developed chorioamnionitis. Although latency period (defined as the time from rupture of the membranes to the onset of labor) had no correlation with the incidence of chorioamnionitis, the mean latency period was significantly shorter for those gestations complicated by infection. The risk of chorioamnionitis was found to be inversely related to gestational age. The length of labor, once chorioamnionitis was diagnosed, had no correlation with neonatal outcome, but the development of chorioamnionitis led to a statistically significant increase in neonatal mortality, infection rate, incidence of respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), and five-minute Apgar score less than 7. Maternal endometritis and other complications of infection were increased in the presence of chorioamnionitis, especially in patients delivered by Cesarean section. Useful predictors of early chorioamnionitis were maternal leukocytosis, fetal tachycardia, and elevated maternal C-reactive protein titers.

The purpose of this randomized study was to evaluate whether the combined use of corticosteroids and thyrotropin-releasing hormone would enhance fetal lung maturation to a greater degree than would corticosteroids alone. The study was restricted to patients under 34 weeks' gestation with a lecithin/sphingomyelin (L/S) ratio less than 2.0. The patients were randomized into a study group receiving intravenous thyrotropin-releasing hormone along with intramuscular corticosteroids over 48 hours and a control group receiving only corticosteroids. Patients undelivered 1 week after the onset of therapy underwent a repeat amniocentesis to document changes in the L/S ratio. In those patients delivering within 1 week of therapy, the neonatal clinical course was established by two investigators blinded to the antenatal therapy. Compared with the control group, the group receiving antenatal corticosteroids plus thyrotropin-releasing hormone showed a greater post-therapy increase in L/S ratio, fewer respirator days, and a lower incidence of bronchopulmonary dysplasia. The results of this study suggest that the combined use of corticosteroids and thyrotropin-releasing hormone results in enhanced fetal pulmonic maturation superior to that achieved with corticosteroids alone.

To establish the effect of rapid detection and chemoprophylaxis of group B streptococcal genital colonization in preterm gestations with premature rupture of membranes, 260 singleton pregnancies were cultured. Through the use of a rapid test based on coagulation methods, group B streptococcus was identified in 84 (32%) patients, of which 18 (7%) had heavily colonized infections. The treatment of 36 patients resulted in no cases of chorioamnionitis or neonatal sepsis compared with 11 (23%) cases of chorioamnionitis and 13 (27%) of neonatal sepsis among 48 untreated patients (p less than 0.01). Although the risk of infection was significantly higher in patients with heavily colonized infections, characterized by less than 5 hours' growth for detection, even light colonization, requiring 20 hours for detection, resulted in a 14% rate of maternal and 16% rate of neonatal infection, respectively.

A total of 147 preterm pregnant women at Orlando Regional Medical Center were screened for group B streptococci by using Lim Group B Strep Broth (GIBCO Laboratories, Madison, Wis.) and the Phadebact Strep B Test (Pharmacia Diagnostics, Piscataway, N.J.). Test results were available within 20 h of culture and, in the case of heavily colonized women, within 5 h. This procedure is useful in rapid diagnosis of preterm pregnant women for group B streptococcal colonization.

Percutaneous umbilical cord sampling is gaining widespread acceptance for diagnostic and therapeutic procedures on the fetus. The sampling technique has been reported to be relatively safe in experienced hands. Attainment of the skills for this procedure follows a learning curve, with improvement in successful sampling occurring over time. This paper presents a practical instructional model for percutaneous umbilical cord sampling.

A randomized study was conducted to investigate the effects of antenatal corticosteroids and ampicillin in the management of preterm pregnancies under 34 weeks complicated by premature rupture of membranes. Patients with documented lecithin/sphingomyelin (L/S) ratios of less than 2.0 and a singleton gestation were eligible to participate in the study. One hundred sixty-five patients qualified and were randomized, using sealed envelopes, to four study groups. All patients were followed expectantly. Group I (41 patients) received neither ampicillin nor corticosteroids. Group II (43 patients) received 24 mg of antenatal betamethasone. Group III (37 patients) received 2 g of intravenous ampicillin every 6 hours, with discontinuation of antibiotic therapy if cultures were negative for pathogenic bacteria. Group IV (44 patients) received both corticosteroids and ampicillin as described for groups II and III, respectively. Compared with patients not receiving corticosteroids, those administered antenatal corticosteroids experienced a reduction in the incidences of respiratory distress syndrome (53 versus 26%), bronchopulmonary dysplasia (23 versus 9%), severe grades of intracranial hemorrhage (15 versus 3%), and patent ductus arteriosus (18 versus 6%), with no difference in the incidence of maternal or neonatal infection. Compared with patients not receiving antenatal antibiotics, the group of patients treated with ampicillin on admission had a lower incidence of clinical chorioamnionitis (4 versus 26%) and neonatal sepsis (5 versus 10%). This reduction in infectious morbidity by antenatal ampicillin was restricted to those patients (28.4% of the study population) colonized with group B streptococci.(ABSTRACT TRUNCATED AT 250 WORDS)

This prospective study was designed to evaluate the effects on glucose metabolism of terbutaline used as an oral tocolytic agent. Eighty-six patients were studied when admitted for preterm labor from 24 to 35 weeks' gestation. After intravenous tocolysis, these patients were maintained on 5 mg of terbutaline every 4 or 6 hours. An oral 50 gm, 1-hour glucose challenge test was done 48 hours after terbutaline dosing began. All abnormal glucose challenge test results (greater than or equal to 135 mg/dl) were followed by a standard 100 gm oral glucose tolerance test. Sixty-three percent (54 of 86) of the terbutaline group had an abnormal 1-hour screening result, which was significantly different than the 26.7% (23 of 86) observed in the control group (p less than 0.001). The mean fasting blood sugar and 1-hour postchallenge values were significantly higher in the study than in the control group (p less than 0.0001). Ten of 86 in the treated group (11.6%) and 2 of 86 in the control group (2.3%) with abnormal results met the criteria for gestational diabetes. These numbers achieve statistical significance at p less than 0.05. This study shows a significant effect of oral terbutaline therapy on glucose tolerance during pregnancy. Patients receiving oral terbutaline therapy for suppression of preterm labor should undergo screening for gestational diabetes.

A prospective blinded randomized study was carried out to determine the effect of antepartum administration of dexamethasone on the incidence of respiratory distress syndrome in 250 patients with gestations between 28 and 33 weeks complicated by premature rupture of membranes. The incidence of respiratory distress syndrome was not lowered by the length of rupture of membranes in the 124 untreated patients. The overall incidence of respiratory distress syndrome was reduced from 51% to 25% by the administration of corticosteroids. Further, the dexamethasone-treated group had a statistical significant reduction in the incidence of intraventricular hemorrhage, total time of hospitalization, and average cost per patient. No statistical difference was encountered in the incidence of maternal or neonatal sepsis.

The effect of birth order, presentation, and mode of delivery on neonatal outcome in nondiscordant twin gestations under 1500 g was investigated. All neonates had echoencephalograms performed by the fourth day of life to diagnose the presence and severity of intraventricular hemorrhage. One hundred fifty-six sets of twins were included in the study, of which 59 were in a vertex/vertex presentation, 59 in vertex/nonvertex presentation, and 38 with twin A in a nonvertex presentation. Second twins were characterized by a higher incidence of respiratory distress syndrome (RDS): 66 versus 54% (P less than .05), and severe grades of intraventricular hemorrhage: 30 versus 19% (P less than .01). For vertex/vertex twins, cesarean delivery did not result in improved outcome. Rather, the incidence of RDS was significantly increased in neonates from this group delivered by cesarean birth: 67 versus 46% (P less than .01). Among twins in which at least one of the fetuses was in a nonvertex presentation, those born via cesarean delivery demonstrated a lower incidence of both severe grades of intraventricular hemorrhage and mortality. However, after multivariate analysis to correct for differences in birth weight between the groups, no advantage for cesarean delivery could be demonstrated. Therefore, differences in birth weight, rather than in mode of delivery, accounted for the differences in the neonatal outcome of nonvertex-presenting twins.

The effect of intraventricular hemorrhage on developmental handicaps was studied in 303 surviving very low birth weight (less than 1500 g) infants at corrected one year of age. The outcomes were established by Bayley mental and psychomotor developmental scales as well as by neurologic handicaps. Infants with no intraventricular hemorrhage had a statistically significant incidence of higher mean mental scores (96.5 +/- 18.1 versus 90.1 +/- 18.3) and psychomotor scores (95.5 +/- 17.6 versus 86.7 +/- 16.8), and a lesser proportion of serious neurologic handicaps (7 versus 11.5%), than those with minor hemorrhages (grade I or II), although no difference was noted between infants who had experienced grade I versus grade II hemorrhages. Similarly, the outcomes of those infants with severe intraventricular hemorrhage were significantly worse than those with minor hemorrhages, with the worst outcomes in those with grade IV. Evaluation of 94 infants at three years of age indicates that the mental and neurologic assessments performed at one year of age were accurate predictors of later status.

This report investigates the effect of chorioamnionitis on infant mental and psychomotor development at one year through the prospective study of 698 preterm pregnancies complicated by premature rupture of membranes and managed expectantly without antenatal corticosteroids or tocolytic agents. Ninety-two mothers (13%) developed chorioamnionitis, resulting in a statistically significant increase in neonatal mortality (25 versus 6%), respiratory distress syndrome (RDS) (62 versus 35%), intraventricular hemorrhage (56 versus 22%), and sepsis (28 versus 11%). A multidisciplinary team examined 43 surviving infants at corrected one year of life and measured their mental and psychomotor development by the Bayley scales. No statistically significant difference in outcomes was observed when their development was compared with that of a control group matched for birth weight, gestational age, severity of intraventricular hemorrhage, and severity of RDS.