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OBJECTIVE To evaluate the association between the cystic fibrosis (CF) genotype and the rate of diabetes complicating pregnancy. METHODS We conducted a retrospective cohort analysis of all pregnant patients with CF from 1972-2011 at a single institution. Patients who were homozygous for the ΔF508 mutation were compared with patients who were heterozygous for the ΔF508 mutation. Primary outcomes measured were incidence of CF-related diabetes and gestational diabetes mellitus (GDM) stratified by CF genotype. Secondary outcomes measured included pancreatic insufficiency, preterm premature rupture of membranes, preterm delivery, mode of delivery, gestational age at delivery, and maternal mortality. RESULTS We identified 54 pregnancies among 36 women who met inclusion criteria. Of these pregnancies, 28 (51.9%) were carried by women who were homozygous for the ΔF508 mutation. Homozygous women had a significantly greater incidence of pancreatic insufficiency (89.3% compared with 61.5%, P=.03) and diabetes complicating pregnancy (60.7% compared with 23.1%, P

Labor is induced in approximately 20% of pregnancies in Europe and North America. Labor induction in patients with an unfavorable cervix is associated with a higher incidence of prolonged labor and higher rates of operative and cesarean delivery. Prostaglandins used for cervical ripening lead to shorter labor, less use of oxytocin and a greater likelihood of vaginal delivery within 24 h. Dinoprostone (prostaglandin E2) has been used since the 1970’s and is recognized as an agent that not only results in cervical ripening but also activates myometrial contractility. A proprietary sustained- and controlled-release dinoprostone vaginal insert releases a continuous dose of dinoprostone for 12 h and has been shown to decrease the time to vaginal delivery compared with placebo. This controlled-release insert has been compared with various prostaglandin agents and provides safe and efficacious cervical ripening in women with an unfavorable cervix.

Background: Beckwith-Wiedemann syndrome (BWS) is a distinct clinical syndrome with unique features, generally diagnosed postnatally. Case: A 26-year-old patient, gravida 4, para 3-0-0-3, was noted to have an abnormal maternal serum screen. Amniocentesis with imaging studies were remarkable only for a two-vessel umbilical cord and prominent maternal ovaries. The patient developed HELLP syndrome at 28 weeks and delivered a viable female infant with distinct clinical features. The diagnosis of BWS was confirmed by hypermethylation of the H19 gene on chromosome 11p15.5. Conclusion: This case describes a novel presentation of BWS and underscores the diagnostic potential of routine prenatal screens.

Preterm premature rupture of the membranes (PPROM) occurs in approximately 3% of all pregnancies, and accounts for one third of all preterm births. Despite its prevalence, optimal management of PPROM remains largely undefined and lacks conformity. In this article, we review the pathophysiology of PPROM, and summarize the available literature describing various management strategies in an effort to define current controversies in the management of PPROM.

Objective To compare cervical length and induced shortening changes during gestation among singleton, twin, and triplet pregnancies. Study design Thirty-two healthy gravidas (12 singleton, 13 twin, and 7 triplet pregnancies) between 17 and 20 weeks' gestation were prospectively enrolled in this longitudinal investigation of cervical length. Serial transperineal cervical length ultrasound assessments were made weekly until 34 weeks' gestation under 3 conditions: 1) supine, 2) supine with the Valsalva maneuver, and 3) standing. Cervical length, internal os diameter, and presence of cervical funneling were assessed under each condition. Multiple regression models were created using generalized estimating equations to predict these measures and accounting for confounding effects from covariates and adjusting for correlations from repeated measurements on each woman. Results A total of 1286 cervical sonographic measurements were made. In a multiple linear regression generalized estimating equations model, estimated cervical length was significantly different among singleton, twin, and triplet pregnancies. Overall, changing maternal position from supine to standing resulted in a nonsignificant change (−0.1 ± 0.4 mm) in cervical length (P = .85). In contrast, measurement of cervical length during the Valsalva maneuver resulted in a significant reduction in cervical length when compared with the cervical length measured in supine (−1.0 ± 0.3 mm) (P = .0009) and standing positions (−0.9 ± 0.4) (P = .009). The observed induced shortening changes were similar across gestation, irrespective of singleton, twin, or triplet gestation. Conclusion Longitudinal cervical length changes differ significantly throughout gestation among singleton, twin, and triplet pregnancies. Cervical length measurements made in a standing position are comparable with those measured while supine, whereas cervical lengths measured during the Valsalva maneuver are significantly shorter than those made in either the supine or standing position.

To characterize the frequency and timing of cardiotocographic abnormalities associated with the use of 3 commercially available prostaglandin analogues, misoprostol, dinoprostone gel, and dinoprostone pessary, as labor preinduction agents.One-hundred and eleven women undergoing induction of labor with an unfavorable cervix were randomized to receive either misoprostol 50 microg every 6 hours x 2 doses, dinoprostone gel 0.5 mg every 6 hours x 2 doses, or dinoprostone pessary 10 mg x 1 dose for 12 hours intravaginally. Oxytocin induction was initiated per standardized protocol. Cardiotocographic tracings were blindly reviewed, with abnormalities coded using established definitions.Fifty-five percent of women treated with misoprostol demonstrated an abnormal tracing event within the initial 24 hours of induction, compared with 21.1% with dinoprostone pessary and 31.4% with the dinoprostone gel. The mean (+/- standard deviation) number of abnormal events was significantly greater in women treated with misoprostol (5.0 +/- 5.9) versus the dinoprostone pessary (1.6 +/- 2.5) and gel (2.2 +/- 3.1) (P.05). In addition, these events occurred earlier after initial misoprostol dosing (5.0 +/- 4.0 hours), compared with the dinoprostone pessary (9.4 +/- 5.6 hours) and gel (7.7 +/- 6.6). Thirty-nine percent of the misoprostol-treated women had abnormal patterns within 6 hours of initial dosing, compared with those treated with the dinoprostone pessary (7.9%) and gel (17.1%).Cardiotocographic abnormalities are more frequent after misoprostol administration compared with the dinoprostone analogues. The early onset and frequent nature of the tracing abnormalities associated with misoprostol raises concern for the potential use of misoprostol for outpatient cervical ripening.

To test the hypothesis that preterm delivery of fetal gastroschisis prevents serious gastrointestinal compromise, facilitates primary surgical closure, and improves surgical outcome, we enrolled 16 women in a management plan. This included high-resolution ultrasound, weekly re-evaluation of the fetal gut (> or = 26 weeks), corticosteroids, and delivery if evidence of bowel compromise was present > 30 weeks. These fetuses were compared with 16 consecutive patients treated prior to establishment of this plan. Comparison of prospective trial patients with controls revealed significant differences in age at delivery (34.2 versus 37.7 weeks), serious bowel compromise (0 versus 70%), use of a surgically constructed silo (0 versus 77%), wound complications (0 versus 23%), duration of total parenteral nutrition (18.7 versus 34.7 days), time to full enteral feeding (19.1 versus 35.1 days), and hospital discharge (22.7 versus 37.7 days). Elective preterm delivery using specific ultrasound criteria resulted in improved surgical outcome without significant morbidity secondary to prematurity.

Objective To evaluate peripheral joint laxity during pregnancy and to correlate changes with serum cortisol, estradiol, progesterone, and relaxin. Methods Forty-six women with first-trimester singleton gestations consented to participate in this longitudinal observational study. Bilateral wrist laxity measurements (flexion-extension and medial-lateral deviation) were made using a clinical goniometer, and serum levels of cortisol, estradiol, progesterone, and relaxin were determined during each trimester of pregnancy and postpartum. Patients were also screened for subjective joint complaints. Statistical analysis included Student t test, analysis of variance, and linear regression analysis. Results Eleven women (24%) were excluded from the study after spontaneous first-trimester pregnancy loss. Fifty-four percent (19 of 35) demonstrated increased laxity (10% or higher) in either wrist from the first to the third trimester. Although serum levels of cortisol, estradiol, progesterone, and relaxin were significantly elevated during pregnancy, no significant differences in these levels were noted between those who became lax during gestation and those who did not. Linear regression analysis of wrist joint laxity and level of serum estradiol, progesterone, and relaxin demonstrated no significant correlation. Wrist flexion-extension laxity, however, did significantly correlate with level of maternal cortisol (r = 0.18, P = .03). Fifty-seven percent of women developed subjective joint pain during pregnancy, which was not associated with increased joint laxity, but was associated with significantly increased levels of estradiol and progesterone. Conclusion Peripheral joint laxity increases during pregnancy; however, these changes do not correlate well with maternal estradiol, progesterone, or relaxin levels.

To evaluate whether vaginal pH alters the efficacy of the controlled-release dinoprostone vaginal insert (Cervidil) for cervical ripening/labor induction.Thirty-four women with an unfavorable cervix undergoing labor induction were enrolled in this prospective, double-blind investigation. Vaginal pH and Bishop score assessments were made by an independent examiner. All women received preinduction with the dinoprostone vaginal insert 10 mg intravaginally for 12 h. Twelve hours later, oxytocin induction initiated according to the standardized protocol and outcome data were collected.Mean (+/- SD) initial vaginal pH was 4.9 +/- 0.5 for the study cohort. No significant differences were noted between women with a high vaginal pH (4.5, n = 18) and those with a low vaginal pH (or = 4.5, n = 16) with respect to maternal age, parity, gestational age, or initial Bishop score. Similarly, Bishop score change over the preinduction interval (3.2 vs. 3.3), time to active labor (28.6 vs. 24.6 h) and time to delivery (33.7 vs. 31.4 h) were not significantly different between the low and the high pH groups, respectively. Linear regression analysis revealed no significant association between vaginal pH and Bishop score change during the preinduction interval, time to active labor, time to complete dilatation, or time to delivery.Vaginal pH does not appear to influence the efficacy of the controlled-released dinoprostone vaginal insert for cervical ripening/labor induction.

This study was undertaken to determine the incidence of clinically overt postpartum urinary retention after vaginal delivery and to examine what maternal, fetal, and obstetric factors are associated with this problem.This was a retrospective case-controlled study of women who had overt postpartum urinary retention after vaginal delivery from August 1992 through April 2000.Fifty-one of 11,332 (0.45%) vaginal deliveries were complicated by clinically overt postpartum urinary retention. In most cases (80.4%), the problem had resolved before hospital dismissal. Persons with urinary retention were more likely than control subjects to be primiparous (66.7% vs 40.0%; P.001), to have had an instrument-assisted delivery (47.1% vs 12.4%; P.001), to have received regional analgesia (98.0% vs 68.8%; P.001), and to have had a mediolateral episiotomy (39.2% vs 12.5%; P.001). On multivariate logistic regression analysis, of these 4 variables, only instrument-assisted delivery and regional analgesia were significant independent risk factors.Clinically overt postpartum urinary retention complicates approximately 1 in 200 vaginal deliveries, with most resolving before hospital dismissal. Factors that are independently associated with its occurrence include instrument-assisted delivery and regional analgesia.

As there is evidence that ligamentous laxity is affected by the female hormones, we hypothesized that hormonal changes occurring during pregnancy could have a therapeutic role in preventing the development of a joint contracture. Knee joint contractures were created in pregnant and nonpregnant rats. After 2 wk of immobilization, the degree of contracture was measured with structural properties of the medial collateral and anterior cruciate ligaments and the pubic symphysis. Although not statistically significant, there was a general trend toward reduced contracture in pregnant compared with nonpregnant rats. Cutting the posterior capsule significantly decreased contracture for both the pregnant and nonpregnant groups, confirming the contribution of capsular structures to contracture. Ultimate loads of the medial collateral and anterior cruciate ligaments significantly decreased after immobilization compared with control, but there was no significant effect due to pregnancy. Stiffness and ultimate load of the pubic symphysis were not significantly different between pregnant and nonpregnant groups. The trend toward reduced contracture with pregnancy points toward a possible therapeutic role for female hormones in the prevention of postoperative and/or posttraumatic joint contracture.

To evaluate the incidence and chronology of sonographic markers of neurological compromise in prenatally diagnosed neural tube defects.We reviewed our ultrasound database from 1988 to 1999 to identify all cases of prenatally diagnosed neural tube defects. All patients received an initial detailed targeted ultrasound evaluation with subsequent evaluations every 4-6 weeks. Cases involving multiple congenital anomalies, aneuploidy, or inadequate follow-up were excluded. Specific ultrasound markers assessed included the presence of ventriculomegaly (10 mm) and clubfoot.Forty-seven cases of neural tube defects were identified over the study interval. After exclusions, 42 cases were available for evaluation. The overall incidence of ventriculomegaly and clubfoot in the study cohort was 86% and 38%, respectively. In the 33 patients with initial ultrasound examination performed at24 weeks' gestation, 76% (25/33) had evidence of ventriculomegaly and 30% (10/33) and clubfoot. Only 9% (1/11) of the patients managed expectantly developed evidence of ventriculomegaly and 3/11 (27%) developed clubfoot from the time of the initial ultrasound examination to delivery.Ultrasound markers of neurological compromise are early and frequent findings associated with fetal neural tube defects. Development of ventriculomegaly is an uncommon occurrence later in gestation, while the risk for developing clubfoot appears to increase as gestation progresses.

Profound physiologic changes in the gastrointestinal tract are encountered in pregnancy. Gastrointestinal motility and gastric emptying are decreased. These changes and the displacement and physiologic relaxation of the cardiac sphincter result in increased gastric reflux. In addition, function of the gallbladder and pancreas are altered in pregnancy. These changes can make the diagnosis and treatment of various gastrointestinal disorders difficult. Although pregnancy does not predispose the gravid woman to cholecystitis or pancreatitis, it does increase the risk of cholelithiasis and biliary sludge formation. 35,63 Disease of the gallbladder or pancreas can have a large impact on fetal morbidity and mortality. 45 Knowledge of these physiologic changes and of the management of specific disease processes is key to improving the outcome for the pregnant woman and fetus.

Cardiovascular adaptations of pregnancy are generally well tolerated in the healthy gravida; however, these changes can place undue stress on women with underlying cardiovascular disease and can result in increased risk for morbidity and mortality. In this article, we will review issues related to preconceptional counseling, cardiovascular adaptations of pregnancy, and the prognosis and management of the gravida with cardiac disease in pregnancy.

Objective: We sought to evaluate whether vaginal pH has an effect on the relative efficacy of misoprostol for cervical ripening and labor induction. Study Design: Thirty-seven gravid women with an unfavorable cervix and indication for labor induction were enrolled in this prospective, double-blind, observational study. Baseline assessments of cervicovaginal pH and Bishop score were made at the time of enrollment by an independent examiner. All patients received 50 μg misoprostol intravaginally every 6 hours for 12 hours. After the initial 12 hours of preinduction, a repeat Bishop score assessment was made by the same initial examiner. Patients not in active labor at 12 hours were placed on a standardized oxytocin induction regimen. Labor was managed by the on-call obstetric team, who remained blinded to pH assessment. Clinical outcomes were evaluated. Statistical analyses were made by the Student t test, the Fisher exact test, and linear regression analysis. Results: Average initial vaginal pH was 4.8 ± 0.5 (range, 3.5-7.0) for the study cohort. No significant differences were noted between those patients with low vaginal pH (≤4.5) compared with those with high pH vaginal (>4.5) with respect to maternal age, parity, gestational age, or initial Bishop score. Similarly, Bishop score change over preinduction interval (5.6 vs 4.9), time to active labor (16.3 vs 17.1 hours), time to complete dilatation (20.0 vs 19.9 hours), and time to delivery (21.0 vs 21.6 hours) were not significantly different between the low and high pH groups, respectively. Linear regression analysis revealed no significant association between vaginal pH and Bishop score change during preinduction interval, time to active labor, time to complete dilatation, or time to delivery. Conclusion: Vaginal pH does not appear to influence the efficacy of intravaginally administered misoprostol for cervical ripening and labor induction. (Am J Obstet Gynecol 2000;182:1616-9.)

Syphilis is an indolent systemic spirochetal infection that remains a global health concern. Increased rates of HIV infection and intravenous drug abuse have slowed attempts to eliminate syphilis. Although the incidence of syphilis is currently declining in the United States, it remains an important health concern for women. As women are often affected by syphilis during their reproductive years, the potential risks to offspring are great. Treponema pallidum , the etiologic agent of syphilis, readily traverses the placenta, resulting in fetal infection. Vertical transmission may occur at any gestational age and at any stage of syphilis. Congenital syphilis is a serious infection with profound effects on the fetus/neonate. Clearly, access to prenatal care is an important factor in prevention of this condition. In spite of the plethora of antibiotics presently available in our medical armamentarium, penicillin remains the only safe and effective agent for the treatment of syphilis in pregnancy. Penicillin desensitization is indicated in patients with proven penicillin allergy. Clearly, additional research to improve our prevention, diagnostic, and treatment strategies is needed as we move into the new millennium, to further reduce the morbidity and mortality associated with syphilis and congenital syphilis.

BACKGROUND: Fallopian tube prolapse is reported to most commonly occur after vaginal hysterectomy. Both diagnosis and management have varied, resulting in differing efficacies of treatment. METHODS: We reviewed the presentation, diagnosis, management, and outcomes of 18 cases of tubal prolapse in 17 women. RESULTS: Most cases (65%) occurred after abdominal hysterectomy. The post-hysterectomy course was complicated by cuff cellulitis in three women, an infected cuff hematoma in one, and post-extubation pulmonary edema in one; four were observed for elevated temperature only. At presentation, 44% complained of dyspareunia, 39% vaginal bleeding, 33% vaginal discharge, 28% abdominal pain, and 28% were asymptomatic. Seven women had vaginal excision (one requiring an additional abdominal procedure), three had laparotomy with salpingectomy, and seven (41%) had spontaneous disappearance of prolapsed fallopian tube without treatment. CONCLUSIONS: In our series, tubal prolapse most commonly occurred after abdominal hysterectomy. Moreover, women with tubal prolapse may be asymptomatic, and observation alone may lead to resolution.

Ultrasonography (US) is the modality of choice for prenatal screening, but occasionally additional imaging information is needed. Magnetic resonance (MR) imaging is an attractive alternative but until recently has been limited by motion artifact. Single-shot fast spin-echo MR imaging was used to depict normal and abnormal anatomy in 26 fetuses. Thirteen studies were performed for maternal indications and 13 were performed to evaluate fetal abnormalities identified or suspected at US. Three of the fetal abnormalities involved the central nervous system (CNS) and 10 involved other anatomic sites. Results were correlated with findings at postnatal clinical examination, imaging, and pathologic analysis. MR imaging demonstrated normal fetal anatomy without substantial motion artifact. CNS structures were well visualized as early as 18-20 weeks gestation, as were most other normal anatomic structures except the heart. MR imaging also allowed characterization of a variety of abnormalities of the CNS (Arnold-Chiari malformation, Walker-Warburg syndrome, amniotic band syndrome) as well as of other structures (renal agenesis, multicystic dysplastic kidney, abdominal masses, severe limb-body wall defect, clubfoot with arthrogryposis, diaphragmatic hernia). US findings were confirmed in most cases, and additional information about the precise diagnosis or the severity or location of the anomaly often helped guide clinical management. Single-shot fast spin-echo MR imaging of the fetus is a useful adjunct to US in difficult diagnostic situations.

Diabetic ketoacidosis (DKA) remains a medical emergency with high maternal and fetal mortality. Prompt recognition and resuscitative therapy markedly improves outcome. The pathophysiology and management of DKA in pregnancy is discussed in detail in this article.

Hypertensive disease remains second only to embolic phenomena as a leading cause of maternal mortality. This article covers the major physiologic and pathologic findings to be considered when managing pregnant women with eclampsia. Attention to detail and an increased degree of suspicion will improve fetal and maternal outcomes.

Cardiac transplantation is becoming more common, with over 3,000 cases annually in the United States. The increase in the number of cases and survival rates has resulted in a rise in the number of women of reproductive age receiving transplants. Special considerations for pregnant cardiac transplant recipients include the development of a baseline tachycardia (vagal denervation), asymptomatic myocardial ischemia (sensory denervation), tachyarrhythmias, and maternal death due to rejection. Perinatal morbidity and mortality are increased due to a rise in the incidence of preterm delivery, hypertensive disorders, renal insufficiency, small for gestational age infants, and infectious complications. The obvious benefits of immunosuppressant medications far outweigh any presumed fetal risks. A team approach to management can result in the most favorable outcome for mother and child.

In this article, we describe two pregnancies in the same patient after pancreatic-renal transplantation. Severe, labile hypertension necessitated delivery at 35 weeks during the patient's first pregnancy and at 30 weeks (associated with renal graft obstruction) during her second pregnancy. Women with insulindependent diabetes mellitus who undergo pancreatic-renal transplantation can have a successful pregnancy if adequate multidisciplinary, specialized medical care is rendered.

Although venous thromboembolism is a rare complication of pregnancy, it is one of the leading causes of maternal mortality. As many as 40% of asymptomatic women with deep venous thrombosis may indeed have a pulmonary embolism. Therefore, pregnant women with thromboembolic disease, a history of thromboembolic disease, or those who are at increased risk of thromboembolism (mechanical cardiac valve prostheses, antithrombin II, or protein C or S deficient) should receive anticoagulant therapy. The choice of anticoagulant therapy in a pregnant woman as well as the dose and duration will depend on the specific condition being treated. Although anticoagulant therapy is beneficial, it is not without risks to both mother and fetus. This article discusses the use of anticoagulants and thrombolytics in pregnant women.

Background An arteriovenous fistula in the female pelvis is a rare finding. We report a pelvic arteriovenous fistula diagnosed antepartum. Case At 38 weeks' gestation, a 32-year-old woman, gravida 3, para 1, was found on bimanual examination to have a pulsating mass on the left vaginal sidewall. Magnetic resonance imaging revealed a tangle of arteries feeding into an aneurysmal dilation of a branch vein of the left internal iliac, extending to the left lateral wall of the cervix and vagina, and ending in a large varix in the lateral wall of the vagina. The patient was asymptomatic and underwent primary cesarean delivery of a healthy female infant. Twice during her postpartum course, she underwent angiography and embolization of extensive left- and right-sided feeding vessels. Five to 6 weeks after each embolization, the vaginal mass recurred. Conclusion A pelvic arteriovenous malformation diagnosed antepartum presents a dilemma in regards to risk of hemorrhage, congestive heart failure, and successful ablation.

Objective To investigate the hypothesis that meconium aspiration syndrome, the major hazard of meconium during labor, may be associated with superimposed fetal acute acidemia. Methods: Umbilical artery blood gases were measured in 7816 term pregnancies with meconium in the amniotic fluid (AF) and the results were correlated with intrapartum and neonatal outcomes. Results Sixty-nine (1%) infants developed meconium aspiration syndrome and 31 (45%) of these were in association with fetal acidemia at birth. Moreover, umbilical blood gas analysis and intrapartum events suggested that the fetal acidemia linked to meconium aspiration was an acute event rather than a long-duration process, which might be expected if meconium was itself a marker of an antecedent fetal asphyxiai event. Conclusion Meconium in the AF may be a fetal environmental hazard when acidemia supervenes rather than solely a marker of preexisting fetal compromise leading to the release of meconium.

OBJECTIVE: Our purpose was to determine the cause and describe the natural history of acute pancreatitis complicating pregnancy and its effect on maternal and perinatal outcomes. STUDY DESIGN: Over the last decade we admitted 43 pregnant women with acute pancreatitis to our hospital. We reviewed presentation, diagnosis, management, and maternal and perinatal outcomes. RESULTS: The incidence of acute pancreatitis was one in 3333 pregnancies. The mean age of these 43 women was 24 years, 31 (72%) were multiparous, and pancreatitis was associated with biliary disease in 29 (68%). All had a favorable response to supportive therapy that included bowel rest, intravenous hydration, and antimicrobial therapy. Cholecystectomy was performed for persistent or recurrent biliary or pancreatic disease ante partum in eight women and post partum in another 12. Of 39 women who were delivered at our hospital, 32 were at term and their infants did well. The other six infants were delivered preterm; two were stillborn and another died after birth. One woman underwent a therapeutic abortion. CONCLUSIONS: Most pregnant women with acute pancreatitis have associated biliary tract disease. With prompt hospitalization, supportive care, and surgical intervention when indicated, maternal and fetal morbidity and mortality are not prohibitive. Fetal death and preterm delivery may result from severe disease.

To determine the correlation between transperineal or translabial ultrasound and digital examination of the cervix in the third trimester in women presenting to the obstetrical triage area complaining of uterine contractions and/or rupture of membranes.One hundred women were evaluated initially with an ultrasound unit using a 5-MHz glove-covered curvilinear transducer applied to the perineum in the sagittal plane. Immediately after the ultrasound evaluation, another examiner assessed the cervix digitally, blinded to the sonographic results. Cervical dilatation, length, and station were assessed.Transperineal ultrasound correlated (P.001) with digital cervical examination in the assessment of dilatation (Pearson correlation coefficient 0.87), length (Pearson correlation coefficient 0.80), and corrected station (Pearson correlation coefficient 0.69).There is a statistically significant correlation between the digital cervical examination and the sonographic assessment of cervical dilatation, length, and station by the transperineal approach.

Objective : Our purpose was to study the efficacy of ephedrine versus angiotensin II prophylactic infusions to counter maternal hypotension that occurs during spinal anesthesia at cesarean delivery. Study Design : Healthy pregnant women undergoing elective repeat cesarean delivery at term with spinal anesthesia were randomized either to a control group ( n = 10) or to one of two prophylactic infusion groups: angiotensin II ( n = 10) or ephedrine ( n = 10). Prophylactic infusions were titrated to a maternal diastolic blood pressure 0 to 10 mm Hg above baseline. Maternal and fetal blood samples for angiotensin II levels and acid-base status were obtained. Student's t test, χ 2 , and analysis of variance were used. Results : Mean arterial pressures were maintained after spinal anesthesia in the ephedrine and angiotensin II groups but decreased ( p ≤ 0.05) in the control group. Maternal angiotensin II levels rose with angiotensin II infusions but were unaltered in the other groups. Umbilical artery and vein angiotensin II levels were unaltered by angiotensin II infusions. Mean umbilical artery blood pH was lower ( p ≤ 0.05) in the ephedrine group than in the angiotensin II and control groups. Conclusions : In the healthy term fetus there is an advantage in using angiotensin II to maintain maternal blood pressure during regional anesthesia.

Background: Salmonella typhi may be a cause of significant morbidity and mortality in both the mother and fetus. Febrile illness during pregnancy, especially that associated with hemolysis, is associated with chorioamnionitis, pyelonephritis, or viral syndrome. As such, S. typhi should be considered when a patient presents with a fever and hemolysis. We present a case of S. typhi complicating pregnancy.Case: A primigravida at 26 weeks gestation presented with persistent spiking temperature and severe hemolysis. Her presenting signs and symptoms included fever, vomiting, cough, earache, jaundice, dark urine, and anemia. After 4 units of blood, her posttransfusion hematocrit was 29%. Hemolysis was evident on a peripheral blood smear. Total bilirubin was 2.5 mg/dl and direct bilirubin was 1.2 mg/dl. Gentamicin and clindamycin were administered empirically. Stool, blood, and urine cultures were obtained. Blood cultures were positive for S. typhi. Antibiotic coverage was changed to gentamicin and ceftriaxone. She defervesced on the 5th day and had no further problems. A healthy male infant was delivered vaginally at term.Conclusion: Typhoid fever is a serious infection, and special concern arises when S. typhi complicates pregnancy. The diagnosis of S. typhi should be considered in a gravida presenting with fever with prompt institution of antibiotic therapy. Appropriate cultures are essential for confirming the diagnosis.

A 37-year-old pregnant woman presented at 18 weeks' gestation with unrelenting chest and shoulder pain, massive pleural effusion, and a large thoracic mass. Biopsy revealed an undifferentiated sarcomatous pleural mesothelioma. Malignant mesothelioma is a rare thoracic malignancy, which has not been described in pregnancy and appears to be minimally affected by the pregnant state.

Objective. The purpose of this study was to compare 2 protocols for the antenatal management of isolated mild fetal pyelectasis and perform a cost analysis. Methods. A retrospective analysis of unilateral and bilateral mild fetal pyelectasis followed at our institution from 2003 to 2006 was conducted. Fetuses with additional congenital anomalies or aneuploidy were excluded. x 2 analysis was used, and P

Breech presentation occurs at term in approximately 3% to 4% of singleton gestations. This presentation is associated with a variety of maternal and fetal conditions including preterm labor, abnormal amniotic fluid volume, hydrocephaly, anencephaly, mullerian anomalies, abnormal placentation, and multifetal gestation. Cesarean delivery has been associated with increased risk of subsequent accreta, placenta previa, hemorrhage, and hysterectomy. The Term Breech Trial initially suggested that planned vaginal breech delivery is associated with increased neonatal morbidity and mortality compared with planned cesarean delivery. Long-term follow-up of these vaginally delivered infants contradict the initial findings. Current debate surrounds the dilemma of whether the untoward complications of cesarean delivery are warranted given uncertain minimal increases in neonatal survival and improvement in neurologic outcome with planned cesarean.

To characterize variation and factors associated with the perceived gestational age for the threshold of viability among maternal-fetal medicine (MFM) providers.We performed a web-based online survey of 1375 MFM providers. For this secondary analysis, a subset of survey questions targeted toward perceptions of the limit of viability was analyzed to identify how the respondents viewed the optimal threshold of viability gestational age. Comparative statistics were performed to assess various characteristics that influence the perceived threshold of viability.Five hundred and eight providers (37%), representing all 50 states and 13 countries, responded to the survey. The reported threshold of viability varied among survey respondents: 22 weeks, 2.0%; 23 weeks, 37.2%; 24 weeks, 55.3%; 25 weeks, 3.4%; and 26 weeks, 2.2%. No significant differences were noted in the reported threshold of viability with respect to practitioner age (50 years old vs.or =50 years old, p = 0.42), nursery availability (level III vs. other, p = 0.46), and years in practice (10 years vs.or =10 years, p = 0.86). Significant differences in the reported threshold of viability were noted with respect to practitioner gender with males tending to have a lower gestational age threshold than females (p = 0.005). Significant differences were also noted among practitioners from academic vs. community/private practice settings (p = 0.008). A logisitic regression model, adusting for both gender and practice setting, revealed that male gender was independently associated with selection of a threshold of viability less than 24 weeks of gestation: male gender OR 1.8 (95% CI 1.3-2.7, p = 0.002); academic practice setting OR 1.1 (95% CI 0.8-1.6, p = 0.50).Perceived threshold of viability among MFM providers varies with the majority of practitioners identifying 23-24 weeks of gestation. Significant difference, however, exists between practitioner genders.

Budd-Chiari syndrome is a rare and serious thrombotic event with significant morbidity and mortality. Recommendations regarding future conception and management during pregnancy have not been defined. We present a patient with history of idiopathic Budd-Chiari Syndrome and subsequent orthotopic liver transplantation who was successfully managed during pregnancy. A 24-year-old white female, gravida 1 para 0, status postorthotopic liver transplantation 5 years previously for Budd-Chiari syndrome with post-transplant insulin-dependent diabetes mellitus presented to our clinic at 7 weeks of gestation for initial prenatal evaluation. Maintenance immunosuppressive therapy and prophylactic heparin anticoagulation was administered throughout the pregnancy, which was uneventful until 35 weeks gestation, at which time pre-eclampsia and premature preterm rupture of membranes prompted labor induction. The patient developed no evidence of acute or chronic hepatic rejection and no evidence of recurrent Budd-Chiari syndrome during the pregnancy or post-partum convalescence. Prudent use of prophylactic anticoagulation, close immunosuppressive monitoring, and periodic fetal and maternal surveillance are warranted in patients with previous orthotopic liver transplantation for idiopathic Budd-Chiari syndrome and may reduce risk of recurrence during pregnancy.

To compare preterm premature rupture of membranes (PPROM) management between maternal-fetal medicine (MFM) providers practicing in an academic university (AU) versus other settings (NAU).Secondary analysis of a national survey of 1375 MFM providers of whom 504 (37%) responded and answered queries on demographic and practice characteristics and various PPROM management issues.Fifty-three percent of the respondents were in an AU practice setting. Providers in AU and NAU settings reported a similar prevalence of corticosteroid (99% vs. 100%), antibiotic (99% vs. 100%), and tocolytic (74% vs. 76%) use. There was significant variability between NAU and AU providers in issues related to the evaluation and expectant management of PPROM. NAU providers, as compared to AU providers, more commonly reported performing diagnostic amniocentesis in the acute evaluation of PPROM (72% vs. 61%, p = 0.02). There was a higher prevalence of fetal lung maturity assessment among NAU providers (84%) as compared to AU providers (73%, p = 0.005) and significant variability was noted with respect to the fetal lung maturity tests used (p0.0001). NAU providers continued expectant management later into gestation than AU providers (p = 0.002). Significant variability was also noted in the use of antepartum surveillance techniques (p = 0.01).MFM practitioners from academic universities and non-academic settings utilize similar management strategies for PPROM in regard to corticosteroid, tocolytic, and antibiotic use. However, differences are evident in issues related to the evaluation and expectant management of patients with PPROM.

Objective This study was undertaken to characterize variations in the management for women with preterm premature rupture of membranes (PPROM) among maternal-fetal medicine (MFM) specialists in the context of current recommendations for clinical practice and evidenced-based practice. Study design We performed a Web-based survey of 1375 MFM providers. Participants were queried on practice characteristics and management issues including use of tocolytics, antibiotics, steroids, and timing of delivery. Results A total of 508 providers (37%), representing all 50 states and 13 countries, responded to the survey. Only 30% reported a formal departmental protocol for managing women with PPROM. Consistent use of steroids (99.4%) and antibiotics (99.6%) were reported. Administration of steroids was confined to ≤32 weeks by 37%, and ≤34 weeks by 51% of practitioners. Repeated dosing of steroids was uncommon (16%). The antibiotics use and rationale for use varied among respondents. Tocolytics were used by 73% of respondents with magnesium sulfate the main agent used (98%). Use of tocolytics was generally used for 48 hours or less to attain steroid benefit (88%). Amniocentesis was used by 66% of practitioners in the acute evaluation of PPROM. Fetal lung maturity testing was reported by 78% with variability noted with respect to the test used. Outpatient management of women with PPROM after viability was noted by 43% of respondents. Gestational age at which expectant management is abandoned in women with PPROM varied significantly between respondents: ≥34 weeks by 56%, ≥35 weeks by 26%, ≥36 weeks by 12%, and ≥37 weeks by 4.0%. Conclusion Although many management practices for women with PPROM are consistent with currently available evidence and practice recommendations, substantial variations still exist among MFM providers.

A 30-year-old pregnant woman with a history of an uncomplicated curettage for incomplete abortion was seen at 33 weeks' gestation with decreased fetal movement and intermittent abdominal pain for 1 week. Ultrasonographic evaluation demonstrated a singleton vertex pregnancy, oligohydramnios, and a fundal uterine rent continuous with a large, fluid-filled cystic mass. Laparotomy revealed a right cornual uterine rent with hourglass amniotic sac and fluid. A healthy infant was delivered by cesarean section.

We report three consecutive hydropic fetuses with fetal tachyarrhythmias treated with amiodarone—two in combination with digoxin and one with digoxin, procainamide, and propranolol. Sinus rhythm was achieved in one case and ventricular rate control was achieved in two cases. All fetuses treated with amiodarone gradually improved. Observed side effects of amiodarone were a maternal rash in one mother and transient neonatal hypothyroidism in one infant. We conclude that amiodarone might be effective and safe for fetal tachyarrhythmias and impending hydrops. The small number of patients suggests that a multicenter cooperative approach is required in order to determine if this is correct.

T cells are produced through 2 mechanisms, thymopoiesis and proliferative expansion of postthymic T cells. Thymic output generates diversity of the pool, and proliferation achieves optimal clonal size of each individual T cell. To determine the contribution of these 2 mechanisms to the formation of the initial T-cell repertoire, we examined neonates of 30 to 40 weeks' gestation. Peripheral T cells were in a state of high proliferative turnover. In premature infants, 10% of T cells were dividing; the proliferation rates then declined but were still elevated in mature newborns. Throughout the third trimester, concentrations of T-cell–receptor excision circles (TRECs) were 10 per 100 T cells. Stability of TREC frequencies throughout the period of repertoire generation suggested strict regulation of clonal size to approximately 10 to 20 cells. Neonatal naive CD4+ and CD8+ T cells were explicitly responsive to IL-7; growth-promoting properties of IL-15 were selective for newborn CD8+ T cells. Neonatal T cells expressed telomerase and, in spite of the high turnover, built up a telomeric reserve. Thus, proliferative expansion, facilitated by increased cytokine responsiveness, and thymopoiesis complement each other as mechanisms of T-cell production in neonates. Maintaining optimal clonal size instead of filling the space in a lymphopenic host appears to regulate homeostatic T-cell proliferation during fetal development.

Objective: The purpose of this study was to characterize the pharmacokinetics of orally administered azithromycin in the term gravid woman. Study Design: Twenty women who were scheduled for elective cesarean delivery were enrolled prospectively and received 1 g of oral azithromycin at either 6, 12, 24, 72, or 168 hours before the operation. All women received spinal anesthesia, at which time a sample of cerebrospinal fluid was obtained for analysis. Maternal serum and urine were obtained immediately before the operation. Intraoperatively, samples of myometrium, maternal adipose tissue, placenta, amniotic fluid, and umbilical arterial and venous cord blood were obtained. Azithromycin levels were determined quantitatively with high-pressure liquid chromatography with electrochemical detection. Results: All participants tolerated the preoperative azithromycin without significant adverse reactions. Peak maternal serum azithromycin levels occurred within 6 hours of drug administration. Although high serum levels of azithromycin were reached early, a rapid decline in drug concentration was noted over the initial 24 hours after the drug administration (6-hour: 311 ng/mL; 24-hour: 63 ng/mL). In contrast, azithromycin levels in myometrial, adipose, and placental tissue were higher (>500 ng/mL) and sustained for up to 72 hours after administration. High urine levels of azithromycin (>5000 ng/mL) were noted similarly during the initial 72 hours after drug administration. Umbilical arterial and venous serum azithromycin levels were low (19-38 ng/mL) during the first 72 hours. Amniotic fluid levels were highest at 6 hours (151 ng/mL) and declined rapidly. Maternal cerebrospinal azithromycin concentrations were undetectable for all time points. Conclusion: Azithromycin has a rapid serum half-life in the term gravid woman with a prolonged half-life and high-sustained antibiotic levels noted within myometrium, adipose, and placental tissue. Given the broad antimicrobial spectrum and placental penetration, azithromycin may have potential use for the treatment of perinatal infections. (Am J Obstet Gynecol 2003;188:714-8.)

The purpose of this study was to compare the relative efficacy and cost of three commercially available prostaglandin analogs, misoprostol (Cytotec), dinoprostone gel (Prepidil), and dinoprostone insert (Cervidil), as labor preinduction agents.One-hundred eleven women with an unfavorable cervix who underwent labor induction were assigned randomly to receive either misoprostol 50 microg every 6 hours for two doses, dinoprostone gel 0.5 mg every 6 hours for two doses, or dinoprostone insert 10 mg for one dose intravaginally. Twelve hours later, oxytocin induction was initiated per standardized protocol. Efficacy and cost of the labor preinduction/induction with the study treatments were compared.Mean Bishop score change (+/-SD) over the initial 12-hour interval was significantly greater in the misoprostol group (5.2 +/- 3.1) compared with the dinoprostone insert (3.2 +/- 2.3) or the dinoprostone gel groups (2.2 +/- 1.3, P.0001). The proportion of women who reached complete dilation (68.4%, 50.0%, 51.4%, respectively; P =.14) and who were delivered (60.5%, 47.4%, 40.0%, respectively; P =.10) within 24 hours of the initiation of induction were not significantly different between the misoprostol, dinoprostone insert, and dinoprostone gel groups. Induction-to-delivery intervals, however, were significantly shorter among women who treated with misoprostol (24.0 +/- 10.8 hours) compared with either the dinoprostone gel (31.6 +/- 13.4 hours) or the dinoprostone insert (32.2 +/- 14.7 hours, P.05). Overall mean cost per patient that was incurred by labor induction was significantly less for the misoprostol group ($1036.13) compared with the dinoprostone insert group ($1565.72) or the dinoprostone gel group ($1572.92, P.0001). No significant differences were noted with respect to the mode of delivery or to the adverse maternal/neonatal outcome.Misoprostol is more cost-effective than the comparable commercial dinoprostone prostaglandin preparations as an adjuvant to labor induction in women with an unfavorable cervix.