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The efficacy of cervical ripening with two Foley catheter volumes, 30mL and 80mL, is compared in a study. Results show that ripening of the unfavorable cervix in primiparous women with a Foley catheter balloon inflated with 80mL of sterile saline resulted in more dilation, faster labor, and a decreased need for oxytocin than with a balloon inflated with a 30mL of the solution.

Pregnancies complicated by diabetes may result in fetal birth defects only if poor blood sugar control occurs at specific times of fetal development. Researchers induced high blood sugar levels in pregnant rats to determine their effect on fetal development. High blood sugar levels caused defects in fetal development during days 10 and 11 of the rat pregnancy. A 20% rate of defects occurred at blood sugar levels double the normal concentration, a 50% rate of defects at blood sugar levels four times the norm, and a 100% rate of defects at blood sugar levels six times the norm. High blood sugar levels had to be sustained for at least two hours for defects to occur. Defects may not occur if high blood sugar levels are not present during critical periods of development.

Byline: Zion J. Hagay, Galya Biran, Asher Ornoy, E.Albert Reece Keywords: Congenital cytomegalovirus infection; prenatal diagnosis; serologic tests; mass screening Abstract: OBJECTIVE: The purpose of this study was to review the accuracy of current tests used for the diagnosis of in utero cytomegalovirus infection and to discuss the potential value of preconceptional and postconceptional screening programs for prevention of congenital infection. STUDY DESIGN: A computer-assisted search was performed for relevant English language publications between 1987 and 1994. We identified 119 cases of suspected intrauterine cytomegalovirus infection in which either amniotic fluid or fetal blood had been analyzed antenatally. RESULTS: Congenital cytomegalovirus infection affects 0.5% to 2.5% of all newborns. The rate of transmission to the fetus after primary infection during pregnancy ranges from 15% to 50%. Of the fetuses infected in utero, 10% exhibit congenital cytomegalovirus syndrome. Evaluation of 119 cases of suspected infection has shown that polymerase chain reaction and cultures of amniotic fluid are the most reliable tests for prenatally determining the presence of viral particles. However, efficacy of routine antenatal screening in reducing the rate of fetal disease is limited. CONCLUSION: It is concluded that at present the accuracy of tests used for the diagnosis of in utero cytomegalovirus infection is undetermined. Serologic screening of all pregnant women is of limited value and at present is not recommended. (AM J OBSTET GYNECOL 1996;174:241-5.) Author Affiliation: Rehovot and Jerusalem, Israel, and Philadelphia, Pennsylvania Article History: Received 15 December 1994; Revised 24 March 1995; Accepted 4 May 1995 Article Note: (footnote) [star] From the Departments of Obstetrics and Gynecology, Kaplan Hospital,a the Jerusalem Institute of Child Development and Laboratory of Teratology, The Hebrew University, Haddasah Medical School, b and Temple University School of Medicine. , [star][star] Reprint requests: Zion J. Hagay, MD, Department of Obstetrics and Gynecology, Kaplan Hospital, Rehovot, Israel., a 0002-9378/96 $5.00 + 0 6/1/66061

Higher than normal levels of the copper zinc superoxide dismutase gene in fetuses may protect them from developing abnormally as a result of diabetes in their mothers. Copper zinc superoxide dismutase is an enzyme that may rid the body of oxygen free radicals, which are overproduced in connection with diabetes mellitus and may cause fetuses to form abnormally. Researchers induced diabetes in mice that were pregnant with embryos either with the human copper zinc superoxide dismutase gene or without it. Mouse embryos with the copper zinc superoxide dismutase gene did not experience growth reductions, had a low rate of malformation and a low rate of fetal death, whereas embryos without the gene were more likely to be small, malformed, or to die before the end of pregnancy.

Brief episodes of moderate low blood sugar do not appear to affect the fetus of insulin-dependent diabetic women. While it is known that tight metabolic control improves pregnancy outcomes among insulin-dependent diabetics, this results in frequent episodes of hypoglycemia. Ten insulin-dependent diabetic women at gestational ages ranging from 27 to 37 weeks underwent a controlled reduction of blood sugar by infusing insulin. Maternal blood sugar was reduced to 45 mg/dl for 40 minutes. Electronic fetal monitoring and ultrasound imaging evaluated fetal heart rate, fetal practice breathing movements (a measure of fetal well-being), and fetal limb movements. Placental perfusion was evaluated via Doppler ultrasound studies as well. No adverse fetal effects were found. The effects of long-term or severe hypoglycemia on the fetus has not been studied.

OBJECTIVE: New portable devices have become available for home monitoring of fetal heart rates; these devices have the potential to immediately transmit these tracings to a medical facility. The null hypothesis of this study is the inability of mothers to perform their own nonstress tests (self-nonstress tests) and that such tests are not comparable to those performed by professional medical personnel (assisted nonstress tests). STUDY DESIGN: The feasibility of maternal self-testing was established in 50 high-risk patients followed by a controlled clinical trial conducted in 60 patients. The latter study represents the first controlled trial in which patients performed self-nonstress tests at their homes and transmitted the tracings via telecommunication to our perinatal unit. In all cases these patients came to our hospital within 60 minutes after the self-nonstress tests to have a perinatal nurse perform a second nonstress test. The pairs of self and assisted fetal heart rate tracings were independently reviewed by two investigators. RESULTS: The self and assisted tracing pairs were judged satisfactory for interpretation in 100% and 90%, respectively; self and assisted were interpreted by each examiner to be nonreactive in 20% and 14%, respectively. However, both examiners were unable to distinguish between tracings generated by assisted nonstress and self-nonstress tests. Furthermore, cost analysis revealed an estimated twofold savings with self-nonstress testing compared with the assisted nonstress test. CONCLUSION: Self-nonstress testing is a reliable and accurate method of antepartum fetal heart rate testing. This method of fetal assessment not only introduces a new approach to fetal surveillance with added convenience to patients, but may also significantly reduce medical cost without compromising the results of fetal testing. (Am J Obstet Gynecol 1992;166:489-92.)

Accurate, rapid diagnosis of the presence of microbes in the amniotic fluid is essential to prevent complications, which can include premature delivery and a host of problems for both mother and infant. However, many medical centers that use amniocentesis (sampling of amniotic fluid) analyze their samples using the Gram stain, a microbiological method that can fail to detect microorganisms in as many as half the cases in which they are present. In this study, the amniotic fluid white blood cell count was evaluated as a method of diagnosing microbial invasion. Amniotic fluid samples were taken from 195 patients undergoing preterm labor with a single fetus; the patients underwent treatment with tocolytic agents (to inhibit uterine contractions). The samples were evaluated with the Gram stain and in tissue culture, as well as for concentrations of white blood cells. Pregnancies progressed to term in 84 cases (43 percent) and microorganisms were present in 25 cases (12.8 percent). Those with positive culture results had higher levels of white blood cells than those with negative results. The sensitivity of the white blood cell count (extent to which that test correctly identified the infected women) was 80 percent; and its specificity (extent to which the test correctly diagnosed the absence of infection) was 87.6 percent. The sensitivity of the white blood cell count was higher than that of the Gram stain, but its specificity was lower. On the whole, the amniotic fluid white blood cell count is sensitive, simple, and inexpensive. Patients with levels equal to or less than 50 cells per cubic millimeter were at risk for premature delivery. (Consumer Summary produced by Reliance Medical Information, Inc.)

Women with ovarian cystic teratoma can probably become pregnant and deliver a healthy baby. In a study of 49 women with this benign tumor, 63 out of 68 pregnancies were not affected by the tumor, and the tumor did not grow bigger during the pregnancy.

Ureaplasma urealyticum was isolated from the amniotic fluid of a patient with preterm premature rupture of membranes at 24 weeks. A second amniocentesis performed 48 hours later indicated an increase in the number of neutrophils in the amniotic fluid. Treatment with erythromycin, ampicillin, gentamicin, and clindamycin was instituted for a period of 6 days. Amniotic fluid analysis from a third amniocentesis performed 24 hours after discontinuation of antibiotic treatment revealed only a few white blood cells and was negative for microorganisms. The pregnancy continued for 22 days after admission, at which time spontaneous labor began. The neonate survived with no sequelae and had negative blood cultures. Antibiotic treatment was associated with eradication of Ureaplasma urealyticum from the amniotic cavity, pregnancy prolongation, and neonatal survival. (Am J Obstet Gynecol 1992;166:618-20.)

Retained placenta is a placenta that does not spontaneously separate from the uterus within 30 minutes after delivery of the infant. Retained placenta appears to occur at a higher rate in preterm deliveries (between 20 and 36 gestational weeks) than in term deliveries. Since approximately one-fifth of the women who deliver preterm infants also have microbiological evidence of bacteria in the amniotic fluid (in which the fetus floats), it is possible that retention of the placenta is associated with infection. To learn more about this, medical records were reviewed from 231 preterm vaginal deliveries and 561 term vaginal deliveries (the latter served as controls) at one medical facility. The preterm patients had undergone amniocentesis (removal of a sample of amniotic fluid) upon admission to the hospital for evaluation of possible microorganism content. One hundred twenty-five women had preterm labor with intact membranes (the membranes that surround the fetus) and 106 had premature rupture of membranes (PROM). Slightly more than 9 percent of the women with preterm vaginal delivery had retained placentas, compared with slightly more than 1 percent of the women with term deliveries, a statistically significant difference. No difference in the proportion of retained placentas was found between the PROM and non-PROM groups. The greater incidence of retained placenta in preterm births was not associated with either a positive result for microorganisms or with the presence of chorioamnionitis (inflammation of the amniotic membranes). The results show that preterm delivery is associated with retained placenta, but suggest that intrauterine infection and inflammation are not associated with retention. Other possible explanations are discussed. (Consumer Summary produced by Reliance Medical Information, Inc.)

Although it is feasible today to perform laparoscopic surgical staging and treatment of ovarian low malignant potential tumors and early-stage ovarian cancer safely, it is still generally agreed that a patient with ovarian cancer should have a laparotomy. Concerns related to laparoscopy in managing gynecologic malignancy include the accuracy of intraoperative diagnosis, inadequate resection, significance of tumor spillage, improper or delay in surgical staging, delay in therapy, and the possibility of port-site metastasis. On the other hand, laparoscopy has the advantages of being a minimally invasive surgery, with shorter hospitalization, decreased postoperative pain, and quicker return to normal daily activities. We review the current literature discussing the consequences of laparoscopic surgery in ovarian tumors of low malignant potential and early-stage ovarian cancer.

Objectives Ripening of the cervix with a Foley catheter commonly results in cervical dilatation without contractions. We examined the outcome of labour in women who underwent induction of labour using a Foley catheter, followed by either 1. early amniotomy, or 2. augmentation of labour by oxytocin and late amniotomy

Failed intubation and ventilation are important causes of anesthetic-related maternal mortality. The purpose of this article is to review the complex issues in managing the difficult airway in obstetric patients. The importance of prompt and competent decision making in managing difficult airways, as well as a need for appropriate equipment is emphasized. Four case reports reinforce the importance of a systematic approach to management. The overall preference for regional rather than general anesthesia is strongly encouraged. The review also emphasizes the need for professional and experienced team cooperation between the obstetrician and the anesthesiologist for the successful management of these challenging cases.

To evaluate the efficacy and safety of second-trimester abortions using transcervical catheter insertion and extraovular prostaglandin (PG) administration.

Objective: To evaluate the efficacy and safety of second-trimester abortions using transcervical catheter insertion and extraovular prostaglandin (PG) administration.

Fetal infection by Parvovirus B 19 is a common cause of fetal anemia and nonimmune hydrops fetalis and may result in fetal death. Recent improvements in diagnosing parvovirus infections by sensitive molecular biology techniques now allow for a new insight into its pathogenic rule, immunology, and the varied clinical manifestations. The estimated overall risk of fetal loss after maternal exposure is about 6.5 percent, which is much less than previously thought. Inasmuch as complete spontaneous reversal of fetal hydrops has been commonly described, controversy exists regarding the management of the fetus with clinical signs of infection by Parvovirus B 19. According to the experience that has accumulated, it seems that only cases with severe fetal anemia or signs of fetal compromise should be managed by intrauterine transfusion. This procedure, however, is not without risk. Although an association between fetal viral infection and structural abnormalities has been described, it has not been proved yet. However, infection by Parvovirus B 19 has been recently proposed as a causative factor for congenital red blood cell aplasia.

A review is given of the various methods of assessing carbohydrate tolerance in pregnancy. Oral glucose tolerance screening and diagnostic tests have been in use for more than 25 years. They are easily administered, relatively inexpensive, and present reasonable sensitivity; therefore, they continue to be uses quite extensively. However, lack of reproducibility of the results and side effects such as nurses, vomiting, and headache have led to the use of alternate methods including glucose polymer (Polycose) and standard breakfast meals. These methods have been reported to present satisfactory results in clinical practice. Glycosylated hemoglobin (HbA10) and fructosamie assays are also alternate forms of testing carbohydrate metabolism HbA10measurement have been proven insensitive as a screening test for gestatioal diabetes, while their use as an index of overall glucose control remains valuable. The role of fructosamine in the assessment of carbohydrate intolerance remains controversial with conflicting claims made by various investigators regarding its sensitivity in detecting gestational diabetes and its response to alternations in glycemic control. In this review, the relative advantages ad disadvantages of each glucose tolerance test are discussed and recommendations are given regarding their utility in pregnancy.

The timely recognition of fetal macrosomia may reduce the complications associated with vaginal delivery of a macrosomic fetus. Today, the most frequently used tool for identification of fetal macrosomia is ultrasound. Although many different calculations have been applied, the most commonly used is the estimation of fetal weight. Generally, the detection rate for fetal macrosomia is 33–82, with a specificity of 70–100, a positive predictive value of 40–83, and negative predictive value of 66–92. Adding amniotic fluid volume, cheek-to-cheek diameter or fetal subcutaneous tissue:femur length ratio may improve the accuracy of the diagnosis. Other promising diagnostic tools include the echo-planar imaging and the neural network. Despite the progress that has been achieved since the use of Nagele's rule, our ability to detect fetal macrosomia remains limited.

Consecutive gestational hypertensive or preeclamptic patients with an increased resistance to blood flow in the uterine arcuate arteries as demonstrated by Doppler-ultrasound were divided into two groups, one with unilaterally and one with bilaterally elevated values. The patients in the group with a unilateral increase in resistance were delivered at 36±1.8 weeks, with birthweights of 2276±575 g, whereas the patients in the group with bilaterally increased values delivered at 33±3.2 weeks, with birthweights of 1501±493 g (p < 0.05). Patients with a bilateral increase in resistance to blood flow developed more severe hypertension than patients with unilaterally elevated values. The development of an elevated resistance to flow in uterine arteries and their branches may be related to insufficient uterine arterial adaptation and growth.

The efficacy and safety of labor induction using an intrauterine balloon catheter in twin pregnancies has been evaluated. During the study period (1992–1997), labor was induced at 36–42 weeks in 17 twin gestations. Labor induction was indicated for preeclampsia (n = 10), birth weight discordance (n = 3), suspected fetal distress (n = 2) and postdates (n = 2). Twin A was in vertex presentation in all cases. An intrauterine balloon catheter was inserted transcervically followed by augmentation whenever required. Vaginal delivery was achieved in 15 (88.2%) patients. The mean interval from balloon insertion to delivery was 17.05 h, with 80% deliveries occurring within 24 h of catheter insertion and 80% occurring within 12 h of catheter expulsion. Birth weight was 2,514 ± 244 and 2,421 ± 367 g for twin A and B, respectively. Oxytocin was required in 4 patients. Postpartum hemorrhage was noted in 1 patient. One patient with no progress of labor and 1 with suspected intrapartum fetal distress required cesarean section. All neonates had a 5-min Apgar score of 10. The data suggest that an intrauterine balloon catheter appears to be safe and effective to induce labor in twin gestations.

Colonization of the amniotic cavity with Candida tropicalis was diagnosed in a woman with preterm labor and intact membranes. Treatment with ketoconazole and amphotericin B failed to eradicate the microorganism from the amniotic cavity. Tocolysis was administered and was considered successful in prolonging the pregnancy for 11 days after the initiation of treatment. There was no clinical or microbiological evidence of neonatal infection. The infant survived and was discharged home 2 months after birth.

Fetal infection by Parvovirus B 19 is a common cause of fetal anemia and nonimmune hydrops fetalis and may result in fetal death. Recent improvements in diagnosing parvovirus infections by sensitive molecular biology techniques not allow for a new insight into its pathogenic rule, immunology, and the varied clinical manifestations. The estimated overall risk of fetal loss after maternal exposure is about 6.5 percent, which is much less than previously thought. Inasmuch as complete spontaneous reversal of fetal hydrops has been commonly described, controversy exists regarding the management of the fetus with clinical signs of infection by Parvovirus B 19. According to the experience that has accumulated, it seems that only cases with severe fetal anemia or signs of fetal compromise should be managed by intrauterine transfusion. This procedure, however, is not without risk. Although an association between fetal viral infection and structural abnormalities has been described, it has not been proved yet. However, infection by Parvovirus B 19 has been recently proposed as a causative factor for congenital red blood cell aplasia.

AbstractA cohort of 236 vaginally delivered neonates weighing ≥4,200 g was evaluated. Shoulder dystocia was encountered in 27 deliveries (11.4%) and brachial plexus injury was diagnosed in 3 infants (1.3%). The ‘traditional’ antepartum risk factors could not be associated with shoulder dystocia. In this cohort, primiparity was significantly more frequent among the dystocia cases (OR = 8.58, 99% CI = 1.35–54.35, p = 0.021). Shoulder dystocia could not be attributed to a particular difference between the current and the previous heaviest birth weight. A policy of cesarean section for all infants weighing ≥4,200 g would result in at least 5- to 6-fold increase in cesarean rate in this group of patients. Our data reconfirm that shoulder dystocia and brachial plexus injury are unpredictable, even in macrosomic infants. It is a matter of policy whether to accept the expected 1:9 and 1:79 respective risks associated with vaginal births.

This review provides recent data and clinical opinions on a new technology in assessing fetal well-being during labor, the fetal pulse oximeter. Fetal pulse oximetry is potentially superior to electronic fetal heart rate monitoring because it allows direct assessment of both fetal oxygen status and fetal tissue perfusion. Several studies during recent years have demonstrated that fetal pulse oximetry during labor is feasible and accurate. On the other hand, these very same studies have demonstrated a few potential disadvantages and limitations of fetal oximetry. The main limitation seems to be a wide range of normal values. The correlation of fetal oximetry during labor with perinatal outcome and long-term newborn outcome has not yet been determined. In summary, fetal pulse oximetry during labor merits further randomized prospective studies, especially with regard to improvement of perinatal outcome.