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OBJECTIVE To estimate the current scope of practice and evaluate the experience in training of maternal-fetal medicine specialists in the United States. METHODS We administered an Internet-based, 16-question survey of 1,764 members of the Society for Maternal-Fetal Medicine, inquiring about aspects of fellowship training and scope of practice after completion of training. RESULTS Approximately 36% (n=643) of surveys were returned. Most respondents were between 40 and 49 (230/640, 35.9%) and 50 and 59 (199/640, 31.1%) years old, and 411 were men (64.1%). Nearly all respondents (590/636, 92.8%) were certified in obstetrics and gynecology, and 80.1% (530/628) were certified in maternal-fetal medicine. The majority were in small-group practices of two to seven partners (359/634, 56.6%). Forty-nine percent (306/630) were in university-based practices, 26.8% (169/630) in university-affiliated practices, and 24.6% (155/630) in community-based or hospital-based practices. Most respondents work full time (40 hours per week or more), and the weekly practice profile consists primarily of ultrasonography (33.5%), consultation for high-risk patients (17.1%), and total obstetrical care for high-risk patients (15.4%).Training in most aspects of maternal-fetal medicine practice was felt to be adequate, with the exception of practice management. Time spent in training was spent primarily in high-risk pregnancy management (41%), ultrasonography (22%), and research (18%). CONCLUSION The current scope of maternal-fetal medicine practice incorporates more ambulatory care than hospital-based care. Training programs rate highly in adequacy for high-risk pregnancy management and ultrasonography but lower in other aspects. LEVEL OF EVIDENCE II.

Background Contemporary interpretation of fetal heart rate patterns is based largely on the tenets of Drs Quilligan and Hon. This method differs from an older method that was championed by Dr Caldeyro-Barcia in recording speed and classification of decelerations. The latter uses a paper speed of 1 cm/min and classifies decelerations referent to uterine contractions as type I or II dips, compared with conventional classification as early, late, or variable with paper speed of 3 cm/min. We hypothesized that 3 cm/min speed may lead to over-analysis of fetal heart rate and that 1 cm/min may provide adequate information without compromising accuracy or efficiency. Objective The purpose of this study was to compare the Hon-Quilligan method of fetal heart rate interpretation with the Caldeyro-Barcia method among groups of obstetrics care providers with the use of an online interactive testing tool. Study Design We deidentified 40 fetal heart rate tracings from the terminal 30 minutes before delivery. A website was created to view these tracings with the use of the standard Hon-Quilligan method and adjusted the same tracings to the 1 cm/min monitoring speed for the Caldeyro-Barcia method. We invited 2–4 caregivers to participate: maternal-fetal medicine experts, practicing maternal-fetal medicine specialists, maternal-fetal medicine fellows, obstetrics nurses, and certified nurse midwives. After completing an introductory tutorial and quiz, they were asked to interpret the fetal heart rate tracings (the order was scrambled) to manage and predict maternal and neonatal outcomes using both methods. Their results were compared with those of our expert, Edward Quilligan, and were compared among groups. Analysis was performed with the use of 3 measures: percent classification, Kappa, and adjusted Gwet-Kappa ( P Results Overall, our results show from moderate to almost perfect agreement with the expert and both between and within examiners (Gwet-Kappa 0.4–0.8). The agreement at each stratum of practitioner was generally highest for ascertainment of baseline and for management; the least agreement was for assessment of variability. Conclusion We examined the agreement of fetal heart rate interpretation with a defined set of rules among a number of different obstetrics practitioners using 3 different statistical methods and found moderate-to-substantial agreement among the clinicians for matching the interpretation of the expert. This implies that the simpler Caldeyro-Barcia method may perform as well as the newer classification system

We previously showed that in asphyxiated fetal lambs the duration of hypotension correlated well with the severity of histologic damage to the brain, whereas the duration of bradycardia did not. This study compares fetal heart rate patterns with the degree of histologic damage to the brain.Twelve chronically instrumented near-term fetal lambs were subjected to asphyxia by umbilical cord occlusion until fetal arterial pH was6. 9 and base excess was-20 mEq/L. An additional 4 fetuses served as sham-asphyxia controls. Fetal heart rate (from electrocardiogram), arterial blood pressure, fetal breathing movements, and electrocorticogram were continuously monitored before, during, and for 72 hours after asphyxia. Fetal brain histologic features were categorized as mild (group 1, n = 5), moderate (group 2, n = 4), and severe (group 3, n = 3). Long-term fetal heart rate variability expressed as amplitude range was assessed visually every 5 minutes from 30 minutes before asphyxia until 2 hours of recovery and at 6, 12, 24, 48, and 72 hours of recovery.Long-term fetal heart rate variability amplitude decreased from 32 +/- 17 beats/min (mean +/- SEM) preocclusion to 4 +/- 13 beats/min at the end of occlusion (P.001) without significant differences among the 3 groups. During 10 to 45 minutes of recovery, the long-term variability of group 1 was significantly greater than that of groups 2 and 3. At 24 to 72 hours of recovery, the long-term variability of groups 1 and 2 was significantly higher than that of group 3, which was almost 0. The "checkmark" and sinusoidal fetal heart rate patterns were observed during the recovery period in groups 2 and 3.Decreased long-term fetal heart rate variability and the "checkmark" and sinusoidal fetal heart rate patterns were indicators of the severity of asphyxial histologic damage in the fetal brain.

Objective: Our goal was to present a case series of pregnancy-associated malignant brain tumors. Study Design: A review was conducted from 1978-1998 at 5 hospitals. Results: Ten women were diagnosed with a malignant brain tumor during pregnancy (n = 8) or post partum (n = 2). Patients diagnosed antenatally exhibited severe symptoms, manifest between 27 and 32 weeks' gestation. Six were emergently delivered of their infants because of maternal deterioration, and 2 were delivered electively in the early third trimester after documentation of fetal pulmonary maturity. There were 4 maternal deaths and 1 neonatal death; all of the other infants maintained viability. Conclusions: Malignant brain tumors rarely occur in pregnancy. In contrast to reports that describe an indolent course, each of the 8 antenatal patients experienced a neurologic crisis. If symptoms are amenable to pharmacologic control, we advocate delivery in the early third trimester after documentation of fetal pulmonary maturity. To minimize temporal lobe or cerebellar herniation in neurologically unstable patients, a consideration should be made for cesarean delivery with the patient under general anesthesia, followed by immediate neurosurgical decompression. (Am J Obstet Gynecol 2000;182:1215-21.)

In order to examine the role of oxidative stress in asphyxia-induced perinatal brain damage, near-term fetal lambs were subjected to umbilical cord occlusion for approximately 60min until fetal arterial pH diminished to less than 6.9 and base excess to less than -20 meq/l. The levels of superoxide, hydrogen peroxide, glutathione (GSH) and thiobarbiturate-reactive substances (TBARS) within brain grey and white matter were determined at 72h to correlate with morphological changes. Although the topography and extent of brain damage varied somewhat from case to case, ranging from focal infarction in grey or white matter to subtle and patchy alterations of white matter, the telencephalic white matter appeared to bear the brunt of damage as compared to other regions. The parietal white matter, in particular was often the seat of early pathological changes that could be seen in isolation. These white matter changes were accompanied by significant increases in hydrogen peroxide and TBARS levels as compared to those in grey matter. In another set of experiments, 8 different brain regions were assayed for TBARS, GSH and superoxide dismutase (SOD). A highly significant rise in the levels of TBARS was again noted in the parietal and frontal white matter. SOD levels were higher in the frontal and parietal white matter, basal ganglia and cerebellum. Cerebral cortical and hippocampal neurons were relatively unaffected until accompanied by more severe damage to grey and white matter at other sites. These results suggest that the developing telencephalic white matter appears to be most vulnerable to the effects of intrauterine fetal asphyxia and that oxidative stress may be a major contributing factor in the pathogenesis of perinatal hypoxic-ischemic encephalopathy.

One year's obstetric experience at Los Angeles County-University of Southern California Medical Center was reviewed and compared with previous years. The incidence of cesarean section for fetal distress is low and has remained constant over the past 7 years. Periodic changes and decreased baseline variability of the fetal heart rate accounted for 39% of the diagnoses of fetal distress in this group. Scalp sampling clarified the diagnosis of fetal distress and prevented unnecessary cesarean section. Compromised perinatal outcome in the greater than 2,500 gram weight group was confined to those who were monitored, had indications for monitoring, or had identifiable prospective risk factors, with rare exceptions.

A prospective study of 208 women in labor at term with singleton fetuses in a frank breech presentation was carried out. One hundred fifteen patients were randomized to a vaginal delivery group and 93 to an elective cesarean section group. Of the 93 women scheduled for cesarean section, 88 were delivered according to protocol. Five women progressed rapidly in labor and were delivered vaginally without complications. Of the 115 women scheduled for vaginal delivery, x-ray pelvimetry was obtained on 112. Three women were delivered vaginally without incident before x-ray pelvimetry could be obtained. One of these women was delivered of an infant who died shortly after birth of lethal congenital anomalies. Of the 112 women with x-ray pelvimetry, 52 had one or more inadequate pelvic measurements and were scheduled for indicated cesarean section. Three women, however, were delivered vaginally without incident before operation could be performed. Of the remaining 60 patients in this group, 49 were delivered vaginally without a perinatal death. Eleven women required cesarean section for difficulties during labor. There were no maternal deaths, but 73 (49.3%) of the 148 women who were delivered by cesarean section in this study experienced postpartum morbidity. Only four (6.7%) of the 60 women delivered vaginally had postpartum complications. Based on the data, it seems resonable to allow vaginal delivery in carefully selected cases of term frank breech presentation.

During the period 1971 to 1975, 260 women with diabetes mellitus, Classes B through R, were delivered of their infants at Los Angeles County Women's Hospital. The plan of patient management included frequent clinic visits and hospitalization to assure good control. A program of intensive antepartum fetal surveillance was begun at 34 weeks' gestation, with the use of daily 24 hour urinary estriol determinations and a weekly contraction stress test (CST). A lecithin/sphingomyelin ratio was evaluated for all patients before elective delivery. The perinatal mortality rate in these diabetic pregnant women was 46 per 1,000 as compared to 24 per 1,000 in the general population. Only three stillbirths occurred in the diabetic group, none within one week of a negative CST. Congenital malformations were responsible for almost half of the neonatal deaths. There were no deaths due to iatrogenic prematurity or trauma. Mean gestational age at delivery was 37.9 weeks and vaginal delivery was the mode for approximately half of the women. Two thirds of the infants did experience some morbidity.

In general the use of fetal monitoring has been felt to be of benefit in the prevention of fetal death. The type of recording obtained during labor may also be of significant value to the pediatrician in permitting him to anticipate respiratory distress. In this article an attempt is made to point out the various areas of the fetal heart rate tracing that can be used in such prognostic attempts.

1. 1. The oxygen tension in the maternal intervillous space blood of 64 outpatients has been measured with the polarographic electrode. 2. 2. The mean value is 42.0 mm. Hg. 3. 3. When blood with a high oxygen tension (arterialized) was obtained during different phases of a uterine contraction there was a decrease in the oxygen tension at the apex of the contraction. 4. 4. The location of the needle tip when drawing blood from the uterus has been discussed.

Simultaneous determinations of amniotic fluid levels of the catecholamines dopamine (DA), norepinephrine (NE), and epinephrine (E), and the intraneuronal metabolites of DA, 3,4-dihydroxyphenylacetic acid (DOPAC) and NE, 3,4-dihydroxyphenylglycol (DOPEG), were made, by radioenzymatic assay, in pregnancies resulting in growth-retarded (n = 14) and normal (n = 63) infants. Significant elevations in the mean concentration of NE (p less than 0.000005), E (p less than 0.005), and DOPEG (p less than 0.000001) as well as a significant decrease in the mean concentration of DOPAC (p less than 0.000001) were found in pregnancies resulting in growth-retarded infants as compared to pregnancies resulting in normal infants. Amniotic fluid DOPEG levels were found to be the most discriminative. As amniotic fluid catecholamines are predominantly of fetal origin, these findings suggest that an increase in adrenergic activity and a decrease in dopaminergic activity occur in intrauterine growth retardation as a response to chronic stress.

lomas might have developed. The patient has since conceived, further supporting origin of these organisms outside the reproductive tract. A high index of clinical suspicion for tuberculosis was crucial since routine histologic study of the therapeutic abortion material was not suggestive of an infectious process. The placenta in the second case showed an unusual gross abnormality, the placenta membranacea. This suggests early infection since tuberculous involvement of the decidual tissues may have interfered with first-trimester atrophy of the capsular villi. In conclusion, it is worthwhile to consider tuberculosis when examining placentas, as involvement may lead to the diagnosis or indicate disseminated disease. Acid-fast stains may be rewarding, even in the absence of suggestive histology, and could prove useful in all abortions on tuberculous women.

During the six years 1970--1975, 62,266 deliveries occurred at Women's Hospital, Los Angeles Country--University of Southern California Medical Center. Of these patients, 18,106 (29 per cent) were monitored, with an incidence of 18 per cent in 1970 which rose to 35 per cent in 1975. The patients were divided into monitored and unmonitored groups for comparison of cesarean section rates and various aspects of perinatal mortality. The overall cesarean section rate was 9.6 per cent with 2,830 cesareans performed in monitored patients (16 per cent) and 3,124 in those unmonitored, a 7 per cent incidence including repeat cesarean. The cesarean rate remained remarkably stable over the 6-year study period even though the monitoring incidence nearly doubled. From 1970 to 1975, the intrapartum death rate fell progressively in contrast to the incidence of antepartum fetal deaths, which remained unchanged. Overall, 50 per cent survival rate was achieved in the birth weight range of 1,200 grams. A particular group of perinatal patients who apparently benefited from intrapartum monitoring were those liveborns with birth weights of 1,500 grams or less. Over the study period, the neonatal mortality in monitored patients declined, whereas mortality in the neonates which were not monitored during labor remained high.

One hundred women with moderate-to-very-severe prepartum pain participated in a double-blind study of intravenously injected butorphanol and meperidine that compared the analgesic properties, effect on the process of labor, condition of the newborn and the incidence of side effects associated with the two drugs. Cervical dilation, infant birth weight and Apgar scores were not significantly different between the test groups. The mean fetal heart rate for the butorphanol group was significantly faster than that of the meperidine group. Butorphanol provided significantly more analgesia than meperidine at 30 minutes and one hour after administration, based on pain intensity and pain relief scores. Some side effects, including sedation, dizziness, lightheadedness, nausea, vomiting and pain at the injection site, were reported for both drugs.

A basic understanding of fetal nutrition and metabolism is essential in the clinical management of the obstetric patient. The fetus depends upon a constant infusion of glucose for energy production and growth. Maternal glucose is the prime source of this nutrient. Alterations in maternal carbohydrate homeostasis will lead to changes in fetal metabolism. In diabetes mellitus, hyperglycemia may produce hyperinsulinemia and macrosomia. The growth-retarded fetus may have a decreased supply of maternal glucose and reduced amounts of hepatic glycogen and adipose tissue. The fetus must depend upon these stores for survival during periods of intrauterine hypoxia. In the newborn period, hypothermia and hypoxia may rapidly deplete energy reserves. With this information, the clinician may more knowledgeably manage dietary demands in the antepartum patient, fetal distress during labor, and the immediate newborn period.

A prospective study of the management of term frank breech presentation is currently ongoing at LAC-USC Medical Center. To date, 57 patients have been randomized to an elective cesarean section group and 70 to a vaginal delivery group. Of the 70 patients selected for vaginal delivery, 35 had one or more inadequate pelvic measurements by x-ray pelvimetry and were scheduled for indicated cesarean section. Of the remaining 35 patients in this group, 30 delivered vaginally without perinatal death. Two of the infants, however sustained brachial plexus injuries. Of the 57 patients scheduled, 55 underwent elective cesarean section. There were no maternal deaths, but 20 (36.4%) patients experienced morbidity and 5(9.1 per cent) patients experienced intraoperative complications. Based on the data accumulated to date, it seems reasonable to allow vaginal delivery in carefully selected cases of term frank breech presentation.

A study was done on the occurrence of neonatal seizures in 14,367 infants delivered by cesarean section in a perinatal region in 4 years. Although seizures occurred in 1% of all of these infants, small infants weighing less than 2500 gm at birth had the highest frequency (greater than 4%). Term infants delivered before labor (repeat cesarean section) had the lowest seizure rate (less than 0.2%), and this was a significantly lower (four times) frequency than that seen in term infants delivered by primary cesarean section. These data suggest that brain function as indexed by neonatal seizures can be adversely affected during labor.

NATIONAL INSTITUTES OF HEALTH Consensus Development Conferences have been established to address in a broad manner recent developments in medical practice and research. The Task Force participants are chosen entirely from outside the NIH and are asked to provide a comprehensive review of the state of the art including recommendations for current clinical practice and future research in a given area of medicine. The National Institute of Child Health and Human Development recently established three such Consensus Development Task Forces on antenatal diagnosis. This report summarizes the findings of the Task Force on Predictors of Intrapartum Fetal Distress. The other two concerned predictors of hereditary disease and congenital defects, and predictors of fetal maturity; these will be reported separately. The format for such conferences calls for a broad and detailed examination of the topic at hand, by a task force composed of physicians, epidemiologists, sociologists, ethicists, economists, lawyers, and public (consumer) representatives. The full text of this report was circulated to interested individuals, institutions, and organizations before being presented in summary form at a public forum on March 6, 1979, at The National Institutes of Health. Those interested in commenting on the draft report had an opportunity to do so at that time, either in writing or verbally, after which the Task Force reviewed the comments made, and incorporated them into the repoN as necessary. The entire

1. 1. The intervillous space and the amniotic fluid pressures were recorded simultaneously and continuously for prolonged periods of time. 2. 2. As long as the uterus is not in active systole, the pressures in the two spaces remain virtually identical. 3. 3. Recording on a sensitive scale the pressure difference between the intervillous space and the amniotic fluid shows that during uterine systole the amniotic fluid pressure increases slightly faster than does the pressure in the intervillous space, the average maximum differential being approximately 2.6 mm. Hg. This pressure differential is partially “erased” by virtue of the fact that the pressure in the intervillous space makes up part of the pressure deficit by the time the apex of the contraction is reached. 4. 4. Movement of the patient brings about alterations in the pressure of approximately equal amounts in both spaces, and without appreciable lag. The amniotic fluid-intervillous space pressure relationship seems to be unaffected by either rupture of the membranes or the administration of oxytocin in physiologic dosage.

In an attempt to explain excessive fluid retention, the most common feature in the syndrome of subjective and objective changes called premenstrual tension, we investigated changes in the peripheral circulations of women with this complaint. To obtain evidence on the vascular system's ability to maintain a constant circulating fluid volume, we measured capillary filtration coefficient in the forearm. Women who complained of premenstrual distress showed a significant change in capillary filtration coefficient (CFC) during the month; the lowest CFC values were found immediately after the onset of the menses; the highest values occurred just before the beginning of menstruation. In a group of women who claim to be completely free of the complaint, the CFC was uniform throughout the cycle.

1. 1. In a study of 47 patients by a modified pulse pressure method, changes in cardiac output were recorded during late pregnancy, in labor, and in the early puerperium. This is the first report on cardiac output in labor. 2. 2. During effective contractions in labor, the cardiac output rises an average of 30.9 per cent over the output in the resting state. 3. 3. The act of bearing down in the absence of a contraction results in most cases in a small but transient drop in cardiac output. Bearing down with a contraction, however, may result in an actual increase in output. 4. 4. Pain and anxiety can produce significant elevations in cardiac output. 5. 5. Placental separation per se was not demonstrated to result in consistent variations in cardiac output. Contraction of the uterus post partum, however, may raise the output level significantly. 6. 6. Cardiac output appears to rise during the first stage of labor, and may rise even further at delivery. In some cases a small additional rise is seen in the first few minutes post partum. The output persists at a moderately elevated level for a variable period thereafter.

Cardiac output estimations done by the pulse pressure method were compared to those done simultaneously by the dye method in pregnancy, labor, and in the early puerperium. The subjects selected were young, healthy and without edema or clinical evidence of heart disease. A total of 30 determinations was carried out on 23 subjects. Agreement within 25 per cent of the dye method was attained in 90 per cent of the blood pressure method tests.