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Introduction Electronic methods are adopted for the evaluation of fetal vitality in hypertensive syndromes, comparing pros and cons to contribute when choosing one. Objective Compare two resources of study of fetal vitality: cardiotocography and fetal monitor AN24 (Monica Health Care) in hypertensive pregnancies. Methods This is a study control case with a sample of 22 patients in which we compare the tracing using the conventional cardiotocography, and transabdominal fetal electrocardiography by choice of the fetal monitor AN24. The study was conducted with pregnant women equal or above 34 weeks, alive fetus and single, with hypertensive disorders according to the criteria NHBPEP – 2000 at Hospital Guilherme Alvaro-Santos/SP-Brazil from june to october of 2015. The study had 22 patients with diagnosis of hypertensive syndrome. The applicability of both methods was performed according to the standardized recommendations. The variables examined in the study were: gestational age, analyzed in weeks; number of pregnancies; parity; body mass index (BMI), which was divided into 3 criteria (BMI less than 30; BMI ⩾ 30 and less than 35; BMI ⩾ 35); preparation time, which means the time (in minutes) since the starting of local asepsis up to the beginning of the record of cartography. Also was analyzed the success in capturing, which was defined as the successful capture of the signal to execute the cardiotocography; signal loss, defined as any interruption of cardiotocographic tracing. Finally, it was analyzed the concordance in categorical classification in both methods. Following the criterias divided in class I, II and III (ACOG, 2009).1 Results Afterwards analysed 22 patients, were obtained: average of the gestational age 36,71 weeks, average of pregnancies 2,14, average of births 1,09 and average of BMI 34,17. This study has shown 100% of agreement in categorical classification in both procedures. The success capitation between the methods was similar (p = 0,999). In AN24 monitor, six tracings has showed signal loss, while in the CTB only three has shown this loss (p = 0,505). The monitor AN24 have showed a bigger preparation time than the other method, analysed in 1,94 min. The CTB method showed better results when comparing the variable preparation time in patients with BMI > 35 (p = 0,094). Conclusion No differences were identified concerning the quality of analysis of fetal viability between the resources and were also in agreement on the categorical analysis of each tracing. Both methods showed agreement in the variables: success of capturing in the whole sample and in BMI between 30 and 35. The AN24 showed better results than the CTB, when analyzing the variables: success of capturing in BMI higher than 35 and signal loss, in the whole sample and in BMI between 30 and 35. On the other hand, CTB had more success in capturing only in BMI less than 30, and showed faster preparation time in the whole sample and in all BMI groups. Further studies may broaden the comparison between these current methods. 1. American College of Obstetricians and Gynecologists, ACOG Practice Bulletin No. 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles, Obstet Gynecol. 114(1) (2009) 192–202.

Objective To estimate the effect of specific maternal–fetal high-risk conditions on the risk and timing of fetal death. Methods This study examined 10,614,679 non-anomalous singleton pregnancies delivering at or beyond 24 weeks’ gestation, derived from the U.S. linked birth/infant death data sets, 1995–1997. Fetal death rates for pregnancies at low risk were compared with pregnancies complicated by chronic hypertension, gestational hypertensive disorders, diabetes, small for gestational age infants, and abruption. Adjusted relative risks as well as population-attributable risks for fetal death were derived by gestational age for each high-risk condition compared with low-risk pregnancies. Results The fetal death rate for low-risk pregnancies was 1.6 per 1000 births. Adjusted relative risk for fetal death was 9.2 (95% confidence interval [CI] 8.8, 9.7) for abruption, 7.0 (95% CI 6.8, 7.2) for small for gestational age infants, 1.4 (95% CI 1.3, 1.5) for gestational hypertensive disorders, 2.7 (95% CI 2.4, 3.0) for chronic hypertension, and 2.5 (95% CI 2.3, 2.7) for diabetes. Fetal death rates were lowest between 38 and 41 weeks. The fetal death rate (per 1000 births) for these high-risk conditions was 61.4, 9.6, 3.5, 7.6, and 3.9, respectively. Almost two thirds of fetal deaths were attributable to the pregnancy complications examined. Conclusion High-risk conditions in pregnancy are associated with an increased risk for fetal death, particularly in the third trimester. Delivery should be considered at 38 weeks, but no later than 41 weeks, for these pregnancies.

Objective: The objective of this study was to determine whether there are any indication-specific variations in risk reduction for fetal Down syndrome after a normal genetic sonogram. Study Design: A second-trimester genetic sonogram was offered to all pregnant women who were at increased risk for fetal Down syndrome (≥1:274) because of either advanced maternal age (≥35 years), an abnormal triple screen, or both. Outcome information included the results of genetic amniocentesis (if performed), the results of pediatric assessment, and follow-up after birth. Normal genetic sonography was defined as the absence of all ultrasound aneuploidy markers. Results: The overall prevalence of fetal Down syndrome in the tested population was 1.41% (53/3753 pregnancies); however, in the presence of normal genetic sonography, the overall prevalence of fetal Down syndrome was 0.21% (7/3291 pregnancies). The overall risk reduction for fetal Down syndrome in the presence of normal genetic sonography was 6.64-fold (95% CI, 3.01-14.62); the overall negative likelihood ratio was 0.15 (95% CI, 0.07-0.33). In the presence of normal genetic sonography, the risk for fetal Down syndrome was reduced by 83% in patients with advanced maternal age, 88% in patients with abnormal triple screen, 89% in patients with abnormal triple screen who were Conclusion: There were no significant variations in the risk reduction for fetal Down syndrome in the presence of normal genetic sonography. Regardless of the indication for testing, the likelihood for fetal Down syndrome was reduced by 83% to 89%. This information will be useful in counseling pregnant women who are at high risk for fetal Down syndrome and who prefer to undergo genetic sonography before deciding about genetic amniocentesis. (Am J Obstet Gynecol 2002;187:1226-9.)

This study was undertaken to determine the association, if any, between prenatal care and postneonatal death in the presence and absence of high-risk pregnancy conditions.Data were derived from the national linked birth/infant death data set for the years 1995 to 1997 provided by the National Center for Health Statistics. Analyses were restricted to singleton live births that occurred after 23 completed weeks of gestation. Multiple births, congenital malformations, chromosomal abnormalities, missing data on gestational age, and birth weight less than 500 g were excluded. Multivariable logistic regression analyses were used to adjust for various antenatal high-risk conditions, maternal age, gravidity, gestational age at delivery, birth weight, maternal education, marital status, smoking, and alcohol use. Postneonatal death rate was defined as the number of deaths between 28 and 365 days of life per 1,000 neonatal survivors.For 10,512,269 singleton live births analyzed, 21,962 (2.1 per 1,000) resulted in postneonatal death. Postneonatal death rates were higher for African American women than white women in the presence (3.8 vs 1.7 per 1,000) and absence (11.2 vs 5.3 per 1,000) of prenatal care. Lack of prenatal care was associated with increased relative risk (RR) for postneonatal death, 1.8-fold in African American women and 1.6-fold in white women. Lack of prenatal care was associated with increased postneonatal death rates to a similar degree for the individual high-risk pregnancy conditions for both African American and white women. Lack of prenatal care was associated with increased postneonatal death rates, especially in the presence of postterm pregnancy (RR 2.3, 95% CI 1.6, 3.1), pregnancy-induced hypertension (RR 2.2, 95% CI 1.5, 3.4), intrapartum fever (RR 2.1, 95% CI 1.2, 3.5), and small-for-gestational-age infant (RR 1.6, 95% CI 1.3, 2.0).Lack of prenatal care should be considered as a high-risk factor for postneonatal death for both African American and white women, especially if the pregnancy has been complicated by postdates, pregnancy-induced hypertension, intrapartum fever or small-for-gestational-age infant.

Objective: This study was undertaken to determine the association between prenatal care in the United States and preterm birth rate in the presence, as well as absence, of high-risk pregnancy conditions for African American and white women. Study Design: Data were derived from the natality data set for the years 1995 to 1998 provided by the National Center for Health Statistics. Analyses were restricted to singleton live births that occurred at ≥20 weeks' gestation. Multiple births, fetal deaths, congenital malformations, chromosomal abnormalities, missing data on gestational age, and birth weight less than 500 g were excluded. Multivariable logistic regression analyses were used to adjust for the presence or absence of various antenatal high-risk conditions, maternal age, gravidity, marital status, smoking, alcohol, and education. Prenatal care was considered present if there was one or more prenatal visits. Preterm delivery was defined as delivery at less than 37 completed weeks of gestation. Results: For 14,071,757 births analyzed, 1,348,643 (9.6%) resulted in preterm birth. Preterm birth rates were higher for African American women than white women in the presence (15.1% vs 8.3%) and absence (34.9% vs 21.9%) of prenatal care. The absence of prenatal care increased the relative risk for preterm birth 2.8-fold in both African American and white women. There was an inverse dose-response relationship between the number of prenatal visits and the gestational age at delivery both among African American and white women. Lack of prenatal care was associated with increased preterm birth rates to a similar degree in the presence of pregnancy complications for both African American and white women, ranging from 1.6-fold to 5.5-fold for the various antenatal high-risk conditions. Conclusion: In the United States, prenatal care is associated with fewer preterm births in the presence, as well as absence of high-risk conditions for both African American and white women. Strategies to increase prenatal care participation may decrease preterm birth rates. (Am J Obstet Gynecol 2002;187:1254-7.)

OBJECTIVE: To determine the impact of prenatal care in the United States on the fetal death rate in the presence and absence of obstetric and medical high-risk conditions, and to explore the role of these high risk conditions in contributing to the black-white disparity. METHODS: This is a population-based, retrospective cohort study using the national perinatal mortality data for 1995–1997 assembled by the National Center for Health Statistics. Fetal death rate (per 1000 births) and adjusted relative risks were derived from multivariable logistic regression models. RESULTS: Of 10,560,077 singleton births, 29,469 (2.8 per 1000) resulted in fetal death. Fetal death rates were higher for blacks than whites in the presence (4.2 versus 2.4 per 1000) and absence (17.2 versus 2.5 per 1000) of prenatal care. Lack of prenatal care increased the (adjusted) relative risk for fetal death 2.9-fold in blacks and 3.4-fold in whites. Blacks were 3.3 times more likely to have no prenatal care compared with whites. Over 20% of all fetal deaths were associated with growth restriction and placental abruption, both in the presence and absence of prenatal care. Lack of prenatal care was associated with increased fetal death rates for both blacks and whites in the presence and absence of high-risk conditions. CONCLUSION: In the Unites States, strategies to increase prenatal care participation, especially among blacks, are expected to decrease fetal death rates.

Objective: Recent developments permit the use of pulse oximetry to evaluate fetal oxygenation in labor. We tested the hypothesis that the addition of fetal pulse oximetry in the evaluation of abnormal fetal heart rate patterns in labor improves the accuracy of fetal assessment and allows safe reduction of cesarean deliveries performed because of nonreassuring fetal status. Study Design: A randomized, controlled trial was conducted concurrently in 9 centers. The patients had term pregnancies and were in active labor when abnormal fetal heart rate patterns developed. The patients were randomized to electronic fetal heart rate monitoring alone (control group) or to the combination of electronic fetal monitoring and continuous fetal pulse oximetry (study group). The primary outcome was a reduction in cesarean deliveries for nonreassuring fetal status as a measure of improved accuracy of assessment of fetal oxygenation. Results: A total of 1010 patients were randomized, 502 to the control group and 508 to the study group. There was a reduction of >50% in the number of cesarean deliveries performed because of nonreassuring fetal status in the study group (study, 4.5%; vs control, 10.2%; P =.007). However, there was no net difference in overall cesarean delivery rates (study, n=147 [29%]; vs control, 130 [26%]; P =.49) because of an increase in cesarean deliveries performed because of dystocia in the study group. In a blinded partogram analysis 89% of the study patients and 91% of the control patients who had a cesarean delivery because of dystocia met defined criteria for actual dystocia. There was no difference between the 2 groups in adverse maternal or neonatal outcomes. In terms of the operative intervention for nonreassuring fetal status, there was an improvement in both the sensitivity and the specificity for the study group compared with the control group for the end points of metabolic acidosis and need for resuscitation. Conclusion: The study confirmed its primary hypothesis of a safe reduction in cesarean deliveries performed because of nonreassuring fetal status. However, the addition of fetal pulse oximetry did not result in an overall reduction in cesarean deliveries. The increase in cesarean deliveries because of dystocia in the study group did appear to result from a well-documented arrest of labor. Fetal pulse oximetry improved the obstetrician's ability to more appropriately intervene by cesarean or operative vaginal delivery for fetuses who were actually depressed and acidotic. The unexpected increase in operative delivery for dystocia in the study group is of concern and remains to be explained. (Am J Obstet Gynecol 2000;183:1049-58.)

Objective: To characterize the pattern, content, and management of after-hours telephone interactions between obstetrician-gynecologists and patients. Methods: In a prospective observational study, 12 resident and nine private physicians practicing obstetrics and gynecology completed data cards for after-hours telephone interactions with patients. Chief complaints were categorized as related to either women’s health or primary care and on whether women were pregnant, postpartum, or not pregnant. Triage dispositions (evaluate now, office follow-up, or home care) were compared between groups. Women also were asked what they would have done if they had been unable to contact their physicians by telephone. Results: One hundred ninety-two of 276 calls evaluated (69.6%) were from pregnant women, 20 (7.2%) were from postpartum women, and 64 (23.3%) were from nonpregnant women. Calls were related to primary care health issues in 24.1% ( n = 45) of pregnant women, 40% ( n = 8) of postpartum women, and 28.1% ( n = 18) of nonpregnant women. There were no differences between residents and private physicians in the proportion of women triaged to immediate evaluation for pregnancy (35.1% [ n = 40] versus 41.9% [ n = 31], P = .74) or postpartum (11.1% [ n = 1] versus 10% [ n = 1], P = .96) problems. Among 139 women triaged to office follow-up, 41% ( n = 57) would have come to the hospital for emergency evaluation if they had been unable to reach their physicians. Conclusion: Resident and private obstetrician-gynecologists provide primary care and women’s health care advice during after-hours telephone calls from patients. More than one third of after-hours telephone calls from pregnant women are triaged to immediate evaluation.

Objective: The objective of this study was to perform a cost-benefit analysis of routine second-trimester screening ultrasonography in the United States as compared with performing ultrasonography only in the presence of indications. Study Design: It was assumed that 1 million pregnant women are available annually who otherwise would not have an indication for an ultrasonographic examination. Cost savings from early detection and therapeutic abortion were considered only for fetal conditions for which lifetime cost estimates are available, including spina bifida, major cardiac disease, cleft lip or palate, renal agenesis or dysgenesis, urinary obstruction, lower or upper limb reduction, omphalocele, gastroschisis, and diaphragmatic hernia. Two separate cost-benefit analyses were considered with the range of fetal anomaly detection rates before 24 weeks' gestation as reported by tertiary and non-tertiary centers in the Routine Antenatal Diagnostic Imaging with Ultrasound (RADIUS) trial. Potential cost savings from averting treatment for preterm labor and postdate gestations were also considered. Results: The ratio of savings to cost was between 1.35 and 1.70 (savings of $1.35-$1.70 per $1 spent) if the ultrasonographic examinations were performed in tertiary care centers. The ratio of savings to cost was between 0.40 and 0.74 (loss of $0.26-$0.60 per $1 spent) if the examinations were performed in nontertiary centers. If the screening ultrasonography was performed in tertiary centers, the expected annual net benefits were estimated at $97 to 189 million. If ultrasonographic screening was performed in nontertiary centers, the expected annual net losses were estimated at $69 to 161 million. Conclusion: Routine second-trimester ultrasonographic screening appears to be associated with net benefits only if the ultrasonography is performed in tertiary care centers. (Am J Obstet Gynecol 2000; 182:655-60.)

Objective: The objective of this study was to conduct an economic evaluation of routine prenatal carrier testing for fragile X syndrome.Methods: This economic analysis was conducted from the societal perspective. A cost-benefit equation was developed based on the premise that the cost of routinely offering prenatal carrier testing for fragile X syndrome should be at least equal to, or less than, the cost of the current practice of not offering such testing. Sensitivity analyses included key assumptions regarding therapeutic abortion rates (50–100%) and patient screening acceptance rates (50–80%).Results: A policy of routinely offering prenatal carrier testing for fragile X syndrome may be beneficial only if the cost per screening test is less than $120 during the first year of the screening program, or less than $240 when the program reaches its full maturity. Given the current cost per screening test of $250, prenatal screening for carrier status for fragile X syndrome carries the potential for annual lo...

OBJECTIVE: Plasminogen activator inhibitor-1, the major serum protease inhibitor of fibrinolysis, increases steadily during pregnancy. The study objective was to examine four hormones, namely, estradiol-17β, progesterone, prolactin, and hydrocortisone to determine their individual contributions in the production of tissue plasminogen activator antigen, plasminogen activator inhibitor-1 antigen, and plasminogen activator inhibitor-1 activity. STUDY DESIGN: Human umbilical vein endothelial cells were grown with physiologic third-trimester concentrations of the above hormones, and fibrinolytic parameters were measured. RESULTS: Of the four hormones evaluated, only hydrocortisone significantly increased plasminogen activator inhibitor-1 antigen and activity at both concentrations tested ( p β significantly increased tissue plasminogen activator antigen and progesterone significantly decreased tissue plasminogen activator antigen, but neither affected the overall fibrinolytic balance. CONCLUSION: Hydrocortisone demonstrated antifibrinolytic properties at physiologic concentrations in pregnancy, suggesting that there may be a role for hydrocortisone in the prothrombotic tendency associated with pregnancy. The overall process of fibrinolysis was unaffected by estradiol-17β, progesterone, or prolactin. (Am J Obstet Gynecol 1996;175:168-72.)

The two extremes of birth weight ( 4000g) require antepartum surveillance and anticipation of complications during labor and delivery. Prognosis for the very low birth weight carries with it inherent neurologic impairment even when cared for under the best of conditions. In contrast, the macrosomic fetus enjoys a generally excellent outcome regardless of management. The current concern is too much intervention to avoid a low probability of complications.

There are a variety of approaches to the intrapartum management of twins and triplets. Recommendations based on estimated fetal weight, presentation, and clinical scenario will be discussed.

The objective of this study was to determine whether vacuum extraction is associated with umbilical cord blood acid-base changes when used electively or in the presence of suspected fetal distress. Data from 1,428 patients from a previously published randomized trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation were analyzed to identify differences in umbilical cord blood acid-base measurements associated with the elective use of vacuum extraction (patients with duration of second stage of labor 60 min or less) and also in the presence of suspected fetal distress during the second stage of labor. When used electively, vacuum extraction was associated with lower pH (in both umbilical cord artery and vein), lower venous base excess, and higher venous carbon dioxide tension (PCO2), as compared to normal spontaneous vaginal delivery. After correcting for duration of second stage of labor, elective vacuum delivery was significantly associated only with a decrease in cord venous pH and increase in venous PCO2. However, these cord blood acid-base changes were not accompanied by any differences in perinatal morbidity and mortality or in the number of neonates born with acidemia (cord arterial pH < 7.15 or < 7.10). In cases of suspected fetal distress, the use of vacuum extraction was not associated with any detectable cord blood acid-base changes as compared to normal spontaneous vaginal delivery. These data support the continued use of vacuum extraction, especially in cases of suspected fetal distress during the second stage of labor.

Acute hypotension in the setting of hemorrhage most often signifies abrupt and dangerous blood loss. The physiologic changes of pregnancy are designed to protect the mother from blood loss at parturition. When this protective reserve is exceeded, hypovolemic shock occurs. Ideally, blood loss of this magnitude should not be allowed to occur. Notwithstanding, obstetric hemorrhage continues to be an important cause of maternal mortality. Most deaths due to hemorrhage are preventable. Successful treatment requires that the clinician must react with the immediate institution of effective resuscitative measures. The importance of an organized, team approach with input from relevant specialties in the scheme of management cannot be overemphasized.

Objective To use a meta-analysis of all published randomized trials to determine whether the use of continuous electronic fetal heart rate monitoring (EFM) as the main method of intrapartum fetal surveillance is associated with improved pregnancy outcome compared to intermittent auscultation. Data Sources We used the MEDLINE data base and reference lists of articles to identify all published randomized trials of EFM versus intermittent auscultation. Methods of Study Selection A total of nine randomized trials published in peer-review journals were identified. The selection criterion was the use of EFM or intermittent auscultation as the main intrapartum fetal surveillance technique. Data Extraction and Synthesis A total of 18,561 patients were included in the nine published randomized trials, 9398 in the EFM group and 9163 in the auscultation group. Measures of pregnancy outcome included cesarean delivery, cesarean for suspected fetal distress, overall use of forceps or vacuum, use of forceps or vacuum for suspected fetal distress, overall perinatal mortality, and perinatal mortality due to fetal hypoxia (intrapartum or early neonatal death) attributable to the method of intrapartum monitoring. The metaanalysis showed that the patients monitored electronically had a significantly higher overall cesarean rate (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.17–2.01), higher cesarean rate for fetal distress (OR 2.55, 95% CI 1.81–3.53), overall increased use of forceps or vacuum (OR 1.23, 95% CI 1.02–1.49), increased use of forceps or vacuum for suspected fetal distress (OR 2.50, 95% CI 1.97–3.18), and decreased perinatal mortality due to fetal hypoxia (OR 0.41, 95% CI 0.17–0.98). Conclusion Electronic fetal monitoring is associated with increased rates of surgical intervention and decreased perinatal mortality due to fetal hypoxia.

Clinical chorioamnionitis continues to contribute to fetal and maternal morbidity and mortality. Significant advances have been made in the last 20 years in understanding the pathophysiologic processes leading to chorioamnionitis. This review addresses the history, incidence, pathophysiology, host defenses, risk factors, diagnosis, and maternal and neonatal management of clinically evident chorioamnionitis. After a detailed review of the physiologic processes leading to clinical chorioamnionitis and sepsis, we present a modern management scheme designed to optimize perinatal outcome for both mother and fetus.

Available data on the relationship of multiple parameter biophysical testing and fetal acid-base status suggest that a nonreactive nonstress test and absent fetal breathing are the first manifestations of fetal compromise, whereas absent body movement and tone are associated with more advanced degrees of fetal compromise.

OBJECTIVE: To estimate the value of second-trimester genetic sonography in detecting fetal Down syndrome in patients with advanced maternal age (at least 35 years) and normal triple screen. METHODS: Since July 1999, a prospective collection and recording of all individual triple screen risks for fetal Down syndrome was initiated for all patients with advanced maternal age presenting in our ultrasound unit for second-trimester genetic sonography. Genetic sonography evaluated the presence or absence of multiple aneuploidy markers. Outcome information included the results of genetic amniocentesis, if performed, and the results of pediatric assessment and follow-up after birth. RESULTS: By June 2001, 959 patients with advanced maternal age and normal triple screen were identified. Outcome information was obtained in 768 patients. The median risk for fetal Down syndrome based on maternal age was 1:213 (range 1:37–1:274). The median risk for fetal Down syndrome based on triple screen results was 1:1069 (range 1:275–1:40,000). A total of 673 patients had normal genetic sonography, and none (0%) had Down syndrome; 95 had one or more aneuploidy markers present, and four (4.2%) had fetuses with Down syndrome. The triple screen risks for these four fetuses ranged from 1:319 to 1:833. CONCLUSION: This study suggests that patients with advanced maternal age and normal genetic sonography carried very little risk for Down syndrome. The use of genetic sonography may increase the detection rate of fetal Down syndrome in this group of pregnant women.

The assisted vaginal delivery methods of rigid obstetric forceps and polyethylene vacuum cup extraction were compared in a prospective, randomized study. The 99 women studied had all completed 35 full weeks' gestation, required attempted assisted vaginal delivery, and were randomly assigned to either attempted forceps or vacuum-assisted delivery. All presentations were cephalic, with stations ranging from +1 to +4. Neonates were evaluated at 24 hours by neonatal staff. The infants underwent intracranial ultrasound screening during the first 24 hours of life and ophthalmologic examination within 48 hours. Vaginal delivery was successful with the intended method in 83% of vacuum-assisted deliveries and in 78% of forceps deliveries (not statistically significant). Neonatal retinal hemorrhage was found in 17 and 38% (P less than .043) of the randomized forceps and vacuum deliveries, respectively. No intraventricular hemorrhage was found. Apart from associations between vacuum-assisted delivery and mild hyperbilirubinemia and neonatal retinal hemorrhage (of uncertain clinical significance), and between assisted forceps delivery and an increased potential for facial injury, neonatal outcomes did not differ significantly. Maternal outcomes also did not differ significantly. No significant differences in safety or efficacy were found between polyethylene cup vacuum extraction and rigid obstetric forceps-assisted vaginal delivery in this population of predominantly low-pelvic assisted deliveries. Patients delivered by sequential use of forceps after vacuum or by vacuum after failed forceps application did not suffer significantly increased morbidity relative to those delivered by forceps or vacuum alone. Use of alternate or sequential methods allowed an overall cesarean rate of 3% in this population.

The epitome of FAS and ARBD has been documented substantially in the medical literature. There appears to be little question that alcohol is a teratogen. The precise nature for the mechanism of causing congenital defects, whether it be direct or indirect, is still unknown. There is no unequivocal information that can be conveyed to patients regarding the quantity of alcohol that can be safely consumed during pregnancy. Because pregnant women generally are receptive to suggestions about controlling their alcohol consumption during pregnancy, the professional is presented with an excellent opportunity to encourage behavior modification. Early recognition of the alcohol-abusing women and appropriate counseling are the cornerstones of treatment for these patients.

The value of determination of maternal serum of alpha-fetoprotein (MSAFP) concentration in the second trimester is well established. In addition to open neural tube defects, pregnancies associated with elevated second-trimester MSAFP have been shown to be at increased risk for a variety of problems, including low birth weight, preterm delivery, and pregnancy-induced hypertension (PIH). We evaluated the potential usefulness of MSAFP in the early third trimester. MSAFP concentration was determined in over 200 women at the time of glucose screening. Results were analysed with regard to gestational age at sampling, maternal weight, race, diabetes, and presence of twins. MSAFP was twice as high in twin gestation, but not affected by race or the presence of diabetes. In contrast to levels in early gestation, third-trimester MSAFP does not appear to be predictive of preterm delivery, low birth weight, or PIH.

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

Transabdominal ultrasonography in obese pregnant women is often unsatisfactory because of the poor transmission of ultrasound through a thickened abdominal wall. We report our experience with the placement of a transvaginal probe in the umbilicus to improve resolution in obese pregnant patients. The technique, which involves filling the umbilicus with ultrasound transmission gel and inserting the transvaginal probe into the umbilicus, was applied in 25 consecutive obese patients who had unsatisfactory fetal imaging by the standard transabdominal approach. The most frequent reason for incomplete fetal survey by the standard transabdominal approach was unsatisfactory imaging of the fetal heart (19 of 25 cases, 76%). The transumbilical approach resulted in improved resolution and satisfactory cardiac examination in 18 of these 19 cases (95%). In two cases, color and pulsed Doppler interrogation of intrafetal vessels become possible. A complete fetal survey was accomplished in 96% of the cases.

Objective: The purpose of this study was to determine the association between prenatal care in the United States and the neonatal death rate in the presence and absence of antenatal high-risk conditions. Study Design: Data were derived from the national perinatal mortality data sets for the years 1995 through 1997, which were provided by the National Center for Health Statistics. Analyses were restricted to singleton live births that occurred after 23 completed weeks of gestation. Multivariable logistic regression analyses were used to adjust for the presence or absence of various antenatal high-risk conditions, maternal age, gestational age at delivery, and birth weight. Results: Of 10,530,608 singleton live births, 18,339 (1.7/1000 births) resulted in neonatal death. Neonatal death rates (per 1000 live births) were higher for African American infants compared with white infants in the presence (2.7 vs 1.5, respectively) and absence (10.7 vs 7.9, respectively) of prenatal care. Lack of prenatal care was associated with an increase in neonatal deaths, which was greater for infants born at ≥36 weeks of gestation (relative risk, 2.1; 95% CI, 1.8, 2.4). Lack of prenatal care was also associated with increased neonatal death rates in the presence of preterm premature rupture of the membranes (relative risk, 1.3; 95% CI, 1.1, 1.5), placenta previa (relative risk, 1.9; 95% CI, 1.2, 2.9), fetal growth restriction (relative risk, 1.7; 95% CI, 1.2, 1.6), and postterm pregnancy (relative risk, 1.4; 95% CI, 1.0, 2.9). Conclusion: In the United States, prenatal care is associated with fewer neonatal deaths in black and white infants. This beneficial effect was more pronounced for births that occurred at ≥36 weeks of gestation and in the presence of preterm premature rupture of the membranes, placenta previa, fetal growth restriction, and postterm pregnancy. (Am J Obstet Gynecol 2002;186:1011-6.)

Objective: The purpose of this study was to determine how frequently general obstetricians refer pregnant patients to maternal-fetal medicine specialists in the presence of the clinical indications specified as appropriate for referral or consultation by the 1996 statement of the Society of Perinatal Obstetricians. Study Design: A questionnaire was mailed to 400 randomly selected general obstetricians across the United States. The obstetricians were asked how often they refer their high-risk pregnant patients to maternal-fetal medicine specialists in the presence of (1) a need for diagnostic or therapeutic procedures, (2) medical/surgical disorders, (3) healthy gravid women with high-risk fetuses, and (4) conditions that necessitate admission for reasons other than delivery. Response categories for each individual procedure/high-risk condition included "always," "frequently," "infrequently," "never," and "not applicable." Results: Overall, 55% of the responses indicated referral (always or frequently) to maternal-fetal medicine specialists for procedures or in the presence of high-risk conditions. More than 75% of the obstetricians always or frequently refer to maternal-fetal medicine specialists for most diagnostic/therapeutic procedures and for the following high-risk conditions: acute fatty liver, portal hypertension, pulmonary hypertension, transplantations, fetal hydrops, fetal anomaly/cytogenetic abnormality, fetal supraventricular tachycardia or congenital heart block, isoimmunization, and twin-to-twin transfusion syndrome. Conclusion: Most of the conditions for which >75% of the obstetricians refer to maternal-fetal medicine are rarely seen in practice. Comprehensive ultrasound examination is the only commonly encountered clinical situation that >75% of the general obstetricians refer to maternal-fetal medicine specialists. (Am J Obstet Gynecol 2001;185: 925-30.)

Objective: To compare the cost and benefits of prenatal diagnosis for Down syndrome using the British and American approaches. Methods: This cost-benefit analysis was based on a decision-analytic approach. The British strategy included screening by a first-trimester ultrasound at 10–14 weeks for nuchal translucency thickness, and the American strategy included only second-trimester screening by using maternal age and maternal serum screening. The key probabilities of the decision-tree analysis and all cost estimates were based on American standards. The best scenario of the British strategy assumed ultrasound nuchal translucency thickness sensitivity (for detecting Down syndrome) of 80% and a false-positive rate of 5% and the worst scenario assumed a sensitivity of 50% and a false-positive rate of 10%. The results were expressed in annual costs based on approximately 4 million births per year in the United States. Results: As compared with do-nothing, the American strategy was found to allow savings of approximately $96 million per year and the best scenario for the British strategy was savings of approximately $5 million per year. The financial costs of the British and American strategies would be comparable only if the first-trimester ultrasound had a sensitivity of 80% and a false-positive rate of 5% in detecting Down syndrome. Conclusion: The British strategy does not appear to be economically beneficial in the United States even under the most ideal scenarios of ultrasound accuracy.

Objective: The object of this study was to determine whether there are any clinically significant indication-specific variations in the accuracy of second-trimester genetic ultrasonography and to provide a risk adjustment for fetal trisomy 21 according to the results of genetic ultrasonography. Study Design: From November 1, 1992, to September 30, 1998, a second-trimester genetic sonogram was offered to all pregnant women who were at an increased risk for fetal trisomy 21 (≥1:274) because of either advanced maternal age (≥35 years) or abnormal serum biochemical profile or both of these. Outcome information included the results of genetic amniocentesis if performed and the results of pediatric assessment and follow-up after birth. In determining diagnostic accuracy of the genetic sonogram the presence of ≥1 abnormal ultrasonographic marker was considered an abnormal test result. Results: A total of 1835 fetuses with known outcomes underwent genetic ultrasonography between 15 and 24 weeks' gestation; of these 1792 had normal results, 34 had trisomy 21, and 9 had other chromosomal abnormalities. The likelihood of fetal trisomy 21 was reduced by 80% after a normal result of genetic ultrasonography. The overall sensitivity, specificity, and positive and negative predictive values of genetic ultrasonography for the detection of trisomy 21 were 82%, 91%, 15%, and 99.6%, respectively. There were no significant indication-specific variations in the accuracy of second-trimester ultrasonography. The sensitivity for the detection of fetal trisomy 21 ranged from 80% among women with advanced maternal age to 100% among women with both an abnormal biochemical profile and advanced maternal age. Conclusions: The likelihood of fetal trisomy 21 risk was reduced 80% after a normal result of genetic ultrasonography. In addition there were no significant indication-specific variations in the detection rate of genetic ultrasonography. (Am J Obstet Gynecol 1999;181:1045-8.)

Objective: The objectives of this study were to examine (1) the diagnostic accuracy requirements (from the cost-benefit point of view) of targeted ultrasonography versus genetic amniocentesis for prenatal detection of spina bifida in women with an elevated level of maternal serum α-fetoprotein, (2) the ultrasonographic accuracy of previously published studies from the cost-benefit point of view, and (3) the possible economic impact for the United States of offering targeted ultrasonography instead of routine amniocentesis to this group of patients. Study Design: Our cost-benefit formula was based on the hypothesis that the cost of universal genetic amniocentesis in patients with an elevated concentration of maternal serum α-fetoprotein in the second trimester should be at least equal to the cost of universal targeted ultrasonography, with amniocentesis used only for those with abnormalities on a sonogram. The main components of the formula included the diagnostic accuracy of targeted ultrasonography (sensitivity and specificity for detecting spina bifida), the cost of the amniocentesis package, the cost of targeted ultrasonography, and the lifetime cost of spina bifida not detected by targeted ultrasonography. After appropriate manipulation of the formula, a graph was constructed to represent the balance between the sensitivity and false-positive rate of targeted ultrasonography and was used to examine the accuracy of previously published ultrasonographic studies from the cost-benefit point of view. Sensitivity analyses included a range of prevalences of spina bifida in women with elevated maternal serum α-fetoprotein from 1:50 to 1:200 and false-positive rates of targeted ultrasonography from 1% to 10%. Results: Assuming overall prevalences of spina bifida of 1:50, 1:100, or 1:200 among women with elevated maternal serum α-fetoprotein, we found targeted ultrasonography to be beneficial only if the overall sensitivities for detecting fetal spina bifida were >88%, >76%, and >51%, respectively. All 17 studies published after the mid-1980s, which used the "cranial signs" for detecting spina bifida, had accuracies compatible with economic benefits (sensitivities, 92% to 100%; false-positive rates, 0% to 3%). Conclusion: The benefit of second-trimester targeted ultrasonography for fetal spina bifida depends on diagnostic accuracy (ie, sensitivity and false-positive rate). Currently achieved ultrasonographic accuracies are compatible with net benefits. Targeted ultrasonography in patients with an elevated level of second-trimester maternal serum α-fetoprotein in the United States has the potential for annual savings of approximately $36 million to $49 million and for avoiding 268 fetal deaths. (Am J Obstet Gynecol 1999;180:1227-33.)

Objective: The objective of this study was to perform an economic evaluation of second-trimester genetic ultrasonography for prenatal detection of Down syndrome. More specifically, we sought to determine the following: (1) the diagnostic accuracy requirements (from the cost-benefit point of view) of genetic ultrasonography versus genetic amniocentesis for women at increased risk for fetal Down syndrome and (2) the possible economic impact of second-trimester genetic ultrasonography for the US population on the basis of the ultrasonographic accuracies reported in previously published studies. Study Design: A cost-benefit equation was developed from the hypothesis that the cost of universal genetic amniocentesis of patients at increased risk for carrying a fetus with Down syndrome should be at least equal to the cost of universal genetic ultrasonography with amniocentesis used only for those with abnormal ultrasonographic results. The main components of the equation included the diagnostic accuracy of genetic ultrasonography (sensitivity and specificity for detecting Down syndrome), the costs of the amniocentesis package and genetic ultrasonography, and the lifetime cost of Down syndrome cases not detected by the genetic ultrasonography. After appropriate manipulation of the equation a graph was constructed, representing the balance between sensitivity and false-positive rate of genetic ultrasonography; this was used to examine the accuracy of previously published studies from the cost-benefit point of view. Sensitivity analyses included individual risks for Down syndrome ranging from 1:261 (risk of a 35-year-old at 18 weeks’ gestation) to 1:44 (risk of a 44-year-old at 18 weeks’ gestation). This economic evaluation was conducted from the societal perspective. Results: Genetic ultrasonography was found to be economically beneficial only if the overall sensitivity for detecting Down syndrome was >74%. Even then, the cost-benefit ratio depended on the corresponding false-positive rate. Of the 7 published studies that used multiple ultrasonographic markers for genetic ultrasonography, 6 had accuracies compatible with benefits. The required ultrasonographic accuracy (sensitivity and false-positive rate) varied according to the prevalence of Down syndrome in the population tested. Conclusions: The cost-benefit ratio of second-trimester genetic ultrasonography depends on its diagnostic accuracy, and it is beneficial only when its overall sensitivity for Down syndrome is >74%. (Am J Obstet Gynecol 1998;179:1214-9.)

beta-mimetics have been prescribed by physicians to arrest or prevent premature labor for more than 20 years. Although not approved by the Food and Drug Administration (FDA) for tocolytic use, terbutaline sulfate has been the most widely prescribed beta-mimetic in the United States. Recently, the role of terbutaline in the treatment and prevention of preterm labor has been questioned by the FDA. Because the off-label use of drugs is a formally accepted practice in medicine when scientific studies support such use, we reviewed the currently available clinical literature on terbutaline use in various routes of delivery: intravenous, oral, and subcutaneous via infusion pump. This review describes the clinical evidence that supports the safe and effective use of terbutaline as a tocolytic agent in certain patient populations. Practicing physicians should continue to have unrestricted use of terbutaline for tocolysis as one of the few remaining therapeutic options remaining in the fight against preterm birth.

Objective To test the efficacy of ultrasound in detecting fetuses with trisomy 21. Methods From November 1, 1992, to December 31, 1995, a second-trimester genetic sonogram was offered to all women with singleton fetuses at increased risk (at least 1:274) for trisomy 21, who had either declined genetic amniocentesis or chose to have a sonogram before deciding whether to undergo an amniocentesis. In addition to standard fetal biometry, the following ultrasound markers for aneuploidy were evaluated: structural anomalies (including face, hands, and cardiac [four-chamber view and outflow tracts]), short femur, short humerus, pyelectasis, nuchal fold thickening, echogenic bowel, choroid plexus cysts, hypoplastic middle phalanx of the fifth digit, wide space between the first and second toes, and two-vessel umbilical cord. Outcome information included the results of genetic amniocentesis, if performed, or the results of postnatal pediatric assessment and follow-up. Results Five hundred seventy-three patients had a genetic sonogram between 15 and 23 weeks' gestation: 378 patients had advanced maternal age (at least 35 years), 141 had abnormal serum biochemistry, and 54 had both. The majority (495, or 86.3%) had a normal genetic sonogram (absence of abnormal ultrasound markers); 51 (9%) had one marker present, and 27 (4.7%) had two or more markers present. Outcome was obtained on 422 patients (the remaining were ongoing pregnancies or were lost to follow-up). Twelve of 14 fetuses with trisomy 21, one fetus with trisomy 13, and one fetus with triploidy had two or more abnormal ultrasound markers present; one fetus with trisomy 21 had one abnormal marker and one had a completely normal ultrasound. When one or more abnormal ultrasound markers were present, the sensitivity, specificity, and positive and negative predictive values for trisomy 21 were 92.8%, 86.7%, 19.4%, and 99.7%, respectively. When two or more abnormal ultrasound markers were present, the corresponding values were 85.7%, 96.8%, 48%, and 99.5%. In the study population, the amniocentesis rate was 12.7% overall and 17.3% in cases with known outcome. Conclusion Second-trimester genetic sonogram may be a reasonable alternative for patients at increased risk for fetal trisomy 21 who wish to avoid amniocentesis. In experienced hands, this approach may result in a high detection rate of trisomy 21 (93%), with an amniocentesis rate of less than 20%.

Our purpose was to compare continuous intrapartum electronic fetal heart rate monitoring with intermittent auscultation for detecting fetal acidemia at birth.Data from a previously published randomized trial of electronic fetal heart rate monitoring versus intermittent auscultation were analyzed to identify any differences between the two methods in detecting fetal acidemia at birth. Fetal acidemia at birth was defined as the presence of cord blood arterial pH7.15.A total of 1419 patients with umbilical cord blood acid-base measurements were identified, 739 in the electronic FHR monitoring group and 680 in the auscultation group. Electronic FHR monitoring had significantly better sensitivity (97% vs 34%, p0.001), lower specificity (84% vs 91%, p0.001), higher positive predictive value (37% vs 22%, p0.05), and higher negative predictive value (99.5% vs 95%, p0.001) in detecting fetal acidemia at birth. In addition, electronic FHR monitoring was significantly better in detecting all types of acidemia: metabolic (95.5% vs 26.5%, p0.001), mixed (95% vs 37.5%, p0.001), and respiratory (100% vs 41.5%, p0.001).These data suggest that electronic FHR monitoring is superior to intermittent auscultation in detecting fetal acidemia at birth.

Seventy-five women with a mean age of 27.5 years who requested Norplant implants for contraception were studied over a five-year period. The patients kept daily diaries of their vaginal bleeding and coital frequency, and were seen at least every six months at which time their weight was measured. This study examines the impact of Norplant implants use on menstrual regularity, body mass index and coital frequency. Irregular bleeding was most prevalent during the first two years of Norplant implants use and accounted for the primary reason for discontinuation of this method. No increase in Body Mass Index (BMI) was noted in Norplant implants users over the five-year study period. Women with irregular bleeding did not have a higher or lower BMI compared to women with regular bleeding and irregular bleeding patterns did not impact on coital frequency. Over five years, four pregnancies occurred during Norplant implant use. Norplant implants are a highly effective contraceptive method and women using this method should not expect an increase in body weight. Irregular bleeding is most frequent during the first two years of use and menstrual cyclicity resumes in the majority of women by the third year of use and continues to the fifth year of use.Medical researchers recruited 75 women to participate in a 5-year prospective study of Norplant use that examined their bleeding patterns, changes in Body Mass Index (BMI), the effect BMI had on the bleeding pattern, and the effect irregular bleeding had on coital frequency. Clinicians took a complete medical and sexual history and performed a physical and pelvic examination. Follow up visits occurred at 1, 3, 6, and 12 months after insertion of the Norplant contraceptive implant and every 6 months thereafter until removal at 5 years. The clients maintained a daily record of coital activity and bleeding/spotting patterns. Thirty women completed 5 years of Norplant use. Irregular bleeding occurred most frequently during the 1st 2 years of Norplant use. Its frequency decreased as duration of Norplant use increased. For example, 22.35% of the women experienced spotting and bleeding between menstrual periods in the 1st year, 12.25% in the 2nd year, and 3.1% at 5 years. BMI was similar for women with and without irregular bleeding patterns. BMI did not change significantly over the 5 years. Irregular bleeding did not affect coital frequency. The mean coital frequency for the women was 18-20 acts of sexual intercourse per month. Irregular bleeding (32%) and planned pregnancy (12%) were the leading reasons for discontinuation of Norplant. Most of the women who quit using Norplant for irregular bleeding reasons did so during the 1st 2 years. Just 5 pregnancies occurred during Norplant use. These results suggest that clinicians should adequately counsel potential Norplant users about irregular bleeding to reduce discontinuation for irregular bleeding.

The value of peritoneal closure at the time of cesarean birth was evaluated prospectively. Two hundred forty-eight women undergoing low transverse cesarean through a Pfannenstiel skin incision were assigned to one of two groups: peritoneum open (N = 127) or peritoneum closed (N = 121). The mean (+/- SEM) surgical time in the open group (48.1 +/- 1.2 minutes) was significantly less than for the closed group (53.2 +/- 1.4 minutes) (P less than .005). There were no postoperative differences between the groups in the incidence of wound infection, dehiscence, endometritis, ileus, and length of hospital stay. Our study suggests that leaving the parietal peritoneum unsutured is an acceptable way to manage patients at cesarean delivery.

To determine the feasibility of combining several screening tests for the prenatal detection of Down syndrome, we evaluated the potential relationship among three proposed predictors. We determined the concentration of chorionic gonadotropin in frozen serum samples from women of known maternal age and weight, fetal biparietal diameter, and femur length, and alpha-fetoprotein concentration. When corrected for gestational age and maternal weight, the potential predictors were independent, except for a slight correlation (r = 0.10) between maternal serum alpha-fetoprotein and maternal serum human chorionic gonadotropin. Both maternal serum human chorionic gonadotropin and biparietal diameter/femur length demonstrated an approximately log-normal distribution similar to maternal serum alpha-fetoprotein. Therefore it is scientifically sound to use any or all of these variables in combination for the identification of pregnancies at increased risk for Down syndrome.

OBJECTIVE To evaluate the ability of ultrasound with transfundal pressure to detect the incompetent cervix in pregnant women at risk for this condition. METHODS One hundred fifty pregnant women with no prior pregnancy losses were scanned transabdominally, and 31 asymptomatic pregnant women with a prior history of cervical incompetency or risk for this condition were scanned transvaginally. The control patients were scanned once between 16-24 weeks, and the patients at risk were studied 73 times between 8-25 weeks. After evaluating the cervix and its internal os, transfundal pressure was applied. Cervical cerclages were placed for cervical funneling and shortening in response to transfundal pressure or for a grossly incompetent cervix on ultrasound evaluation. RESULTS Transfundal pressure elicited no changes in the internal cervical os of the 150 control patients, of whom 141 delivered at term, two miscarried at 22 and 23 weeks, and seven delivered prematurely (4.7%). Fourteen of the 31 pregnancies at risk for cervical incompetency revealed opening of the internal os or descent of the fetal membranes with transfundal pressure. Thirteen of these 14 pregnancies were treated with cerclage, with nine (64%) proceeding to term, three (21%) delivering prematurely, and two (14%) aborting. The one patient who did not receive a cerclage also aborted. In six cases, the cervix and its internal os appeared normal but the membranes protruded into the endocervical canal in response to transfundal pressure. CONCLUSION Application of transfundal pressure during transvaginal ultrasound evaluation of the cervix and its internal os may assist in detecting the asymptomatic incompetent cervix.