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Practicing obstetrics today requires not only the latest clinical knowledge but also people-management skills that can help minimize perinatal and maternal risk and reduce your legal exposure. [ABSTRACT FROM AUTHOR]

We sought to evaluate the effectiveness of daily oral micronized progesterone (MP) in preventing recurrent spontaneous preterm birth (RSPB) and whether MP increases maternal serum progesterone. We performed a pilot, single-center, randomized, double-blind, placebo-controlled trial in women with a prior preterm birth and current singleton gestation at 16 to 20 weeks ( N = 33). The primary outcome was the rate of RSPB. Subjects were given either daily MP (400 mg) or placebo from 16 to 34 weeks. Serum progesterone was obtained at enrollment and in the late second/early third trimester. Pregnancy outcome data were collected. RSPB occurred in 5/19 (26.3%) in the MP group versus 8/14 (57.1%) in placebo group ( P = 0.15). The mean age at delivery was 37.0 ± 2.7 weeks for the MP group versus 35.9 ± 2.6 weeks for the placebo ( P = 0.3). Mean serum progesterone at 28 weeks was 122.6 ± 61.8 pg/mL for MP group versus 90.1 ± 38.7 pg/mL for placebo ( P = 0.19). MP was associated with a trend toward a reduction in RSPB and an increase in the maternal serum progesterone. Although the primary outcome in this pilot study did not reach statistical significance, the results suggest a favorable trend meriting further investigation., (© Thieme Medical Publishers.)

Objective: To describe the effects of pregnancy on the growth of leiomyomas using sonographic measurements of leiomyomas taken longitudinally during pregnancy., Study Design: The study population included asymptomatic gravidas with singleton pregnancies in whom we identified uterine leiomyomas. We included all women whose leiomyomas were measured at least twice during the pregnancy. In a subgroup of women we also compared the size of leiomyomas before and after the index pregnancy. Using real-time sonography, we measured each leiomyoma in 3 axes and averaged the measurements. During subsequent studies we calculated the percent change in the size of each tumor. We assessed complications related to the presence of these tumors., Results: We evaluated 137 leiomyomas in 72 women (average, 2.3 +/- 1.8 per woman). Each underwent an average of 3.7 +/- 2.1 scans. The average gestational age at the time of first assessment was 14.4 +/- 5.4 weeks. The average diameter of the leiomyomas at the first study was 34.2 +/- 23 mm. On average, there was no significant change in the size of leiomyomas during pregnancy. We found that the size, location and our ability to visualize leiomyomas varied significantly during pregnancy. Four of the 72 women had obstetric complications related to the presence of leiomyomas., Conclusion: The findings of our longitudinal sonographic assessment of 137 uterine leiomyomas suggest that despite the commonly held belief that they tend to enlarge during the course of pregnancy, this phenomenon is in fact quite rare.

Objective: To evaluate the association between the sonographic appearance of globular placenta and perinatal outcome., Study Design: We prospectively followed the pregnancy course and perinatal outcome in women with globular placentas (hyperechoic, thick and highly vascular placentas with edges that lack the typical "tapering" appearance) during routine sonographic study., Results: Fourteen women were included. In 7 women the globular appearance of the placenta normalized spontaneously, and perinatal outcome was good. The other 7 experienced poor perinatal outcomes. There were no significant differences between the 2 groups. Among pregnancies in which the globular placental appearance persisted, 3 resulted in fetal demise; 3 women had severe intrauterine growth restriction and oligohydramnios and underwent cesarean deliveries at 26, 27 and 31 weeks, respectively; and 1 patient had premature preterm rupture of membranes and underwent a cesarean delivery due to placental abruption., Conclusion: In half the pregnancies complicated by the sonographic appearance of a globular placenta, this shape spontaneously normalized, and the perinatal outcome was normal. However, when the globular appearance of the placenta persisted, the condition was associated with a poor perinatal outcome. Pregnancies complicated by a globular placenta should be followed closely.

Objective: To investigate the potential value of ultrasound examination of the fetal profile for present/hypoplastic fetal nasal bone at 15-22 weeks' gestation as a marker for trisomy 21., Methods: This was an observational ultrasound study in 1046 singleton pregnancies undergoing amniocentesis for fetal karyotyping at 15-22 (median, 17) weeks' gestation. Immediately before amniocentesis the fetal profile was examined to determine if the nasal bone was present or hypoplastic (absent or shorter than 2.5 mm). The incidence of nasal hypoplasia in the trisomy 21 and the chromosomally normal fetuses was determined and the likelihood ratio for trisomy 21 for nasal hypoplasia was calculated., Results: All fetuses were successfully examined for the presence of the nasal bone. The nasal bone was hypoplastic in 21/34 (61.8%) fetuses with trisomy 21, in 12/982 (1.2%) chromosomally normal fetuses and in 1/30 (3.3%) fetuses with other chromosomal defects. In 3/21 (14.3%) trisomy 21 fetuses with nasal hypoplasia there were no other abnormal ultrasound findings. In the chromosomally normal group hypoplastic nasal bone was found in 0.5% of Caucasians and in 8.8% of Afro-Caribbeans. The likelihood ratio for trisomy 21 for hypoplastic nasal bone was 50.5 (95% CI 27.1-92.7) and for present nasal bone it was 0.38 (95% CI 0.24-0.56)., Conclusion: Nasal bone hypoplasia at the 15-22-week scan is associated with a high risk for trisomy 21 and it is a highly sensitive and specific marker for this chromosomal abnormality., (Copyright 2002 ISUOG. Published by John Wiley & Sons, Ltd.)

Objective: To evaluate fetal biophysical testing as a predictor of preterm delivery after preterm labor or preterm rupture of the membranes (PROM)., Methods: We studied 50 women with suspected preterm labor and intact membranes and 25 women with PROM but not in labor between 28 and 36 weeks' gestation. Before treatment, each subject had cervical Bishop scoring and 1-hour ultrasound observation of fetal heart rate, breathing, body movements, and flexion-extensions. Data were compared with t tests, chi 2 tests, or receiver operating curves., Results: The mean gestational age at entry was similar in both groups. Twenty (80%) PROM and ten (18%) preterm labor patients delivered within 72 hours of admission; two (8%) PROM and 38 (76%) preterm labor patients delivered more than 7 days after admission. Absent breathing and body movements had high positive predictive values (100%) but moderate sensitivities (less than 55%) for predicting delivery within 72 hours or 7 days in the PROM and preterm labor groups. These sensitivities increased to nearly 70% with the addition of Bishop scores. The optimal diagnostic cutoffs for delivery within 72 hours or 7 days were a breathing incidence below 1% for the PROM group and a body movement incidence below 1% for the preterm labor group, and a breathing incidence of at most 5%., Conclusions: Complete absence of one biophysical variable confers limited sensitivity but high positive predictive value for early delivery in patients with preterm labor or PROM. The use of cutoff percentages for the incidence of individual variables improved sensitivity for both conditions. Cervical scoring added to biophysical monitoring by improving the sensitivity for early delivery of patients in preterm labor.

Objective: Our purpose was to compare third-trimester fetal biophysical activities in normal and well-controlled insulin-dependent diabetic pregnancies., Study Design: We performed serial bimonthly fetal biophysical studies from 30 to 38 weeks in 18 normal and 18 well-controlled insulin-dependent diabetic pregnancies (White classes B through D). Each study contained 60 minutes of simultaneous ultrasonographic recordings of fetal breathing movements and rates, baseline heart rate, and body movements. Mean daily blood glucose levels of diabetic patients were determined from home monitors; HbA1c was determined every 6 weeks and ultrasonographic fetal growth rates every 3 weeks. Data were compared with t tests, analysis of variance with repeated measures, and chi 2 tests., Results: Women in the diabetic group maintained good glycemic control and were delivered of normal infants of weights similar to those of nondiabetic gravidas. Their fetuses had higher mean incidences of fetal breathing movement, fetal heart rates, and fetal breathing rates but lower fetal movements and fetal heart rate acceleration counts than did controls throughout the study. Neither short- nor long-term maternal glycemic levels correlated well with fetal biophysical performance., Conclusions: In spite of good maternal glycemic control fetuses of diabetic women behaved differently from those of nondiabetic women. Modulation of their biophysical activities may be affected by maternal glycemic status before the last trimester. Different standards might need to be applied to interpret their tests.

Objective: Our objective was to determine how well semiquantitative ultrasonographic measures of amniotic fluid, i.e., maximal amniotic fluid vertical pocket and amniotic fluid index, reflect actual amniotic fluid volumes in 50 near-term patients whose amniotic fluid volume estimates were normal by visual inspection., Study Design: Before amniocentesis for fetal lung maturity, each patient had visual amniotic fluid volume estimates, maximal amniotic fluid vertical pocket, and amniotic fluid index performed by the same examiner, and then each received intraamniotic injection of a 10% paraaminohippurate solution. Amniotic fluid volume was quantitated by spectrophotometric assay of paraaminohippurate concentration. Oligohydramnios and polyhydramnios were defined as < 300 and > 2000 ml, respectively., Results: Quantitative amniotic fluid volume was positively related to both amniotic fluid index and maximal amniotic fluid vertical pocket (r = 0.75 and 0.60, respectively). True-positive rates for oligohydramnios (amniotic fluid index < 5 cm or maximal amniotic fluid vertical pocket < 2 cm) were 100% and 0%, respectively; false-positive rates with either method were 0%. True-positive rates for polyhydramnios (amniotic fluid index > 20 cm and maximal amniotic fluid vertical pocket > 8 cm) were 0%; false-positive rates were 16% and 24%, respectively., Conclusions: Amniotic fluid index appears to be slightly better than maximal amniotic fluid vertical pocket for reflecting actual amniotic fluid volume. Both indirect methods tend to overestimate actual amniotic fluid volume at the upper end of its extremes.

Objective: To determine whether uterine activity, assessed by either fluid-filled or solid pressure catheters, changes with uterine incision at cesarean delivery., Methods: Uterine activity was recorded continuously during low transverse cesarean delivery in ten parturients using fluid-filled pressure catheters and in ten women with solid pressure catheters. Visual analyses were performed of the last 30 minutes of uterine recording before uterine incision and of the period after incision; the analyses were then compared within and between the catheter groups for mean uterine tone and contraction amplitude, frequency, and duration. Oxytocin use, anesthesia method, mean gestational age, birth weight, length of labor, duration of monitoring, and uterine incision-to-delivery time were compared between the groups., Results: All obstetric end points were similar in both catheter groups except for a higher mean birth weight in the solid-catheter group. The mean (+/- standard deviation) duration of post-incision monitoring was 4.7 +/- 0.94 minutes. After uterine incision, mean tone and contraction amplitude were unchanged, whereas mean contraction frequency and duration decreased significantly., Conclusions: Though intrauterine monitoring was brief, this model allows a unique view of "controlled" uterine rupture. Spontaneous uterine rupture may evolve more gradually; however, neither catheter type would be likely to aid its early recognition.

Chronic Chlamydia trachomatis infection has been demonstrated in the fallopian tubes of asymptomatic infertile women. These women have a significantly increased risk of ectopic pregnancies. The purpose of our study was to determine the efficacy of culturing the ectopic site for C. trachomatis, the likely cause of asymptomatic salpingitis in association with a tubal pregnancy. We cultured the fallopian tubes of 21 patients undergoing surgery for tubal pregnancy, all 21 cultures were negative for C. trachomatis. Although infection with this organism is one of the causes of ectopic pregnancy, we were unable to demonstrate the presence of a concomitant chlamydial infection at the time of surgery. Combining chlamydial cultures with nonculture techniques may be more beneficial in further attempts to demonstrate such an association.

Antepartum cervical Chlamydia trachomatis infection is associated with an increased risk of peripartum maternal and neonatal morbidity. Chronic chlamydial salpingitis has been described in asymptomatic women. We studied the incidence of asymptomatic chlamydial colonization of the fallopian tubes during pregnancy, and the influence of such infection on the patients' clinical course, by culturing the fallopian tubes of 53 asymptomatic women who underwent tubal ligation in the immediate postpartum period. One patient had a positive chlamydial culture in one of her tubes, and two others had histologic evidence of acute and chronic salpingitis. These patients had no infectious morbidity during the antepartum, intrapartum, or postpartum periods. Our findings suggest that asymptomatic chlamydial colonization and inflammatory processes may exist in the fallopian tubes during the peripartum period.

Cytogenetic study is an important part of the evaluation of intrauterine fetal death. Many tissue cultures fail to grow because of maceration and autolysis of the fetal tissues. We evaluated eight amniotic fluid cytogenetic cultures from patients whose fetus had died. All patients had sonographic evidence of Spalding's sign. In four patients, urea and PGF2 alpha were simultaneously injected into the amniotic cavity. Seven amniotic cultures, gestational age 19 to 33 weeks, grew successfully, even when a tissue culture obtained after delivery failed to grow. One culture, gestational age 36.5 weeks, failed to grow and could not be analyzed. The use of amniotic fluid culture for cytogenetic evaluation of fetal death, obtained at the time of diagnosis, is superior to culture of fetal tissue obtained after delivery. The amniocentesis may also serve for intra-amniotic induction of labor.