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Conversion hip arthroplasty is defined as a patient who has had prior open or arthroscopic hip surgery with or without retained hardware that is removed and replaced with arthroplasty components. Currently, it is classified under the same diagnosis related group (DRG) as primary total hip arthroplasty (THA), however, it frequently requires a higher cost of care.A retrospective study of 228 conversion THA procedures in an orthopaedic specialty hospital were performed. Propensity score matching was used to compare the study group to a cohort of 510 primary THA patients by age, body mass index (BMI), sex and American Society of Anesthisiology (ASA) score. These matched groups were compared based on total costs, implants used, operative times, llengths of stay (LOS), readmissions, and complications.Conversion THA incurred 25% greater mean total costs compared to primary THA (p.05), longer lengths of surgery (154 vs 122 minutes), and hospital LOS (2.1 vs 1.56 days). A subgroup analysis showed a 57% increased cost for cephalomedullary nail conversion, 34% increased cost for sliding hip screw, 33% for acetabular ORIF conversion, and 10% increased costs in closed reduction and percutaneous pinning conversions (all p.05). There were 5 intraoperative complications in the conversion group versus none in the primary THA group (P.01), with no statistically significant difference in readmissions.Conversion THA is significantly more costly than primary THA and has longer surgical times, and greater LOS. Specifically, conversion THA with retained implants had the greatest impact on cost.

BACKGROUND CONTEXT Sagittal balance in adult spinal deformity is topic of ongoing exploration. Junctional kyphosis and junctional failure are challenging problems whose contributing factors are not entirely understood. A high native pelvic incidence has been shown to be a risk factor for adjacent segment disease. Recent developments in sagittal plane measures include the T1 pelvic angle which was proven to correlate with health-related quality of life scores. PURPOSE To evaluate whether a high preoperative pelvic incidence, postoperative pelvic incidence-lumbar lordosis mismatch, or postoperative T1-pelvic angle is predictive of proximal junctional kyphosis or failure and subsequent revision or persistent pain at long-term follow-up. STUDY DESIGN/SETTING A multicenter, multisurgeon retrospective cohort study. PATIENT SAMPLE All patients who underwent a posterior thoracolumbar fusion with pelvic fixation, with or without interbody fusion, with or without three-column osteotomy between 2010-2019. OUTCOME MEASURES Outcome measures included radiographic evaluation of PJK or PJF, sagittal alignment, adjacent segment disease, revision rate, and back pain needing opiates, pain management, or documentation of surgical revision counseling at or before long-term follow-up. METHODS Patients were separated into cohorts of preoperative pelvic incidence less than or equal to 55° and greater than 55°. -term follow-up ranged from 1 to 8 years post index surgery. Pelvic incidence, lumbar lordosis, T1-pelvic angle, and proximal junctional angle were recorded at preoperative, short term postoperative (less than 3 months) and Long-term postoperative (over 1 year) follow-up. At Long-term follow-up the revision rate and patient symptoms were recorded as well as radiographic parameters. Multivariate statistical analysis is being conducted. RESULTS Preliminary data indicates that 60% of patients with a high native pelvic incidence had evidence of PJK or PJF at or prior to Long-term follow-up. No patients with a low pelvic incidence had junctional kyphosis at Long-term follow-up. Of patients with a T1-pelvic angle over 20°, 55% had evidence of PJK or PJF. The overall rate of revision surgery, continued pain or deformity was 87% in patients with a T1-pelvic angle over 20°. No patients with a T1-pelvic angle less than 20° had PJK or PJF and one patient in this cohort developed symptomatic adjacent segment disease. CONCLUSIONS A native pelvic incidence over 55° may be predictive of Long-term junctional kyphosis and symptomatic adjacent segment disease. A postoperative T1-pelvic angle greater than 20° degrees is associated with continued back pain and revision surgery following thoracolumbar fusions at up to 8 years post surgery. Interestingly, despite correction of PI-LL mismatch within 9° at the short term follow-up, the T1 pelvic angle tended to return to within 10° of the initial preoperative measure in the majority of cases at Long-term follow-up suggesting that the pursuit of sagittal plane correction to meet defined spinopelvic parameters may not account for physiologic kyphosis with increasing age. Data collection is ongoing to meet power analysis and statistical significance criteria. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Work disability presents a major burden and stressor at the levels of the individual and society in general. Factors that inhibit or prevent return to work must continually be researched. PURPOSE A study was conducted to examine and define the rates of return to full-time employment for patients not involved in worker's compensation (WC) and to identify modifying factors thereof. STUDY DESIGN/SETTING A retrospective chart review with a prospective IRB approved telephone questionnaire designed to collect pre and postop work history was utilized. Multiple factors were examined that may affect the return to work (RTW) rate of a patient population working full time 3 months prior to surgery (including baseline data such as comorbidities, gender, surgical complexity, age, BMI, social history, ethnicity). PATIENT SAMPLE An IRB-approved retrospective chart review was performed on all surgical patients who underwent spinal surgery from December 2006 to January 2016 in two spinal surgeons’ practices. A total of 1,648 patients were identified with a minimum of 2-year follow-up. After reaching out to 1,088 sequential patients over a 2-year period, 394 called back. Of these, 325 consented to the questionnaire with 69 patients declining. OUTCOME MEASURES Factors examined to affect rate of return to work with 1 year were: procedure type, levels fused, ethnicity, gender, BMI, smoker status, alcohol consumption status, diabetes, heart disease, osteoporosis, anxiety, depression, DVT, previous spine surgery, IV antibiotics, intraoperative and postoperative complications, and infection. METHODS Subgroups within the patient sample showed no significant difference in male-female ratio. Prospective questionaire asked were: status before work, after work, when they returned full time and when RTW to the same job. Minimum phone follow-up was two years postoperatively. Baseline data (date of birth, gender, BMI, preoperative comorbidities, ethnicity, social history, surgery date, surgery type, levels fused, occupation) was obtained by chart review for these patients. The prospective data collecting pre- and postoperative work history along with the retrospective chart review data was analyzed looking for any trends in patients who were working full time 3 months preop and not returning to full time work within a year of surgical date. RESULTS No comorbidity or other correlative factors of RTW were detected. However, a significant difference of RTW rate was noticed between genders. Examining nonretired patients who reported full-time employment within 3 months of surgical intervention, 87 females and 94 males qualified. Only 60% of patients in the female group and 89% in the male group returned to full-time employment within one year. When subdivided by surgical complexity, in noncomplex cases, the rate of return to full-time employment was 59% for females, and 89% for males vs complex cases, where 64% of females and 90% for males returned to work full-time. Both analyses had a power of 99% with p-values less than .05. CONCLUSIONS Our data demonstrated that the return to work rate is significantly lower in female patients undergoing spine surgery, irrespective of the complexity of the surgery. This information may be helpful in pre- and postoperative management. This difference warrants discussion with patients preoperatively. Attitudes of employers towards employees after spinal surgery and the confidence of females after spinal surgery should be further investigated FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

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

Objectives: The study analyzed the phase relationship between fetal heart rate and arterial blood pressure fluctuation during sinusoidal heart rate patterns in fetal lambs. Study Design: Thirty-two fetal lambs were placed on extracorporeal membrane oxygenation after cesarean delivery at ages ranging between 113 and 133 days' gestation. Sinusoidal heart rate patterns persisting for >10 minutes were analyzed. The relationships between the sinusoidal heart rate cycles and the arterial blood pressure cycles were quantitatively expressed in degrees by timing the zenith and the nadir of each and assigning a phase-angle index (with 0 [360] and 180 degrees being synchronized and reciprocal, respectively). Simultaneous blood samples were taken from the 4 different sites of the fetal circulation for blood gas and acid-base analysis when the sinusoidal heart rate pattern appeared. Regional cerebral blood flow was determined by means of the colored microsphere technique in 8 fetuses with sinusoidal patterns and 7 control fetuses. Results: Sinusoidal heart rate patterns were observed in 13 (40.6%) of the 32 fetal lambs. Two types of fetal heart rate and arterial blood pressure relationship could be recognized during sinusoidal pattern, the reciprocal type (n = 7) and the synchronized type (n = 9). A reciprocal type of sinusoidal pattern preceded a synchronized type pattern in 3 lambs that showed sinusoidal patterns at different stages of the experiment. The reciprocal type was associated with a higher baseline heart rate and amplitude of the sinusoidal heart rate pattern than was the synchronized type. The synchronized type was associated with a lower pH and base excess than was the reciprocal type. The cerebral blood flow in the medulla oblongata was significantly lower during the synchronized type pattern than during the reciprocal type pattern. Conclusion: There are 2 types of sinusoidal heart rate pattern. A synchronized type sinusoidal heart rate pattern may indicate more advanced fetal compromise than is associated with a reciprocal type pattern. (Am J Obstet Gynecol 1999;180:462-8.)

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.

Our purpose was to characterize the histologic changes in the asphyxiated fetal lamb brain and to correlate the severity of these changes with fetal physiologic parameters during and after asphyxia.Seventeen near-term fetuses were used for analysis: control group without manipulation (n = 4, 132 +/- 1.1 days of gestation at autopsy, mean +/- SEM), sham-asphyxia control group (n = 3, 132 +/- 1.3 days), and asphyxiated group, which successfully survived 72 hours after asphyxia (n = 10, 130 +/- 1.0 days). Asphyxia was produced by umbilical cord occlusion lasting for approximately 60 minutes until fetal arterial pH diminished to6.9 and base excess to-20 mEq/L. Fetal heart rate, blood pressure, and electrocorticographic activity were continuously monitored. The fetuses were killed 72 hours after asphyxia, and the brains were fixed in formalin and processed for histologic and immunocytochemical studies.Neuropathologic changes varied from case to case, ranging from almost total infarction of cortical and subcortical structures to extremely subtle and patchy white matter alterations characterized by slight vacuolization of the white matter or slight to moderate increases in cellularity confined to the junction of cerebral cortex and white matter. Even fetuses that showed full recovery of all physiologic parameters, including electrocorticographic activity, demonstrated subtle but distinct white matter lesions. The gray matter, including the hippocampal neurons, was generally spared in these cases. Electrocorticographic parameters, duration of hypotension during asphyxia, and delayed recovery of blood lactate concentrations correlated well with the histologic grading of brain damage.Asphyxia by partial umbilical cord occlusion in near-term fetal lambs produces variable neuropathologic changes. The mildest change is a white matter lesion characterized by vacuolization and loss of myelin or by increased cellularity in the damaged regions.

OBJECTIVE: The purpose of this study was to determine the degree of cardiac oxygenation produced by different routes of extracorporeal membrane oxygenation in fetal lambs submerged in warm saline solution. STUDY DESIGN: Seven fetal lambs ranging in age from 113 to 133 days of gestation were delivered by cesarean section and oxygenated with extracorporeal membrane oxygenation. To maintain the patency of the ductus arteriosus, prostaglandin E 1 was continuously infused intravenously to the fetus. Initially the extracorporeal membrane oxygenation route was from the right atrium to the carotid artery. Then the extracorporeal membrane oxygenation route was changed to flow from the right atrium to the umbilical vein. The fetus was kept in a warm saline solution bath, and the fetal circulation was maintained. Extracorporeal membrane oxygenation flow ranged between 100 and 200 ml/min throughout the experiment. Simultaneous blood samples were taken during both types of extracorporeal membrane oxygenation from the following points in the fetal circulation: premembrane (least oxygenated blood leaving the fetus from the right atrium), postmembrane (oxygenated blood returning to the fetus), the carotid artery, and the left ventricle. The respiratory gases and pH of each sample were measured. Six fetuses received nonradioactive colored microspheres injected into the oxygenated blood returning to the fetus flow before returning to the fetuses during both types of extracorporeal membrane oxygenation. After the animals were killed, microspheres were counted in the myocardium separately taken from the right and left atria and the right and left ventricles to determine cardiac blood flow. RESULTS: During right atrium to carotid artery extracorporeal membrane oxygenation, left ventricle PO 2 remained low as postmembrane PO 2 increased; these values were not significantly correlated ( r = 0.234, p = 0.61). During right atrium to umbilical vein extracorporeal membrane oxygenation, left ventricle and postmembrane PO 2 exhibited a significant positive correlation ( r = 0.855, p = 0.014). When the extracorporeal membrane oxygenation route was switched from the right atrium to carotid artery to the right atrium to umbilical vein, there was a significant increase in left ventricle PO 2 and a decrease in left ventricle PCO 2 , whereas the respiratory gases and pH remained unchanged at other sites in the circulation. Microsphere counts were consistently higher during right atrium to umbilical vein extracorporeal membrane oxygenation than during right atrium to carotid artery extracorporeal membrane oxygenation in all four samples from different parts of myocardium ( p t test). CONCLUSION: More effective cardiac oxygenation is provided by right atrium to umbilical vein extracorporeal membrane oxygenation than by right atrium to carotid artery extracorporeal membrane oxygenation. (AM J OBSTET GYNECOL 1996;174:864-70.)

Objective: The objective of this study was to compare perinatal outcomes of hypertensive and normotensive women experiencing abruptio placentae. Our hypothesis is that hypertensive women have a less favorable perinatal outcome than do normotensive women. Study Design: Women with the diagnosis of abruptio placentae delivered between July 1, 1988, and May 31, 1992, composed the study group ( n = 226) in this case-control study. The incidence of abruptio placentae was 0.7% during this time. Those women with either multifetal gestations ( n = 4) or delivery before 20 weeks' gestation ( n = 2) were excluded from data analysis. The remaining 220 patients were divided according to their hypertensive ( n = 29) or normotensive ( n = 191) status. Maternal and neonatal medical records were reviewed and abstracted for demographic variables, antepartum complications, delivery route, abruptio placentae grade, neonatal gender, birth weight, Apgar score, cord pH, and perinatal mortality. These perinatal outcome variables were compared between the hypertensive and normotensive patient groups. Results: Black women with abruptio placentae were significantly more likely to be hypertensive ( p = 0.0078). Hypertensive women with abruptio placentae had the antepartum complication diabetes mellitus significantly more often than did normotensive women ( p = 0.032). However, they were similar to normotensive women with regard to the frequency of positive urine drug screen and trauma. Hypertensive women were no more likely to be delivered before 32 or 37 weeks' gestation, have neonates weighing p = 0.053), as did significantly lower umbilical cord artery ( p = 0.005) and venous ( p = 0.003) pH values. Neonates from hypertensive women were no more likely to have low 5-minute Apgar scores or to die than those from normotensive women. Conclusion: Although hypertensive women experiencing abruptio placentae are more likely to have higher-grade abruptio placentae and lower umbilical cord pH values, the overall perinatal outcome was not significantly different from that of normotensive women experiencing abruptio placentae.

OBJECTIVE: The purpose of this study was to examine the influence of fetal behavioral states on baroreflex-mediated, variable fetal heart rate decelerations caused by umbilical cord occlusion. STUDY DESIGN: Five chronically instrumented fetal lambs were subjected to intermittent partial umbilical cord occlusion for 1 minute every 3 minutes, lasting 2 hours. Fetal behavioral states determined by electrocorticogram and heart rates by electrocardiogram were monitored continuously during these experiments. RESULTS: The fetuses exhibited an alteration between low- and high-voltage electrocorticogram states. Both the depth and width of the variable fetal heart rate decelerations were greater during high-voltage than during low-voltage electrocorticogram. CONCLUSION: Amplitude and duration of variable fetal heart rate decelerations are affected by fetal behavioral states. (AM J OBSTET GYNECOL 1994;170:689-92.)

Objective: The purpose of this study was to determine which extracorporeal membrane oxygenation (ECMO) route best approximates the normal physiologic pattern of oxygenated blood distribution in fetal lambs submerged in warm saline solution. Study Design: Six fetal lambs ranging from 113 to 129 days of gestation were delivered by cesarean section and oxygenated with ECMO in a warm saline solution bath. We compared the distribution of oxygenated blood flow during intact placental circulation with 3 routes of ECMO, from the right atrium to the carotid artery (V-A), from the right atrium to umbilical vein (V-UV), and from the right atrium with umbilical artery to umbilical vein [(V + UA)-UV], in exteriorized fetal lambs. Distribution of oxygenated blood flow was determined by nonradioactive colored microspheres. Results: The ECMO blood flow rate through the catheters during V-A, V-UV or (V + UA)-UV ECMO ranged at 150 to 300 ml/min. Among the 3 different routes of ECMO, the oxygenated blood distribution in (V + UA)-UV showed the best correlation with placental-fetal blood flow, particularly in the brain and heart. Conclusion: This study indicated that (V + UA)-UV ECMO most closely approximates normal intact placental-fetal blood flow distribution in fetal lambs.

The American Journal of Obstetrics & Gynecology (AJOG) became the premier journal of our discipline in the 20th century after publishing many groundbreaking discoveries that changed the practice of medicine and the lives of women. The stature and reputation of the Journal, coupled with advances in the technologies through which information is conveyed, have compelled us to examine the role that a scholarly clinical journal must play in the first part of the 21st century. This question has implications for the readers, contributors, patients, and professional societies that we serve. Gone are the days when readers awaited the arrival of a journal in the mail to learn about the latest medical advances. Now we hear about breakthroughs on the date of publication through mass media. In addition, the reading habits of most people, including practicing physicians and residents, have changed. The compression of time that we all experience has forced us to master the art of glancing. For this reason and others, physicians increasingly turn to electronic media for clinical information that they would previously have obtained solely from textbooks and journals. Although we stand committed to the traditions of print, we acknowledge that print media cannot provide the interactivity or other features that are integral to electronic media. In short, we recognize that to continue to serve our readers and authors fully,wemust extend our scope to new methods of disseminating information. Several years ago, the editors of AJOG began to think about the future of the biomedical journal and how it can best meet the needs of its readers and contributors and, by extension, of patients. The new format launched with this issue of the Journal is our first comprehensive response to this challenge.What we offer is a departure from the comfortable position of the print-based biomedical journal. We remain strongly committed to our scholarly mission, yet aspire to reach the largest possible audience while providing information-rich content. To accomplish this goal, we have redesigned the Journal both literally and philosophically. The official version of the Journal will appear online at www. AJOG.org. This arrangement permits authors to convey information unconstrained by the limitations of print. In addition, the online version will be published much sooner than was possible before, thus disseminating important information much more rapidly.Weencourageour contributors to submit supplementary material, including video clips, animations, illustrations, and downloadable slide presentations. Authors are invited to use the full scope of available technology tomaximize the understanding and impact of their work. We anticipate that this strategy will enhance medical education and training. The print format of the Journal features abridged versions of all the research articles, which are posted in full at AJOG.org. Running approximately 2 pages, each article summary highlights the key points of the study and discusses its rationale, methods, and results. Elements found only in the summaries are an Overview, which describes the point of the study in a sentence or two, and Clinical Implications, bullet points that quickly apply the significance of the study’s findings to daily practice, future research, or both. References are included only in the online version. Similarly, Clinical Opinions are published in abridged form in print and in full online. The print format contains unabridged review articles and editorials and exciting new features that take full advantage of electronic media: a Journal Club discussion of a research article in the same issue, with the full discussion online and a recap in print; Images in Obstetrics alternating with Images in Gynecology; and Surgeon’s Corner, featuring a video clip online. As a way to provide our contributors with a platform for reaching as broad a readership as possible, the print version of the Journal is being distributed free to all obstetricians and gynecologists in the United States. The new print Journal is lean and easy to read. A glossary of symbols serves as a roadmap for icons that will mark certain article categories and internal cross-references. The goal of the print version is to concisely inform the reader, who may then visit our website for the full article, supplementary information, and extra features. Potential contributors will continue to submit 1 version, unabridged. After acceptance, the editors work with the authors to create the article summary for the paper edition. The citable paper is the full-length article online. We are aware that by implementing these innovations, we challenge the status quo. For writers, the physical existence of their work in paper form has historically been a sign of legitimacy. AJOG authors can be assured that their articles will appear in *.pdf form for printing anywhere, thereby providing the work with physical existence andmaximizing distribution. More people than ever will be able to hold the printed article in their hands. Drastic changes in the nature of communication and in the expectations of readers who wish to be informed and enterDrs Garite and Kim are editors-in-chief; Drs Zuspan and Quilligan are editors emeriti; and Drs Romero, Bump, Carson, Di Saia, Gabbe, Iams, Kilpatrick, and Macones are associate editors of the Journal. 0002-9378/free © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2006.11.024 Editorial www.AJOG.org

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.)

OBJECTIVE: We sought to determine the relationship between the degree of histologic changes in the brain, heart, kidney, and liver in fetal lambs after severe asphyxia and to analyze the role of oxidative stress in the pathogenesis of fetal multiple organ failure. STUDY DESIGN: Eight chronically instrumented near-term fetal lambs were asphyxiated by partial umbilical cord occlusion for approximately 60 minutes until the fetal arterial pH reached

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.

OBJECTIVES: The purpose of this study was to explain the role of oxidative stress in the pathogenesis of brain damage caused by intrauterine fetal asphyxia. STUDY DESIGN: Six chronically instrumented near-term fetal lambs were subjected to asphyxia by partial umbilical cord occlusion for approximately 60 minutes until fetal arterial pH diminished to less than 6.9 and base excess to less than –20 mEq. Another six fetuses surgically prepared but not occluded were used as control. Fetuses were killed after 72 hours and eight different brain regions (frontal and parietal gray matter, frontal and parietal white matter, basal ganglia, thalamus, hippocampus, and cerebellum) were dissected and assayed for thiobarbituric acid reactive substances, glutathione, and superoxide dismutase. RESULTS: Thiobarbituric acid reactive substance levels in asphyxiated animals were elevated in frontal and parietal white matter, basal ganglia, and thalamus compared with those in controls. The concentrations of superoxide dismutase in the asphyxiated group were also higher in frontal and parietal white matter, basal ganglia, and cerebellum compared with those in the control group. Between the two groups, however, glutathione concentrations did not differ significantly. CONCLUSION: These results suggest that oxidative stress may be a major contributing factor to the development of brain damage in intrauterine fetal asphyxia. (Am J Obstet Gynecol 1998;178:474-8.)

An examination of the need for individuals trained in maternal and fetal medicine, and a discussion of the specific training required and certification procedures for such specialists.

The pre-ejection period (PEP) of the fetal cardiac cycle was studied on 22 chronically instrumented pregnant ewes. The PEP was measured from the onset of the Q wave on fetal electrocardiogram to the onset of the upstroke on the fetal arterial blood pressure curve. Lengthening of the PEP was observed in association with an increase in gestational age, fetal body weight, fetal brow-rump length, and fetal heart weight. Consequently, the PEP values were calculated to those at fetal heart weight of 10 grams. The PEPc (calculated) was prolonged by acidosis but no significant relationship was found between the PEPc and arterial blood pO2. An increase in coronary blood flow was associated with a shortening of the PEPc in the fetuses under normal physiologic conditions. Fetal hypoxemia and respiratory acidosis created by administration of 10 per cent O2 and 20 per cent CO2 with 20 per cent O2 to the mother increased fetal coronary flow and was in general associated with a prolonged pre-ejection period.

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.

The effect of elevation of carbon dioxide in the fetal arterial blood on carotid flow has been evaluated using a semichronic fetal preparation. There was only a minimal increase in carotid flow with a moderate increase in carbon dioxide tension.

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.

A group of 13 patients with very stable fetal heart rates throughout labor has been compared to a group of 11 infants with a stable heart rate early in labor but who showed bradycardia with contractions late in labor. No significant alterations in oxygen tension, carbon dioxide tension, pH, lactate, or pyruvate could be detected in the umbilical veins of the two groups. There was evidence of a mild respiratory and metabolic acidosis in the umbilical arterial blood of those infants who showed bradycardia late in labor.

Applying the ICU approach to obstetrics requires a concentration of equipment, procedures, and personnel that enables fetal-maternal indices to be evaluated in much greater detail than usual. But that the approach may be appropriate for all deliveries is suggested by the finding that perinatal mortality among monitored, high-risk patients is in fact slightly lower than among unmonitored, essentially normal (i.e., low-risk) women.

It is entirely likely, states Dr. Quilligan, that the timing of labor, involving not one but two organisms, is regulated by processes of great complexity. He reviews current theories on the roles of progesterone and oxytocin, of cellular events that take place in the myometrium, and of the relative functions of maternal and fetal endocrine systems in the feedback system that may signal the birth of a baby.

1. 1. A group of infants demonstrating fetal bradycardia with contractions and between contractions has been studied by determing umbilical arterial and venous oxygen tension, carbon dioxide tension, pH, and lactate at birth. 2. 2. There is a slight increase in umbilical arterial acidosis in those infants with bradycardia with contractions. 3. 3. There is a marked umbilical arterial acidosis and mild umbilical venous acidosis in those infants showing bradycardia between contractions.

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.