The Northwestern University multihospital twin study: IV. Duration of gestation according to fetal sex

Recently MacGillivray has observed that the average duration of male twin gestations is shorter than that of either female twin or male/female twin gestations. The data from 562 twin gestations from the Northwestern University multihospital twin study were used to test this observation. Male twin gestations were slightly but significantly shorter than other twin gestations as measured by pediatric examination (p < 0.005). Approaching significance at the 0.05 level were findings that male twin gestations were shorter than other twin gestations when measured by dates, and that the male twins were slightly shorter and lighter than other twins. No significant differences were found between male/female twin gestations and female twin gestations. No relationship could be found between twin sex combinations and a variety of maternal and obstetric factors. Taken together, the results suggest that male twin gestations differ in some distinctive biologic sense from other twin gestations.     

Quality of life for the gynecologic oncology patient.

An attempt is made to define the quality of life in terms of the patient with gynecologic cancer. The effect of the diagnosis of cancer and its recurrence or its terminal state on the quality of life is considered. Possible methods of assessing the patient's individual feelings about the quality of her life are reviewed and suggestions made for incorporating these into plans of management at all stages of the disease.     

Placenta previa: aggressive expectant management

We report the outcomes of 95 expectantly managed cases of placenta previa; all were diagnosed after 21 weeks' gestation. Patients at risk for preterm delivery because of hemorrhage or preterm labor received aggressive care, including multiple transfusions, volume expansion and tocolytic therapy, and amniotic fluid surfactant determinations, to achieve the goal of delivery at 37 weeks' gestation with mature fetal lung function. We present guidelines for outpatient management and double setup examination prior to delivery. The role of ultrasound in diagnosis (three asymptomatic cases; 13 cases with preterm labor) and serial placental localization to determine the timing, route, and place of delivery is presented. Eighty-six percent of 19 infants born weighing less than 2500 gm were managed expectantly. Hemorrhage was the determinant in delivery timing in 50 cases. All four deaths were neonatal with birth weights less than 2200 gm. This is the lowest perinatal mortality rate (4.2%) published to date. Use of this aggressive approach is particularly suitable for patients cared for in a teritary center.     

The tap test: A rapid indicator of fetal pulmonary maturity

We present here a new means to assess fetal pulmonary maturity called the tap test. It is rapid, inexpensive, and requires only 1 ml of amniotic fluid. The tap test was compared to the phospholipid profile in 88 fetuses, 70 of whom were delivered before term. All fetuses were born within 72 hours after the amniotic fluid specimen was obtained. The test results were correlated to the absence or presence of the neonatal respiratory distress syndrome. When the tap test was evaluated at 2, 5, and 10 minutes, the predictive values for a mature test result were 100%, 98%, and 98%; the predictive values for an immature test result were 43%, 52%, and 58%, respectively. For the phospholipid profile the predictive values for a mature and an immature test result were 98% and 37%. These findings indicate that the ability of the tap test to predict fetal pulmonary maturity is comparable, if not superior, to that of the phospholipid profile.     

Intracellular organelles and enzymes in cellfree amniotic fluid

Cell-free amniotic fluid obtained during the second trimester of pregnancy was subjected to differential centrifugation, and the relationship of enzymes to intracellular organelles was studied. Electron micrographs of the resultant pellets revealed the presence of intracellular orgenelles including mitochondria, lysosomes, and endoplasmic reticulum. Over 85 per cent of the recovered alkaline phosphatase activity and alpha-1,4 glucosidase activity was localized in the fractions obtained by differential centrifugation, whereas only 6 per cent of the recovered hexosaminidase activity was associated with these fractions. These studies indicate that cell-free amniotic fluid contains enzymes which are localized in intracellular organelles.     

Diminished growth in fetuses born preterm after spontaneous labor or rupture of membranes

We examined biparietal diameter, abdominal circumference, and birth weight in 148 preterm infants to assess fetal growth. A statistically significant proportion of preterm fetuses had biparietal diameter and abdominal circumference values below the fiftieth and tenth percentile levels as compared with that expected in normal fetuses. Similarly, birth weight of infants in the study fell significantly below the fiftieth and tenth percentiles relative to Brenner's curve. We conclude that diminished fetal growth is associated with early delivery secondary to preterm labor or preterm premature rupture of membranes or both. Additionally, since biparietal diameters in preterm fetuses are smaller than those of normal fetuses the prediction of gestational age by cephalometry should be advanced by 7 to 10 days.     

Choriocarcinoma associated with term gestation

Fifty-one patients with choriocarcinoma associated with term pregnancy were treated at the John I. Brewer Trophoblastic Disease Center of Northwestern University Medical School from 1962 through 1981. An overall remission rate of 61% was achieved: 65% for 43 patients who received all of their treatment at the center and 38% for eight patients who received treatment elsewhere before referral to the center. This remission rate was significantly less (P less than 0.005) than the 87% remission rate obtained in patients with choriocarcinoma after hydatidiform mole, abortion, or ectopic pregnancy combined. Three factors were determined which significantly influenced response to treatment in these patients: (1) time from delivery to treatment greater than 4 months (41% versus 80%, P less than 0.0005); (2) presenting symptomatology other than abnormal uterine bleeding (40% versus 87%; P less than 0.001); and (3) metastases to sites other than the lung and/or vagina (22% versus 72%, P less than 0.01). There appeared to be no advantage to treating all patients with choriocarcinoma after term pregnancy with initial multiple-agent chemotherapy unless other high-risk characteristics were present.     

Lack of association between contraceptive usage and congenital malformations in offspring

Previous reports have linked the use of oral contraceptives and spermicides to the occurrence of malformations in offspring. With information from 12,440 women interviewed during the delivery hospitalization we found no relationship between contraceptive method and the occurrence of malformations. Whereas any unnecessary drug should be avoided during pregnancy, prior contraceptive method seems to be unrelated to the risk of congenital malformations.     

Increased beat-to-beat variability during uterine contractions: A common association in uncomplicated labor

A computerized system was used during labor to provide a quantitative and objective analysis of fetal heart rate, beat-to-beat variability, and uterine contractions. Twenty-nine healthy pregnant women at term participated in this study. Each woman was studied for a 40-minute period during the active phase of spontaneous labor. The results indicate that beat-to-beat variability rises from a value of 4.62 ± 1.11 (mean ± SD) between contractions to 6.86 ± 1.53 during contractions. This rise is significant (p < 0.01). At the same time, changes in fetal heart rate are small, inconsistent, and not significant. We conclude that an increased beat-to-beat variability is commonly associated with uterine contractions in normal fetuses. This increase is probably due to mild hypoxia caused by decreased perfusion of the placenta and to increased vagal tone caused by fetal head compression.     

Central and peripheral metabolites of norepinephrine and dopamine in postmenopausal women

Urinary 3-methoxy-4-hydroxyphenylglycol (MHPG) sulfate and glucuronide reflect, in part, central norepinephrine activity while urinary 3-methoxy-4-hydroxymandelic (VMA) reflects peripheral norepinephrine activity. Urinary MHPG and VMA were measured, together with homovanillic acid (HVA), in 20 symptomatic and seven asymptomatic postmenopausal women and 10 premenopausal control women. Urinary HVA reflects, in part, central dopamine metabolism. After nine of the symptomatic women were treated for 2 months with 0.625 mg of conjugated estrogens, urinary catecholamine measurements were repeated. Serum estrogen levels were not different in symptomatic and asymptomatic patients. Urinary MHPG, VMA, and HVA were similar in symptomatic women before and after estrogen treatment and were not different from levels of asymptomatic postmenopausal and control subjects. The ratios of MHPG:VMA, MHPG:HVA, and VMA:HVA also were similar. While body weight and estrogen did not correlate with urinary catecholamines, there was a significant positive correlation between MHPG and age in postmenopausal subjects (r = 0.56, p less than 0.005).     

Antepartum fetal heart rate testing: The nonstress test

Antepartum assessment of fetal well being relies heavily on the observation of FHR. Fetal stress testing was introduced in the early 1970's in an attempt to define the fetus at risk. The stress factor most widely used has been uterine contractions, which isolate the fetus from its oxygen supply, and in the compromised fetus would be anticipated to provoke late decelerations in the FHR. Although the contraction stress test or “oxytocin challenge test” is useful in evaluating fetal condition, it is time consuming, not easily quantitatable or repeatable, and many times difficult to interpret. An attractive alternate approach of antepartum FHR testing (AFHRT) is the “nonstress” test. The positive experience of European investigators has led to interest in this method of fetal assessment in North America. Investigation from the literature contrasting the “stress” versus “nonstress” methods is discussed and observations derived from 2 year experience at LAC/USC Medical Center are presented. A protocol for AFHRT currently being evaluated clinically is presented.     

Sympathoadrenal activity,maternal, fetal,and neonatal responses after epidural anesthesia in the preeclamptic patient

This study confirms that preeclamptic patients have higher plasma levels of catecholamine than those of normal patients. It also demonstrates that epidural analgesia when administered to the preeclamptic patient during labor is followed by a significant reduction in the plasma levels of catecholamines without any adverse effects on maternal blood pressure, uterine activity, fetal heart rate, or the neonate.     

Glycohemoglobin as a screening test for gestational diabetes

This study evaluated the feasibility of utilizing hemoglobin A1c as a screening test for gestational diabetes. We compared this test in 82 women in the third trimester of pregnancy to a glucose tolerance test in which a glucose load of 100 gm was used. At its best index of correlation, hemoglobin A1c at 7% is concordant with the glucose tolerance test in 69% of the cases, false positive in 41%, and false negative in 26%. Though the two procedures correlate very well, the high incidence of false negative and positive for hemoglobin A1c make this test inadequate as a screening procedure for gestational diabetes.