Puerperal infectious morbidity: Relationship to route of delivery and to antepartum Chlamydia trachomatis infection

We investigated the relationship of route of delivery and of antepartum Chlamydia trachomatis cervical infection to selected forms of puerperal infectious morbidity, including intrapartum fever, or early (<48 hours) postpartum fever not attributable to infections of sites outside the uterus and late (48 hours to 6 weeks) postpartum endometritis. Infectious morbidity occurred in 27 (44%) of 62 women who underwent cesarean section and in 33 (10%) of 329 who underwent vaginal delivery (p < 0.001). Postsection infectious morbidity was not correlated with C. trachomatis infection and was largely limited to early postpartum fever. Among women who underwent vaginal delivery, infectious morbidity occurred in 10 (34%) of 29 women with and in 23 (8%) of 300 without C. trachomatis infection (p < 0.001), and chlamydial infection was associated only with intrapartum fever and late postpartum endometritis. Separate matched case-control analyses confirmed that cesarean section was associated with an increased risk of early postpartum fever (p = 4 × 10^?8); whereas among women who underwent vaginal delivery, antepartum C trachomatis infection was associated with an increased risk of development of intrapartum fever or late postpartum endometritis (p = 0.002).     

Lethal thromboembolism and its prevention in pelvic surgery: A review

Five hundred thousand new cases of pulmonary embolism occur annually in the United States and at least 10% of these are fatal. A survey of the members of the Felix Rutledge Society reveals that 84.5% of its members use low-dose heparin prophylactically in high-risk patients. The data supporting the efficacy of thromboembolism prophylaxis are reviewed. Four possible reasons why low-dose heparin is not used by all pelvic surgeons are discussed. The conclusion is that despite hazards in its use, the burden now rests with the gynecologic oncologist who does not use this prophylactic treatment to show cause for its omission.     

Landmarks during the first forty-two days of gestation demonstrated by the beta-subunit of human chorionic gonadotropin and ultrasound

Prospective pregnancy evaluation through the combined use of a radioimmunoassay (RIA) for the beta-subunit of human chorionic gonadotropin (beta-hCG) and ultrasound during the first 42 days of gestation after ovulation was performed on a population asymptomatic for first-trimester spontaneous abortion. One hundred forty-six ultrasonic observations in 98 pregnancies were made with simultaneous beta-hCG RIA performed in 80 patients. The following landmarks of normal gestational growth were identified: (1) Before 26 days, beta-HCG RIA permits definitive diagnosis of growing trophoblastic tissue, and serial samples allow doubling time computation for prognosis while ultrasound shows a nonspecific increasing decidual response within the uterus; (2) between 26 and 36 days after ovulation, serial beta-hCG samples continue to give doubling time results while ultrasonic demonstration of a gestational sac is normally seen by 28 days after ovulation; (3) the lack of fetal heart motion by 42 days after ovulation or within a gestational sac with a mean diameter of greater than 30 mm was prognostic of abortion; (4) the absence of a gestational sac by 28 days after ovulation or with a beta-hCG RIA greater than 1,000 ng/ml is suggestive of an ectopic pregnancy until proved otherwise.     

The maternal and fetal cardiovascular effects of epidural fentanyl in the sheep model

Since the demonstration of opiate receptors in the spinal cord in the mid-1970s, investigators have been looking for the most effective epidural narcotic. With the use of the chronically catheterized maternal sheep model, we injected two different doses of preservative-free fentanyl (50 and 100 micrograms) into the epidural space. No statistically significant changes were observed, either in maternal or fetal arterial pressure and acid-base status or in maternal central venous pressure, systemic and pulmonary vascular resistance, cardiac output, and intrauterine pressure (p greater than 0.05). With a dose of 50 micrograms of fentanyl, maternal levels of fentanyl peaked at 60 minutes (50 pg/ml) and the fetal levels of fentanyl peaked at 45 minutes (20 pg/ml). With the 100 micrograms dose of fentanyl, maternal levels of fentanyl peaked at 45 minutes (230 pg/ml) and the fetal levels peaked at 15 minutes (110 pg/ml). We conclude that the injection of 50 and 100 micrograms of fentanyl into the maternal epidural space has no adverse effects on mother or fetus in the sheep model.     

Antibody to type III group B Streptococcus in the rhesus monkey

Susceptibility to infection due to intra-amniotic type III group B streptococcal infection was studied in 27 rhesus monkeys. Sera from mothers and their offspring were tested to determine the concentration of antibody to the native type III group BStreptococcus antigen. Among 17 controls there was a statistically significant association between the concentration of maternal antibody prior to infection and both the neonatal survival rate and survival time (P < 0.05). Neonatal survival was decreased to ≤6 hours (P = 0.005) if the maternal antibody concentration was <0.5 μg/ml. Modified immune serum globulin was given intravenously to the mothers prior to intra-amniotic infection with (five animals) or without (five animals) neonatal modified immune serum globulin. Neither of the modified immune serum globulin groups demonstrated a significant reduction in the neonatal mortality rate; however, the addition of the modified immune serum globulin provided protection against rapid neonatal death among those animals born to mothers which had low or no detectable antibody. All maternal groups developed a significant increase in the concentration of antibody in postpartum sera. These results indicate that both naturally acquired and passive (modified immune serum globulin) antibodies to type III group BStreptococcus antigen are partially protective against intra-amniotic infection.     

Spiral (uteroplacental) arteries of the human placental bed show the presence of amniotic basement membrane antigens

The spiral arteries of the placental bed lose clearly recognizable arterial features early in pregnancy because of their invasion by extravillous trophoblast. Extensive structural alterations take place in the walls of invaded arteries, their walls containing an amorphous acidophilic "fibrinoid" matrix in which endovascular trophoblast is embedded. Such spiral arteries examined by immunofluorescence techniques in placental bed biopsy specimens obtained at cesarean section show a characteristic pattern of reaction with antisera to epithelial basement membrane amniotic antigens. These antisera have been previously demonstrated to react with the basement membrane of human amnion and of ectodermally derived epithelium such as breast ducts and skin. Interstitial trophoblast usually does not contain these antigens, and it is postulated that, following vascular invasion, endovascular trophoblast produces amniotic antigens to establish its presence. This may be of importance in maintaining the structural integrity of spiral arteries and thereby adequate maternal blood flow to the fetal-placental unit.     

Oral desensitization in Rh disease

Four pregnancies managed with erythrocyte membrane oral therapy because of severe Rh disease are presented. Reduction in anti-(D) production was the goal of the study. A patient was classified as having severe Rh immunization if there was a history of fetal loss due to erythroblastosis fetalis prior to 26 weeks.     

Hysteroscopic sterilization with the use of formed-in-place silicone plugs

Hysteroscopic sterilization with the use of a formed-in-place silicone plug is an office procedure which can be done with paracervical block anesthesia. It appears to be an effective method of sterilization. The present study is a review of 206 of the author's patients who chose this procedure. Thirty-four patients (16.5%) had more than one procedure for a total of 244 cases. Sterilizations were achieved in 188 patients (91.3%). The sterilization was accomplished in 166 patients (80.6%) at the time of the first procedure, in 20 of 40 patients (9.7%) at the second procedure, and in two of four patients (1.0%) at the third procedure. The primary reason for failure to achieve sterilization was tubal spasm. Of the 18 patients (8.7%) who were not sterilized, 16 were considered as failures and dropped from the study and two are awaiting a repeat procedure. No patients have become pregnant and there have been no significant complications.     

Management of preterm prematurely ruptured membranes: a retrospective comparison of observation versus use of steroids and timed delivery

A retrospective study of 38 women with preterm prematurely ruptured membranes was performed. Twenty were treated with intravenous hydrocortisone followed by timed delivery between 48 and 72 hours after initiation of steroid therapy. Eighteen were managed expectantly, with observation for labor and infection. There were no significant differences between steroid-treated patients and observed patients in the incidence of neonatal respiratory distress syndrome, perinatal mortality, or maternal or neonatal infections.     

Ultrasound evaluation of female genital tract anomalies: A review of 64 cases

Sixty-four patients with an ultrasound diagnosis of an anomaly of the female genital tract were studied retrospectively to determine the accuracy and usefulness of sonographic examination of these anomalies in the pregnant (64%) and the nonpregnant (36%) patient. Ultrasound diagnoses in 46 patients with follow-up included: (1) bicornuate/septate uterus in 21 cases, (2) uterus didelphys in 18 cases, (3) cervical and vaginal atresia in three cases, (4) obstructed lower but normal upper genital tract in two cases, and (5) abnormal-appearing uterus in two cases. Ultrasound diagnosis was compared with hysterosalpingographic and/or surgical findings in 43 patients and with physical examination in three patients. Scan results were classified as diagnostic in 26%, confirmatory in 63%, and incorrect in 11%. Ultrasound is a reliable clinically useful method of studying genital tract anomalies in gynecologic patients.     

The use of a radioimmunoassay specific for human chorionic gonadotropin in patients with molar pregnancy and gestational trophoblastic disease

Serum human chorionic gonadotropin (hCG) activity is compared in 14 patients under treatment for gestational trophoblastic disease (GTD) using both a radioimmunoassay (RIA) specific for hCG and a nonspecific rapid solid-phase RIA which measures both luteinizing hormone (hLH) and hCG. The results indicate that the nonspecific RIA is adequate for the diagnosis and management of patients with GTD when the hCG titer is above endogenous hLH levels, but a specific RIA is required to ensure complete remission and to detect early recurrence during follow-up.     

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.     

Maternal administration of dexamethasone in severe pregnancy-induced hypertension

Fourteen patients with severe pregnancy-induced hypertension and low lecithin/sphingomyelin (L/S) ratios were treated with 5 mg of dexamethasone phosphate intramuscularly every 12 hours for four doses to induce fetal pulmonary maturity. A comparison was made of the average gestational age, mean L/S ratio, method of delivery, Apgar scores, mean birth weight, and incidence of respiratory distress syndrome in these patients and in 16 patients with similar demographic backgrounds and clinical presentations who did not receive corticosteroid therapy. There was no significant difference between the two groups except that the time of treatment (or nontreatment) to delivery was longer in the steroid group. There were two cases of neonatal respiratory distress syndrome in the treatment group, and one of these infants died. In the control group, there were two neonatal deaths among four cases of respiratory distress syndrome. There was no clinical evidence of intraventricular hemorrhage in any neonate nor was there aggravation of hypertension in the parturient patients. The administration of corticosteroids to induce fetal pulmonary maturity in patients with severe pregnancy-induced hypertension who are carefully selected and monitored does not appear to be contraindicated.     

Maternal-fetal electrocardiogram conduction with intrapartum fetal death

All parturient patients with fetuses at risk should be simultaneously monitored for relationships of amplitude, duration, and frequency of uterine contractions, and changes in fetal heart rate patterns. Inability to auscultate the fetal heart sounds during labor, in addition to the subjective complaint of the mother of absent fetal movement, should alert the physician to a fetal death despite the display of an electrocardiogram on the oscilloscope and a fetal heart rate record on the paper print-out. Two cases where the maternal electrocardiogram (ECG) was transmitted through a dead fetus to the fetal ECG electrode are presented and discussed.     

Prophylactic antibiotics in cesarean section: A double-blind study

Sixty-one patients were prospectively evaluated as to the worth of prophylactic antibiotics in cesarean section. Ampicillin, kanamycin, and methicillin were administered in double-blind fashion before and 2 and 8 hours after operation. The patients were evaluated for morbidity. An over-all 27 per cent infection rate was found in the antibiotic group as compared to a 61 per cent rate in the placebo group. No correlation was noted in age, hospital stay, organism, or rupture of membranes. The repeat sections in the antibiotic group have a statistically significant lower infection rate.     

Intrauterine incarcerated bowel following uterine perforation during an abortion: a case report

The case of small bowel incarcerated within the uterine cavity following a legal abortion is presented. The case, a 26-year old woman, gravida 5, para 4, was aborted with a rigid-type plastic suction cannula at 13 weeks after her last menstrual period. During the 1st hour after the procedure, the patient developed severe abdominal pain and vomiting. The uterus was felt to be 18 weeks in size, firm, and tender. Sonographic examination revealed multiple well-defined round cystic structures within the uterine cavity. At laparotomy, incarcerated and partially gangrenous small intestine was found in an intrauterine location. The perforation had occurred in the anterior fundal region, distant from the uterine scars from the case's 4 previous cesarian sections. This case illustrates a rare and serious complication of abortion and demonstrates the utility of sonography in postprocedure symptomatic patients. No other such cases have been reported in the literature.     

Scuba diving during pregnancy: A brief review

As more women undertake scuba diving as their occupation or avocation, it is inevitable that pregnancy becomes an important factor in the physician's proper evaluation of the physical problems associated with diving. Understanding of the physiology of scuba diving and the medical complications associated with this activity is essential for proper obstetric management.     

Trial labor following previous cesarean section

Elective repeat cesarean section continues to remain the standard of care in the United States. This paper is a study of 242 patients with previous cesarean section who requested and were allowed a trial of labor. One hundred sixty-six (69%) achieved successful vaginal delivery with no maternal or fetal mortality or significant morbidity. Review of the English literature indicates similar results in other independent studies. Continued accumulation of cases showing the efficacy of post-cesarean section trial of labor should encourage a reassessment of the continuing practice of elective repeat cesarean section.     

Effects of diuretics on plasma volume in pregnancies with long-term hypertension

The purpose of this randomized, prospective study was to investigate the effects of diuretics on plasma volume findings and perinatal outcome in pregnancies complicated by mild long-term hypertension. Twenty patients were in their first trimester and were receiving diuretics at time of entry to the study: Ten patients were allowed to continue their diuretic medication throughout pregnancy (diuretic group), whereas for the other 10 patients, diuretics were discontinued immediately. Plasma volume was serially measured throughout pregnancy with the use of the Evans blue dye-dilution technique. Initial plasma volume was similar in the two groups. However, in the diuretic group, subsequent plasma volume findings at various stages of gestation were markedly reduced when compared to respective plasma volume findings in the other group. In addition, plasma volume expansion was minimal in the diuretic group (mean increase of 18%), whereas it was normal in the other group (mean increase of 52%)_. Two patients in the diuretic group and one patient in the other group required other antihypertensive medication. There was no difference in perinatal outcome between the two groups. These results suggest that in hypertensive pregnancies, diuretics prevent normal plasma volume expansion without influencing perinatal outcome.