Prolonged pregnancy: surveillance of the fetus and the neonate and the course of labor and delivery

The perinatal events in 184 term control pregnancies and 129 prolonged pregnancies were prospectively compared. Fetal surveillance consisted of weekly biophysical profile testing. Thirty-two infants were dysmature, and 10 of these had advanced dysmaturity. The incidence of advanced dysmaturity rose quickly after 44 weeks. This group was at greater risk for fetal distress, lower Apgar scores, and emergency cesarean section. The combination of oligohydramnios, a suboptimal nonstress test, and a low profile score was highly predictive of a neonate with advanced dysmaturity. In the control pregnancies, the rate of induction of labor was 13.81% compared with 39.84% in the prolonged pregnancies. The induced labor group had a 51.32% cesarean section rate. Our approach to prolonged pregnancy consists of elective induction of labor when the cervix is favorable and biweekly profile testing when it is not; however, the high incidence of advanced dysmaturity after 44 weeks warrants delivery.     

Nonimmunologic hydrops fetalis

Twenty cases of nonimmunologic hydrops fetalis were reviewed. The incidence of nonimmunologic hydrops fetalis was 1/2,029 (20 cases in 40,588 deliveries). The diverse etiologies of nonimmunologic hydrops fetalis are demonstrated. The incidence of erythroblastosis fetalis caused by Rh isoimmunization declined markedly. The perinatal mortality rate was 14/18 or 78%. Prematurity, the presence of congenital anomalies, and the severity of hydrops fetalis contribute to this poor prognosis. However, a better understanding of the pathophysiology of hydrops fetalis, along with early detection by ultrasonography, preterm delivery with the liberal use of cesarean section, and availability of high-risk perinatal units, may enable us to improve the prognosis. A precise diagnosis should be attempted by careful antenatal and postnatal evaluation, so that accurate genetic counseling can be offered.     

A new computer technique for continuous measurement of the pre-ejection period in the human fetus: Physiologic significance of pre-ejection period patterns

A new interactive computer graphics system was developed for continuous online or offline measurement of the pre-ejection period (PEP) in the human fetus during both the antepartum and the intrapartum period. A significant feature is the system's ability to accurately measure PEP from the onset of the QRS complex to the beginning of aortic opening with a resolution of less than 2 milliseconds. Normal patterns of PEP prolongation were observed with fetal movement and occlusion of the umbilical cord, whereas progressive shortening of PEP was noticed with late decelerations associated with acute hypoxia. A pathologic pattern of PEP prolongation associated with late decelerations and poor heart rate variability was observed with chronic hypoxia and acidosis. These patterns suggest that continuous monitoring of PEP may be a useful adjunct to current monitoring methods when attempting to assess fetal cardiac performance and well-being.     

The effect of multiparity on intrasellar prolactinomas

A complete reassessment of ovulation, pituitary reserve and function, and sella turcica anatomy was carried out in nine multiparous patients with intrasellar prolactinomas to determine whether long-term bromocriptine therapy was required and to document the natural history of the disease after two or more pregnancies. After the last pregnancy, bromocriptine was discontinued and pituitary function and anatomy and prolactinoma activity were reassessed with documentation of ovulation (basal body temperature graphs and menstrual history), search for fat droplet-positive galactorrhea, pituitary fossa tomography, computerized tomographic scan, triple-bolus testing, and visual fields. These data were compared with a similar workup carried out prior to the first pregnancy. Three groups of eventual outcomes were identified radiologically. Anterior pituitary gland function and reserve remained normal in all, and no neurological sequelae were noted. Four patients did not require long-term treatment. A hypothesis of autoinfarction of the adenoma is raised, since three patients were shown to have empty sellae.     

Genetic amniocentesis in seventy twin pregnancies

Genetic amniocenteses were performed in 70 twin pregnancies over an 11-year period. Both sacs were successfully sampled in 49 of 62 patients (79%). The success rate was decreased (68%) with two placentas (anterior and posterior) and was improved with gestational age greater than or equal to 17 weeks (88%) and with ultrasound visualization of the septum (86%). Of three spontaneous abortions, two were attributed to amniocentesis (chorioamnionitis). When twin pregnancy is diagnosed in a patient with an indication for genetic amniocentesis, a careful reevaluation and discussion of risk factors with the couple are recommended.     

Aromatase activity in human granulosa cells during follicular development and the modulation by follicle-stimulating hormone and insulin

Granulosa cells were isolated from follicles that ranged in size from 0.4 to 2.0 cm in diameter, obtained from patients during the follicular phase of the menstrual cycle. Aromatase activity, assessed by the release of tritiated water from [1β-³H]testosterone, was undetectable in follicles with a diameter of less than 1.0 cm; thereafter, there was a direct correlation between aromatase activity and follicular diameter. When cultured in the presence of 200 ng of National Institutes of Health follicle-stimulating hormone-15 per milliliter, aromatase activity was stimulated in cells isolated from all sizes of follicles from 0.4 to 1.5 cm. Insulin (500 ng/ml) further augmented follicle-stimulating hormone (FSH)-induced aromatase activity, as evidenced both by an increase in 17β-estradiol production and by the release of tritiated water from [1β-³H]testosterone by granulosa cells. This study further delineates the role of FSH in estrogen production during human follicular development and suggests that insulin or insulin-like growth factors may play a role in modifying the FSH-dependent cellular differentiation of human granulosa cells.     

The predictive significance of biologic risk factors for deficits in children of a high-risk population

Two hundred forty-two high-risk children and 47 low-risk children were prospectively studied to assess the relationship between biologic risk factors that occurred during the perinatal period and the motor and cognitive deficits that were identified during the first year of life. Multiple risk factors were present in 80% of the children of the high-risk group. Provisional deficits were classified on the degree of abnormality found in a clinical and behavioral assessment that included neurological examinations, Bayley Physical and Mental Development Scales, and the Uzgiris and Hunt Scale. Provisional deficits occurred in 10% of the children of the low-risk group. High-risk children had a significantly greater incidence of provisional deficits, particularly in respect to positive deficits. In high-risk children, the probability of a deficit was 17% in those without infection or encephalopathy, 30% in those with infection, and 40% in those with encephalopathy.     

Changing patterns of birth asphyxia and trauma over 20 years

Comparison of birth asphyxia and trauma in the same obstetric service during periods 18 years apart shows some reassuring and some disquieting findings. Liberalized cesarean sections, electronic monitoring of fetal heart in labor, and replacement of opiate sedation by epidural anesthesia have had their effect. There has been dramatic reduction in perinatal death and neonatal encephalopathy due to birth asphyxia and trauma and only rarely do affected infants now develop permanent cerebral injury. Severe birth asphyxia, defined by need for prolonged ventilation, has, however, remained unchanged in frequency. Unexpectedly, fractures and paralyses have dramatically increased. The major hazard today for the term infant is the use of midforceps, which has become much more common in parallel with the increased use of pain relief by continuous epidural anesthesia.     

Carcinoma in situ of the vagina

A review was made of 136 cases of carcinoma in situ of the vagina seen over a 30-year period, 1953 to 1982. The patients ranged in age from 17 to 77 years, with a mean age of 55 years. One hundred sixteen patients (85%) presented with an abnormal Papanicolaou smear. Colposcopically directed biopsies were used for diagnosis in 62% of the patients. The upper one third of the vagina was the most common site of disease, with 54% of patients having unifocal lesions. A previous hysterectomy had been performed in 71% of patients, 35% of whom had undergone operation for benign disease. A concomitant, subsequent, or prior neoplasm of the lower genital tract or pelvis was noted in 109 patients. Surgical intervention in the form of either wide local excision or partial or total vaginectomy was the most frequently used method of treatment. Radiotherapy, usually in the form of a vaginal mold, was the second most commonly used method of treatment, and it was used in 27 patients. Radiotherapy and more extensive surgical treatment methods gave the best results. Four patients subsequently developed invasive carcinoma of the vagina.     

The cytologic history of 245 patients developing invasive cervical carcinoma

A review was made of the cytologic history of 245 patients who developed invasive carcinoma of the cervix, and three groups of patients were identified. Group 1 included 149 patients (60.8%) who had never had a cervical cytologic examination, group 2 included 26 patients (10.6%) whose cytologic history in terms of frequency of examination and or timing was considered to be unsatisfactory, and group 3 included 70 patients (28.6%) whose cytologic history was considered to be satisfactory. Only 53 (35.6%) of the patients in group 1 had Stage I disease. Stage I disease was present in 16 patients (61.5%) of group 2 and in 54 patients (78.6%) of group 3. There was no significant difference between the three groups with respect to site of residence or access to the health care system. Of the patients in group 3, 20 (28.6%) had normal cytologic findings and 50 (71.4%) had abnormal cytologic findings. Of the 50 patients with abnormal cytologic findings, 31 (62.0%) did not have further examination for 6 months or longer after identification of the abnormal smear. The majority of these patients had minor degrees of cytologic abnormalities. A review of 299 original cervical smears revealed that 52 (17.4%) had been significantly undercalled, but only 21 (7.0%) had been undercalled as normal. In this study, 28 patients (11.4%) developed adenocarcinoma. In these patients, staging was unrelated to screening.     

Use of oral VP16-213 as primary chemotherapeutic agent in treatment of gestational trophoblastic disease

Thirty-seven patients with persistent or metastatic gestational trophoblastic disease were treated with oral etoposide (VP16-213). All responded well and achieved permanent remission. The hematologic toxicity was mild. Alopecia was present in all patients. Etoposide is an effective drug against trophoblastic disease. In patients who have received chemotherapy for long periods oral etoposide would eliminate the problem of venous access.     

The relationship between movements and accelerations in fetal heart rate at twenty-four to thirty-two weeks' gestation

The purpose of this study was to establish the relationship between fetal heart rate accelerations and fetal body movements in fetuses at 24 to 32 weeks' gestation. The results suggest that body movements in younger fetuses do not occur with accelerations that are readily recognizable (i.e., less than 15 bpm), but as fetuses get older, the interaction between body movements and fetal heart rate becomes more evident and accelerations become more recognizable (i.e., greater than or equal to 15 bpm). The data presented suggest that there is a maturational aspect to the relationship between fetal heart rate and fetal body movements as fetuses increase in gestational age from 24 to 32 weeks. The conclusion, therefore, is that the nonstress test, as presently defined for older fetuses, is not valid for gestations below 32 weeks, and new criteria must be established.     

Intrapartum fetal asphyxia: clinical characteristics, diagnosis, and significance in relation to pattern of development.

The clinical and fetal heart rates and acid-base characteristics and their sequelae have been reviewed in 587 patients. The relevant clinical factors in the asphyxia group were the preterm fetus, the intrauterine growth retarded fetus, maternal toxemia, and midforceps delivery. The duration of the developing metabolic acidosis in the asphyxia group ranged from terminal to the last two hours of labor. Marked patterns of total decelerations and moderate and marked patterns of late decelerations are of predictive value in the diagnosis of intrapartum fetal asphyxia with a trend to an increased incidence in the longer duration categories, between four and two hours prior to delivery, and a significant increase in all categories during the last two hours of labor. The significance of intrapartum fetal asphyxia to the newborn infant is evident from the low Apgar scores, increased incidence of moderate and severe respiratory distress syndrome, and central nervous system complications in the asphixia group in relation to the normal group.     

Successful induction of ovulation and conception with pulsatile intravenous administration of human menopausal gonadotropins in anovulatory infertile women resistant to clomiphene and pulsatile gonadotropin-releasing hormone therapy

Gonadotropins are released in a pulsatile fashion at a frequency of between 1 and 2 hours in the follicular phase of the menstrual cycle. Human menopausal gonadotropins are usually administered intramuscularly. We evaluated the gonadal response to intravenous human menopausal gonadotropins administered in a pulsatile fashion over nine treatment cycles in three anovulatory infertile women. Human menopausal gonadotropin pulses in doses up to 12 IU follicle-stimulating hormone at frequencies between 2 to 3 hours over 3 to 17 days resulted in ovulation in five cycles with one pregnancy being conceived. In the ovulatory cycles (5,000 to 10,000 IU of human chorionic gonadotropin was used to induce ovulation), the 17 beta-plasma estradiol level was 961 +/- 128 versus 326 +/- 95 pg/ml (mean +/- SEM) in the anovulatory cycles (p = 0.015). The dose of human menopausal gonadotropins (in ampules of Pergonal, 75 IU of follicle-stimulating hormone and 75 IU of luteinizing hormone) in the intravenous cycles needed to induce ovulation was 12.3 +/- 1.4 versus 20.4 +/- 0.9 for intramuscular cycles (n = 80 in 23 women, p = 0.008). Treatment was well tolerated and without complications. We are continuing to explore the use of this apparently more efficient mode of administering human menopausal gonadotropins to anovulatory patients resistant to other techniques of ovulation induction therapy.     

Production of active and acid-activated renin by cultured explants of human fetal tissues

Various fetal tissues with gestational ages that ranged from 6 to 22 weeks were cultured as explants, and the culture media were examined for the production of both active and acid-activated renin. Media from cultures of fetal kidney, both the male and female genital tracts, and umbilical cord vessels were found to contain large quantities of active and acid-activated renin. Consistent differences in the production patterns of renin were found between the tissues, which may reflect the different potentials of the tissues to produce renin in vivo.     

The effect of cone biopsy on subsequent pregnancy outcome

One hundred and thirty-one pregnancies occurring in 97 patients following cone biopsy were reviewed. Excluding therapeutic abortions, 27.1% of the remaining pregnancies terminated in spontaneous abortions and 11.3% in labor prior to 36 weeks. However, because of other abnormal preceding factors in many of these cases, in only a few could cone biopsy be implicated as a likely etiological factor. The majority of viable pregnancies and labors were uncomplicated. Nonetheless, it would seem advisable to minimize the risk of complications with the use of colposcopy and a “shallow” cone or by the use of cryosurgery in the treatment of preclinical carcinoma of the cervix.     

Midtrimester amniocentesis: obstetric outcome and neonatal neurobehavioral status

The possible effects of midtrimester genetic amniocentesis on neurobehavioral status were studied in newborn infants of women who had had the procedure (N = 100) and in newborn infants of women who had declined the test (N = 56). Brazelton's Neonatal Behavioral Assessment Scale was administered to newborn infants born at term and did not reveal consequences of amniocentesis on neonatal orientation, range of state, motor ability, autonomic regulation, regulation of state, response decrement, or reflexes. Information on obstetric complications also was obtained. The findings raised questions regarding the temporal relationship between amniocentesis and fetal loss and focused attention on preterm birth as a potential risk that warrants further investigation. This study provides the foundation for our prospective longitudinal follow-up in which the cohort will be reassessed later in infancy and in childhood.     

Maternal glucose injections do not alter the suppression of fetal breathing following maternal ethanol ingestion

In order to determine whether intravenous injections of glucose could reserve the effects of maternal ingestion of ethanol (0.25 gm/kg), glucose (25 gm intravenously) or an equal volume of saline solution was administered to eight pregnant women at 37 to 40 weeks' gestation after ingestion of ethanol. Fetal breathing movements were abolished within 30 minutes after ingestion of ethanol and were not increased by maternal intravenous injections of glucose. Maternal heart rate was increased by ethanol. The disposition of ethanol in maternal blood was not altered by injection of glucose, and fetal gross body movements were not influenced by maternal ingestion of ethanol or by injections of glucose after ethanol.