Prenatal screening using maternal serum alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol: two-year experience in a health maintenance organization

The objective of this study was to evaluate a 2-year experience in a health maintenance organization with mid-trimester maternal serum screening with alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and unconjugated estriol (UE) as a screen for fetal Down's syndrome. Women at 15-20 weeks gestation were offered triple marker screening. A patient-specific second trimester risk of 1:295 for Down's syndrome was used as a threshold for referral. Women at risk for trisomy 18 were identified by a protocol with fixed low cutoffs. The AFP threshold for referral for neural tube defects (NTD) was 2.0 multiples of the median (MoM). Patients at risk were offered ultrasonography, genetic counseling, and prenatal diagnosis. A total of 6,474 samples were drawn. The initial screen positive rate for Down's syndrome was 7.1%. After ultrasound evaluation, 351 (5.7%) of the remaining 6,197 women were still at risk for Down's syndrome. After genetic counseling, 292 (4.7%) women underwent prenatal diagnosis. Overall, 12 of 16 (75%) cases of Down's syndrome were detected antenatally by triple marker screening. Using AFP alone, only 3 of 14 (21%) cases of Down's syndrome in women under 35 years would have been detected. We detected 1 abnormal karyotype (including one 45, X) for every 22 amniocenteses performed for abnormal Down's syndrome screening. For trisomy 18, 13 women (0.2%) were at risk and, of these, 3 cases were diagnosed. All 6 cases of NTD during the study period were detected by AFP after identifying 3.8% of women as at risk. In conclusion, in the setting of a health maintenance organization where abnormal screening tests were managed by a single referral center, triple marker screening was effective not only for screening for fetal Down's syndrome, but also for trisomy 18 and NTD.

Midtrimester hemoperitoneum caused by placenta percreta in association with elevated maternal serum alpha-fetoprotein level

We report a case of hemoperitoneum in the second trimester due to placenta percreta which was associated with an elevated maternal serum alpha-fetoprotein. A 29-year-old woman, gravida 4, para 1-0-2-1, was seen at 17 weeks' gestation with an acute abdomen. Maternal serum alpha-fetoprotein in a sample drawn 1 week previously revealed a value of 5.0 multiples of the median. At laparotomy, placenta percreta was discovered. This case of placenta percreta diagnosed in the second trimester was associated with an elevated maternal serum alpha-fetoprotein level. Physicians counseling patients with unexplained elevated maternal serum alpha-fetoprotein levels should include placenta accreta or percreta in the differential diagnosis and should maintain an awareness of its existence in patients with acute abdomen in pregnancy.

The definition of acute perinatal asphyxia

Perinatal asphyxia remains a concern for physicians, patients, and attorneys. The history of concern for this condition is reviewed, and efforts in neonatal-perinatal medicine to identify at risk patients and prevent serious sequelae are discussed. A definition consistent with the American Academy of Pediatrics-American College of Obstetrics and Gynecology Guidelines for Perinatal Care, requiring multiple biochemical and clinical indices for asphyxia, is given.

Nifedipine for treatment of preterm labor: a historic prospective study

OBJECTIVES

The purpose of this study was to ascertain whether adverse fetal and/or neonatal effects occurred during nifedipine treatment of preterm labor and to assess maternal tolerance of nifedipine therapy in patients intolerant of a beta-sympathomimetic agent.

STUDY DESIGN

We undertook historic prospective review of medical records of 102 women admitted to an antepartum ward for treatment of preterm labor who received nifedipine. Data were collected regarding maternal side effects, fetal surveillance, and neonatal outcome.

RESULTS

The number and severity of reported maternal side effects were significantly reduced when patients were switched from terbutaline to nifedipine. No discontinuance of nifedipine occurred because of maternal side effects. Fetal surveillance testing and neonatal outcome data failed to reveal deleterious in utero effects of nifedipine.

CONCLUSIONS

Nifedipine was a well-tolerated and safe tocolytic in this population and warrants further investigation.

Effect of routine weekly cervical examinations at term on premature rupture of the membranes: a randomized controlled trial

OBJECTIVE

The purpose of this study was to determine whether routine antepartum cervical examinations at term are associated with premature rupture of membranes (PROM).

METHODS

This was a randomized controlled trial conducted at a health maintenance organization in metropolitan Denver. The subjects were 604 term gravidas randomized to a no examination or examination group. Exclusions included preterm labor, third-trimester bleeding, cerclage, multiple pregnancy, history of PROM (rupture before the onset of labor), and planned induction or cesarean. In the no examination group, routine examinations (without clinical indication) were not performed. In the examination group, weekly examinations were performed from 37 weeks until delivery.

RESULTS

No statistically significant difference in PROM or prolonged PROM (more than 6 hours) was observed between those unexposed and those exposed to routine cervical examinations at term. In addition, there were no differences between the groups in other relevant outcomes including cesarean delivery, induction, augmentation, chorioaminionitis, or neonatal infectious morbidity.

CONCLUSION

In our population, there is no association between routine weekly antepartum cervical examinations at term and PROM or other study end points.

The association of maternal low birthweight and infant low birthweight in a racially mixed population

The association between maternal low birthweight (LBW) and infant low birthweight has been explored in previous studies in mainly middle and upper income, Caucasian populations. This study investigated whether the association found in these populations is true in a racially mixed, low socio-economic group. A case-control methodology was used and estimates of association were derived by means of logistic regression analyses. Data were gathered for 167 LBW infant-mother dyads and 338 adequate weight infant-mother controls matched on race and parity. The odds of a LBW infant having a LBW mother were 80% more likely than for adequate weight infants (OR = 1.80, 95% CI 1.14-2.84). This association was stronger for Hispanic women and their infants than for Black or non-Hispanic White women and their infants. Women who were both preterm and LBW had the higher estimate of risk for infant LBW than women who were LBW due to intrauterine growth retardation (IUGR). As found in previous research, the estimate of association between maternal LBW and infant LBW was greater for those infants who were LBW due to IUGR than those who were LBW due to being premature. The question of whether maternal LBW is also associated with increased risk of neonatal mortality and morbidity is as yet left unanswered.

Occlusion of umbilical artery in acardiac, acephalic twin

In the acardiac, acephalic twin malformation the normal co-twin is put at risk because of the extra cardiac work-load. Surgical procedures may be hazardous to the mother. We describe a novel approach--the insertion of a helical metal coil to induce thrombosis in the umbilical artery of the acardiac twin--which immediately interrupted flow. The co-twin was delivered at 39 weeks and his neonatal course has been normal.

Intrauterine resuscitation with tocolysis. An alternate month clinical trial

Fifty patients were compared for the purpose of investigating the usefulness of intrauterine resuscitation with tocolysis (IURT). Terbutaline was given, as an intravenous bolus, to 31 women in labor in whom fetal distress was diagnosed and urgent delivery by cesarean section was indicated. In alternate months, a control group of 19 women with similar diagnoses was urgently delivered after standard interventions such as maternal positioning, oxygen administration, hydration, and discontinuation of oxytocin. Improvement in perinatal outcome was shown in infants after IURT. Apgar scores were less than 7 in 42% of the study group and in 71% of the control group at 1 minute (P = .04). Five-minute Apgar scores less than 7 occurred in 7% of the study group and 24% of the control group. A low venous pH was seen in 55% of the control group compared with 29% of the infants resuscitated with terbutaline. Estimated maternal blood loss and hematocrit change was not different in the two groups. Maternal blood pressure and pulse changes following IURT were modest and of doubtful significance. We conclude that intravenous terbutaline administered as a bolus injection at the time of fetal distress in labor improves infant outcome as evidenced by more vigorous Apgar scores and less acidemia without significant adverse physiologic effects on the mother.

Are there health risks in using risking systems? The case of perinatal risk assessment

Health risk management is receiving widespread public and professional attention. Relationships between risks and health effects are often assumed to be real and taken for granted. While health risk assessments are increasingly conducted, they are sometimes not well grounded and frequently poorly studied. Knowledge of the sensitivity, specificity and predictive value of risk factors in clearly identified target populations is required if appropriate interventions are to be designed. 'Risking systems' are often comprised of risk factors which have little predictive usefulness. In the field of perinatal medicine, the identification of risk factors has a long history. The changing risk status of pregnant women during the prenatal period, in labor, and at the time of delivery poses problems for the research and clinician who rely on risking systems to characterize the likelihood of adverse events. Currently used risking systems, antepartum and intrapartum, are not sufficiently robust for this task. The assignment of a high risk status often results in overcalling a problem and a cascade of technological interventions may follow. In the current climate of 'managing' pregnancies, a thoughtful review of the quality of risking systems is required. Are we being over-risked and over-served?

Short- and long-term risks after exposure to diagnostic ultrasound in utero

A total of 425 children exposed to diagnostic ultrasound at three Denver hospitals during the period May, 1968, through August, 1972, and 381 matched control children were studied for adverse effects at birth and again at a special examination between seven and 12 years of age. Apgar scores, gestational age, head circumference, birth weight, length, congenital abnormalities, neonatal infection, and congenital infection were measured at birth. At seven to 12 years of age, measurements included conductive and nerve measurements of hearing, visual acuity and color vision, cognitive function, behavior, and a complete and detailed neurologic examination. No biologically significant differences between exposed and unexposed children were found.

The effects of internal electronic fetal heart rate monitoring on maternal and infant infections in high-risk pregnancies

A controlled prospective study of the effects of fetal monitoring on mothers and infants was conducted at Denver General Hospital, Denver, Colorado. A total of 690 high-risk patients in labor were randomly assigned to one of three groups; auscultation alone, electronic fetal monitoring and electronic fetal monitoring with the option to obtain a scalp pH sample. Maternal and neonatal infectious morbidity after vaginal or cesarean delivery was unchanged with internal fetal monitoring. Despite frequent antibiotic prophylaxis (95% cesarean section v. 11% vaginal), cesarean section was the most significant factor associated with increased maternal puerperal infectious morbidity (13.75% cesarean section v. 3.9% vaginal). Although hours of labor, hours of rupture of membranes, hours of internal catheter, number of exams and presence of meconium were not associated with increased maternal infection, prolonged hours of internal catheter usage greater than 8 hours and prolonged rupture of membranes greater than 12 hours were associated with increased antibiotic usage in the neonate.

The relation of electronic fetal monitoring patterns to infant outcome measures in a random sample of term size infants born to high risk mothers

In the rush to use a new medical technology the fact that relative risk is not a measure of the predictive validity of a variable is sometimes forgotten. In the present paper both the relative risk and predictive value of electronic fetal monitoring patterns are examined to see whether they are associated with problematic neonatal outcomes. It is shown that nonreassuring or ominous patterns are not good predictors of problematic neonatal outcomes. This suggests either that there is no risk associated with these patterns or if in fact there is such a risk, it is moderated by some as yet unknown variables between the time that the pattern is seen and the actual birth of the infant. This fact has implication for the management of labor and delivery using electronic monitoring equipment, since it appears that the use of such equipment will lead to a significant increase in the cesarean section rate. If this increase in the cesarean section rate comes about because of the assumed predictive value of a nonreassuring or ominous pattern, it may represent an unnecessary increase in cost and risk of delivery.

Experience in a series of fimbriectomies

In a series of 247 consecutive sterilizations by fimbriectomy performed at the Denver General Hospital, a failure rate of 2.4% was found. The literature is reviewed, and these results are compared with results of other series. In several of the fimbriectomy series with more successful outcome, modifications of the technique originally described were used. The difficulties associated with the Kroener technique are discussed. The fimbriectomy failures were caused by either lack of resection of all of the fimbriae or the presence of tuboperitoneal fistulas, both congenital and acquired. Fimbriectomy should not be regarded as the method of choice for sterilization unless one can ensure adequate surgical exposure and complete removal of the fibria, including the fimbria ovarica.

Pediatric follow-up of a randomized controlled trial of intrapartum fetal monitoring techniques

A controlled prospective study was conducted to evaluate possible effects of the use of three intrapartum fetal monitoring techniques on the offspring of high-risk mothers in labor after at least 34 weeks' gestation. Six hundred and ninety women were randomly assigned to one of the three monitoring groups: auscultation alone, electronic monitoring alone, and electronic monitoring with option to obtain fetal scalp pH. There were no significant differences among the three groups of offspring with respect to neonatal mortality or morbidity, Apgar scores, cord blood gas values, or Brazelton examinations at ages 2 to 3 days. Assessment of the infants at 9 months revealed no significant differences in their growth and development as assessed by physical examination. Bayley Scales of Infant Development, and Milani-Comparetti tests. The frequency of delivery by cesarean section was significantly higher in the electronically monitored group than in the auscultated group. This study failed to show beneficial effects of electronic fetal monitoring over auscultated monitoring for high-risk but relatively mature fetuses.

Prental diagnosis and subsequent team approach to the management of omphalocele

The diagnosis of omphalocele can now be made in the prenatal period with the use of ultrasound and the intraamniotic injection of radiopaque contrast material. By diagnosing omphalocele prior to birth a combined obstetric, neonatal and pediatric surgical approach can lead to a successful outcome of pregnancy and subsequent development of a normal infant.

Cholestatic jaundice of pregnancy: new perspectives

Cholestatic jaundice of pregnancy is a condition characterized by pruritus, icterus, or both during pregnancy. A total of 9 pregnancies complicated by cholestatic jaundice are presented. Three of these cases are presented in detail because they reflect complications that can occur with this condition. The literature on cholestatic jaundice is reviewed. This condition has been regarded in the past as benign to the mother and fetus, but these cases and other recent investigations suggest high perinatal mortality and morbidity rates.

A controlled trial of the differential effects of intrapartum fetal monitoring

A controlled prospective study of the differential effects of intrapartum fetal monitoring on mothers and infants has been conducted at Denver General Hospital, Denver, Colorado. A total of 690 high-risk obstetric patients in labor were randomly assigned to one of three monitoring groups--auscultation, electronic fetal monitoring alone, or electronic monitoring with the option to scalp sample. There were no differences in immediate infant outcomes in any measured category (Apgar scores, cord blood gases, neonatal death, neonatal morbidity, nursery course) among the three groups. There were no differences in rates of infant or maternal infections. The cesarean section rate was markedly increased in the electronically monitored groups, especially in the electronically monitored alone (18%) as compared with the auscultated (6%) (P less than 0.005). In this controlled trial electronic monitoring did not improve neonatal outcomes and the mothers were at increased risk of cesarean section.

The evaluation of continuous fetal heart rate monitoring in high-risk pregnancy

Intrapartum electronic fetal heart rate monitoring of the high-risk obstetric patient is thought to improve the perinatal outcome. A prospective randomized study of 483 high-risk obstetric patients in labor was carried out comparing the effectiveness of electronic fetal monitoring with auscultation of fetal heart tones. The infant outcome was measured by neonatal death, Apgar scores, cord blood gases, and neonatal nursery morbidity. There were no differences in the infant outcomes in any measured category between the electronically monitored group and the auscultated group. The cesarean section rate was markedly increased in the monitored group (16.5 vs. 6.8 per cent in the auscultated patients). The presumptive benefits of electronic fetal monitoring for improving fetal outcome were not found in this study.