Vaginal operative delivery in Germany: a national survey about experience and self-reported competency

Background: To determine German obstetricians' self-perceived experience with vacuum and forceps deliveries.Patients and methods: Using a web-based survey, German obstetricians were invited to participate in a survey. This survey was approved by the German society of obstetrics and gynecology.Results: Surveys of 635 obstetricians were received. All obstetricians reported performing significantly less forceps than vacuum deliveries. Almost all obstetricians want to perform more delivery, which indicates the willingness to learn both. More obstetricians felt confident to perform vacuum than forceps. In a similar obstetrical indication, most of the obstetricians would prefer to perform a vacuum assisted delivery. The majority of the obstetricians wished to receive more training in vaginal operative deliveries.Conclusion: Most of the German obstetricians prefer to use vacuum-assisted vaginal deliveries and feel less confident to perform forceps deliveries. Standardized training to improve the quality of care is recommended.

Vacuum and forceps training in residency: experience and self-reported competency

OBJECTIVE

Determine chief residents' experience with vacuum and forceps deliveries and self-perceived competencies with the procedures.

STUDY DESIGN

Study 1: A written questionnaire was mailed to all fourth year residents in US RRC approved Ob/Gyn programs. Study 2: The study was replicated using a web-based survey the following year. Data were analyzed with chi (2) and Wilcoxon Signed Rank tests using SPSS.

RESULTS

Surveys were received from 238 residents (20%) in Study 1 and 269 residents in Study 2 (23%, representing 50% of all residency programs). In both studies, residents reported performing significantly less forceps than vacuum deliveries. Virtually all residents wanted to learn to perform both deliveries, indicated attendings were willing to teach both, and felt competent to perform vacuum deliveries (Study 1, 94.5%; Study 2, 98.5%); only half felt competent to perform forceps deliveries (Study 1, 57.6%; Study 2, 55.0%). The majority of residents who felt competent to perform forceps deliveries reported that they would predominately use forceps or both methods of deliveries in their practice (Study 1, 75.8%; Study 2, 64.6%). The majority of residents who reported that they did not feel competent to perform forceps deliveries reported that they would predominately use vacuum deliveries in their practice (Study 1, 86.1%; Study 2, 84.2%).

CONCLUSION

Current training results in a substantial portion of residents graduating who do not feel competent to perform forceps deliveries. Perceived competency affected future operative delivery plans.

A comparison of costs associated with screening for gestational diabetes with two-tiered and one-tiered testing protocols

OBJECTIVE

The Fourth International Workshop on Gestational Diabetes recently suggested that two techniques, a 2-tiered protocol and a 1-tiered protocol, to screen for gestational diabetes mellitus are acceptable alternatives. This study was undertaken to compare the direct costs and patient time expenditures associated with implementing both techniques.

STUDY DESIGN

A MEDLINE search was undertaken to determine the prevalence of positive and negative screening results. Direct costs of testing were estimated by determining the range of supply costs from manufacturers' catalogs and the labor costs by estimating the time required to perform each procedure and multiplying by the appropriate range of wages; these costs were then multiplied by the appropriate range of the number of procedures required to implement both protocols, and the totals were summed. Patient time expended was estimated by assigning test times of 1, 2, and 3 hours for the 50-g screening glucose challenge test, the 75-g oral glucose tolerance test, and the 100-g oral glucose tolerance test, respectively. If additional visits were required, 2 travel-time units were assigned each time a patient underwent a procedure. These units were multiplied by the range of patients undergoing various tests to implement the alternative protocols.

RESULTS

We identified low and high direct costs, test times, and travel units per patient screened by the 1- and 2-tiered testing protocols. Low and high direct costs were $3.46 and $7.88, respectively, for the 2-tiered protocol and $5.64 and $10.88, respectively, for the 1-tiered protocol (relative ratios, 1.63 for low direct costs in each protocol and 1.38 for high direct costs in each protocol). Low and high test times were 1.4 and 1.5 hours, respectively, for the 2-tiered protocol and 2.0 and 2.0 hours, respectively, for the 1-tiered protocol (relative ratios, 1.47 for low test times in each protocol and 1.32 for high test times in each protocol). Low and high travel units for the 2-tiered protocol were 0.2 and 0.3, respectively, when the glucose challenge test was given at the prenatal visit, and 2.2 and 2.3, respectively, when the test was not given at that time. Low and high travel units for the 1-tiered protocol were 8.3 and 5.8, respectively, when the glucose challenge test was given at the prenatal visit, and 0.89 and 0.85, respectively, when the test was not given at that time.

CONCLUSIONS

The 2-tiered protocol appears to be associated with lower direct implementation costs and less patient time expenditure than the 1-tiered scheme. The 1-tiered protocol is associated with slightly less travel time, but this is unlikely to offset the test time advantage of the 2-tiered protocol. Until further data regarding the relative clinical utility of the 2 protocols become available, these factors may be important for clinicians in deciding which screening format to follow.

Teaching vaginal breech delivery and external cephalic version. A survey of faculty attitudes

OBJECTIVE

To ascertain current faculty attitudes regarding teaching of vaginal breech delivery (VBD) and external cephalic version (ECV).

STUDY DESIGN

A questionnaire was sent to obstetrics and gynecology residency programs. Respondents were queried regarding demographic parameters, resident and practice experience, and attitudes toward teaching these procedures.

RESULTS

Fifty-four (96%) surveys were returned. Sixteen (30%) respondents were female and 38 (70%) male. Sixteen (30%) completed residency prior to 1980, 17 (32%) during the 1980s and 21 (48%) during the 1990s. Nineteen (35%) trained locally. Forty-seven (87%) received training in VBD during residency. Thirty-five (65%) received training in ECV. Thirty-two (60%) had performed VBDs in practice. However, only 18 (33%) continued to perform this procedure. During the proceeding three years, they reported performing an average of five VBDs per chief resident per year. Thirty-seven (69%) performed ECV in clinical practice. The 17 who did not indicated that they referred to others. They reported performing an average of 15 ECVs per chief resident per year. Fifty-two (96%) thought residents should still be taught VBD. All faculty thought that residents should be taught ECV. None of the above parameters exerted a statistically significant effect on these opinions.

CONCLUSION

There was nearly universal faculty support for continuing to teach VBD to residents. However, only one-third of faculty members currently perform this procedure. There do not appear to be sufficient numbers of VBDs to teach this procedure utilizing a "hands on" approach. There is universal support for teaching ECV. There appear to be both enough individuals with experience and enough procedures to accomplish this education.

The prevalence of thromboembolic events among women with extended bed rest prescribed as part of the treatment for premature labor or preterm premature rupture of membranes

OBJECTIVE

This study was undertaken to determine the prevalence of thromboembolic events among women with extended bed rest prescribed as part of the treatment of premature labor or preterm premature rupture of membranes.

STUDY DESIGN

A retrospective chart review was undertaken of all women who had bed rest of >/=3 days' duration prescribed as part of the treatment of premature labor or preterm premature rupture of membranes in the Akron General Medical Center Perinatal Unit during the period January 1, 1997-December 31, 1998. The prevalence of thromboembolic events in this population was determined. The charts of all additional gravid women with antepartum or postpartum deep vein thrombosis or pulmonary embolism diagnosed during the study period were also reviewed. The prevalence of these disorders among the pregnant population for whom extended bed rest was not prescribed as part of the treatment of premature labor or preterm premature rupture of membranes was also calculated. Statistical comparison of the prevalences in the 2 populations was undertaken by means of the chi(2) analysis with the Fisher exact test.

RESULTS

There were 192 patients admitted during the study period who had extended bed rest prescribed as part of the treatment of premature labor or preterm premature rupture of membranes. Three of these women had thromboembolic events, for a prevalence of 15.6 cases per 1000 women. Five additional gravid women were admitted for the treatment of deep vein thrombosis or pulmonary embolism. There were 6164 deliveries among women not treated with extended bed rest for premature labor or preterm premature rupture of membranes during this period. Thus the prevalence of these phenomena among the remaining pregnant women was 0.8 cases per 1000 women. The prevalences of these disorders in the 2 populations were highly significantly different.

CONCLUSION

The prevalence of thromboembolic events among women for whom extended bed rest is prescribed as part of the treatment of premature labor or preterm premature rupture of membranes is significantly increased with respect to that among gravid women who do not receive this therapy and is substantially higher than previously reported. If this finding is confirmed in other populations, it may be prudent to undertake further studies to determine whether this prevalence can be reduced.

Drug prescribing for chronic medical disorders during pregnancy: an overview

Women of reproductive age with chronic medical disorders are often concerned about hazards from drug exposure during pregnancy. The avoidance of any medication after conception may be ideal but is often unwise for maternal well-being. Adverse fetal effects are often not clinically apparent. Current standards for prescribing these medications during pregnancy are discussed from a review of the recent literature.

Pregnancy complicated by Marfan's syndrome with aortic arch dissection, subsequent aortic arch replacement and triple coronary artery bypass grafts

A patient with Marfan's syndrome suffered aortic dissection with subsequent aortic arch replacement and coronary artery bypass grafts during pregnancy. Antepartum therapy consisted of bed rest, heparin anticoagulation, propranolol and fetal evaluation. After amniocentesis to determine fetal lung maturity, cesarean section with epidural anesthesia and invasive hemodynamic monitoring was performed at 34 weeks' gestation, resulting in delivery of a viable girl without demonstrable congenital abnormalities. The maternal postoperative course was uneventful. This report is the first of such a case.

Ultrasound experience with prenatal genitourinary abnormalities

The ability to diagnose genitourinary abnormalities in the fetus frequently poses management dilemmas for the urologist. Our experience with 13 cases of abnormal fetal ultrasonography examinations thought to be genitourinary in nature underscores difficulties posed by this new technology. In 3 cases the prenatal diagnosis was eventually found to be incorrect. In 1 case, vesicoureteric reflux gave the appearance of hydronephrosis that resolved after birth. In 3 cases in which intervention was deemed necessary, the eventual outcome was unaffected. Prenatal ultrasound is most useful when detecting occult hydronephrosis that would have gone unnoticed in the routine newborn physical examination. However, our patients received no benefit from fetal intervention.

Screening of high-risk and general populations for gestational diabetes. Clinical application and cost analysis

Two thousand seventy-seven women attending a university-based prenatal clinic were screened for gestational diabetes. The patients were divided into two groups. Group 1 consisted of 959 patients with historic or clinical factors traditionally employed to identify patients as being at high risk for the occurrence of gestational diabetes. Group 2 consisted of the remaining 1118 patients. The O'Sullivan 50-g 1-h test, with an upper limit of normal for serum glucose of 150 mg/dl, was employed as the initial screening procedure. Patients with an abnormal screening test underwent a 3-h oral glucose tolerance test (GTT) with a 100-g load. The values recommended by the First American Diabetes Association Workshop-Conference on Gestational Diabetes were employed for interpretation. Group 1 patients underwent screening at their initial visit and again at 28 wk gestation. Group 2 patients underwent an identical screening sequence between 28 and 32 wk gestation. Cost analysis was performed. The prevalences of positive screening tests were 7.2% and 6.1%, and the frequencies of abnormal GTTs were 1.5% and 1.4% among group 1 and group 2 patients, respectively. These rates were not statistically significantly different. Overall, 46.7% and 53.5% of the cases of gestational diabetes were identified among the patients with and without risk factors, respectively. The total cost of the screening program was +9869.00. The cost per patient screened and the cost per case of gestational diabetes identified were +4.75 and +328.96, respectively. These results reemphasize the inadequacy of screening only those patients with traditional risk factors for gestational diabetes and demonstrate the feasibility of implementing a program of universal glucose screening among a large obstetric population.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous abortion among insulin-dependent diabetic women

A prospective study was undertaken to evaluate the frequency of spontaneous abortion in clinically apparent pregnancies among insulin-dependent diabetic women evaluated prior to pregnancy. The study was done in 132 pregnancies occurring in 91 diabetic women. The spontaneous abortion rate was 30%; 70% of the pregnancies progressed beyond 20 weeks. The abortion rates for Classes B, C, D, and F through RT were 0%, 25%, 44%, and 22%, respectively. Initial serum levels of the beta-subunit of human chorionic gonadotropin above 6000 mIU were usually associated with favorable outcome while levels below 6000 mIU were not predictive of outcome. Data from this study suggest that the risk of spontaneous abortion among insulin-dependent diabetic women may be substantially higher than for the general population. Higher abortion rates were generally associated with more advanced White classification of diabetes. Age at diagnosis was the only factor which showed a significant contribution to the risk of abortion.

Multiple gestation: time interval between delivery of the first and second twins

A clinical investigation was undertaken to challenge the commonly accepted view that the interval between the birth of the first and second twins should be preferably within 15 minutes and certainly no more than 30 minutes. During 1981 and 1982, 115 patients with live-born twins at 34 or more weeks' gestation underwent an attempted vaginal delivery at four regional perinatal centers. The interval between vaginal delivery of the first and second twins (mean, 21 minutes, range, one to 134 minutes) was 15 minutes or less in 70 (61%) cases and more than 15 minutes in 45 (39%) cases. Excluding conditions associated primarily with prematurity, all second twins delivered beyond 15 minutes did well despite the delay and had no signs of excess trauma or low five-minute Apgar scores. Maternal complications were also uncommon, although combined vaginal-abdominal delivery was more frequent if there was a delay of more than 15 minutes (eight of 45 versus two of 70, P less than .02). The authors conclude that if there is continuous fetal and uterine monitoring, a time restriction for the delivery interval between the first and second infants is not necessary.

Relationship of nonstress test reactivity and gestational age

The relationship between gestational age and reactivity during the nonstress test was evaluated in 297 high-risk patients. When the incidence of nonreactive tests at gestational ages of 28 to 44 weeks was evaluated week-by-week, either on the basis of tests performed or patients tested, there was no statistically significant relationship between reactivity and gestational age (P = .184 tests; P = .222 patients). Four grouped gestational-age intervals were evaluated. Interval A consisted of the period from 28 to 32 weeks' gestation, interval B consisted of the period from 33 to 36 weeks' gestation, interval C consisted of the period from 37 to 41 weeks' gestation, and interval D consisted of the period from 42 to 44 weeks' gestation. The incidences of nonreactive tests were 15.3, 3.9, 2.5, and 5.9% in intervals A, B, C, and D, respectively. The differences in the incidences of nonreactive tests between those performed in intervals A and B and intervals A and C were highly statistically significant (P less than .001). Differences in the incidences between other intervals did not reach statistical significance. The incidences of patients who experienced a nonreactive test were 10.2, 2.4, 2.8, and 4.7% in intervals A, B, C, and D, respectively. The differences in the incidences of patients who experienced a nonreactive test in intervals A and B and intervals A and C were highly statistically significant (P less than .001). Differences in the incidences between other intervals did not reach statistical significance.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical experience with one hundred seven diabetic pregnancies

Clinical experience with 45 pregnancies in women with Class A diabetes and 62 pregnancies in women with insulin-requiring diabetes is described. The perinatal mortality rates were 0, 16.1, and 9.3, respectively, among the Class A, insulin-requiring, and total diabetic populations. Diabetic mothers experienced significantly higher prevalences of cesarean section and ketoacidosis than did the overall population. There were no other significant differences in maternal complications. Diabetic mothers demonstrated high rates of abnormal estriol levels and relatively low rates of positive contraction stress tests. Positive contraction stress tests were highly correlated with abnormal outcome. Delivery occurred either at or after 37 weeks in 93% of the Class A and in 81% of the insulin-requiring women. In comparison to infants in the general population, those of diabetic mothers experienced significantly elevated rates of being large for gestational age, macrosomia, and hypoglycemia. Congenital abnormalities were significantly higher in the Class A, but not in the insulin-requiring population. Neonatal morbidity could not be related to maternal diabetic control and was only minimally related to gestational age.

Neonatal outcome among low birth weight infants delivered spontaneously or by low forceps

In a population of 1065 singleton, low birth weight infants (1000 to 2500 g) delivered vaginally from vertex presentation, the neonatal mortality and morbidity of 394 delivered by low forceps were compared with those of 671 delivered spontaneously. There were no significant differences between the groups, either across the population as a whole or among any of the following birth weight subgroups: 1000 to 1500 g, 1501 to 2000 g, and 2001 to 2500 g. The data in the current study, as well as those from previous reports, argue against the routine use of prophylactic low forceps delivery and in favor of a more individualized approach to the vaginal delivery of infants in vertex presentation in this weight group.

Blood ordering in obstetrics and gynecology: recommendations for the type and screen

The number of units of blood preoperatively crossmatched to the number of units transfused was studied retrospectively in patients undergoing four common obstetric and gynecologic procedures. Associated medical problems and the timing of and reasons for transfusions were evaluated. Patients with risk factors associated with an increased incidence of required transfusion were identified. Based on these results, a type and screen method for preoperative blood ordering is recommended for most patients undergoing cesarean section, abdominal hysterectomy, and vaginal hysterectomy. Using this method, sera are preoperatively tested for unexpected antibodies and ABO/Rh typing is done. If the antibody screen is negative, crossmatching is not done. Should a transfusion be ordered, crossmatching can be done in 20 minutes, or type-specific blood can be available after a 15-second saline spin. Through application of the type and screen method, a substantial savings in money and laboratory personnel time can be expected without compromising patient care.

Abdominal trauma during pregnancy

In summary, trauma occurs relatively frequently among pregnant patients. Various anatomic and physiologic changes of pregnancy may alter the type of injury experienced by pregnant women. These changes may also alter the manifestations of given injuries and the treatment required to reestablish maternal-fetal hemostasis. Fortunately, most trauma experienced by pregnant individuals is minor and is associated with good prognosis for both the mother and her fetus. Blunt trauma as a result of automobile collision is the most frequent form of serious injury involving pregnant women. However, several cases of penetrating abdominal wounds have also been reported. Both blunt and penetrating trauma may frequently injure the uterus. Fetal intracranial injury and fracture, as well as abruption, often occur as a result of blunt trauma. Multiple direct fetal, placental, and cord injuries have been reported as a result of penetrating trauma. Both blunt and penetrating trauma frequently cause injury to other intraabdominal organs, and blunt trauma is associated with an especially high incidence of pelvic fracture and retroperitoneal hemorrhage. Laparotomy is often required to treat such injuries. At the time of the laparotomy, difficult decisions are required in determining whether the fetus is best delivered or left in utero. Recent technologic advances for assessing fetal status may be helpful in these decisions. Rarely, a mother may expire with her living fetus undelivered, and a rapid postmortem cesarean section may save the fetal life. During the last several years, the prognosis for both trauma victims and gravid women with complicated pregnancies and their fetuses has improved markedly. Hopefully, during the next several years, the knowledge and therapeutic modalities developed to treat each group will be combined to provide optimal care for the pregnant trauma victim and her fetus.

Selective management of abruptio placentae: a prospective study

Antenatal diagnosis and selective management of abruptio placentae were studied prospectively over a 17-month period. Diagnosis was confirmed by placental inspection in 59 (1.3%) of 4545 deliveries. Among the 50 patients admitted with a living fetus, the diagnosis was made antenatally in 31 (62%). Fifteen were delivered vaginally and 16 by cesarean section. When these infants were compared to all other liveborn infants delivered during this period using a weight-adjusted chi 2 analysis, no significant difference was found in neonatal mortality or duration of hospitalization. There was a significant increase in the incidence of both respiratory distress syndrome and low Apgar scores among the study infants (P less than .005), but these increases were not correlated with mode of delivery or diagnosis-to-delivery interval. It is concluded that optimal fetal survival and an acceptable cesarean section rate may be obtained by selective management, especially in infants weighing more than 1500 g.

Effect of maternal ketoacidemia on the pregnant ewe and the fetus

Poorly controlled diabetic pregnancies are associated with hyperglycemia and elevated ketones. While glucose is known to cross the placenta, there is limited information regarding the placental transfer of ketones and their associated cardiovascular and metabolic effects in the fetus. Thus, the present study was undertaken to evaluate the transfer of the ketoacid beta hydroxybutyrate across the ovine placenta and to determine the effects of this ketoacid on maternal and fetal physiologic and metabolic parameters. Pregnant ewes (110 to 120 days' gestation) were instrumented with catheters in the lateral branch of both uterine arteries, uterine veins, femoral artery, and femoral vein, and electromagnetic flow probes were placed on both middle uterine arteries. Catheters were placed in the fetal carotid artery and jugular vein, and a catheter and balloon were placed in the amniotic fluid. Beta hydroxybutyrate (0.39 mmole/100 ml of uterine blood flow) and antipyrine (00.27 mmole/100 ml of uterine blood flow) as a second reference marker, were infused simultaneously into the uterine arteries for a period of 2 hours. The beta hydroxybutyrate concentrations in the uterine vein increased to 5.93 +/- 1.32 mmoles/L, and were associated with a significant increase in maternal heart rate and a slight but significant reduction in uterine blood flow. No changes in maternal arterial blood gas values were noted. The concentration of beta hydroxybutyrate in the fetal carotid arteries increased from 0.01 +/- 0.01 mmole/l to 0.15 +/- 0.03 mmole/L, and were associated with a significant reduction in fetal PaO2 (24.2 +/- 0.9 to 17.9 +/- 1.9 mm Hg) and an elevation of fetal lactate levels (1.86 +/- 0.17 to 5.07 +/- 1.56 mmoles/L).

Cardiovascular and biochemical effects of infusion of beta hydroxybutyrate into the fetal lamb

Previous studies from our laboratory have shown that beta hydroxybutyrate crosses the ovine placenta in small amounts during maternal hyperketonemia and produces significant reductions in fetal PaO2 and increased fetal lactate levels. The present study evaluates the effects of fetal hyperketonemia on fetal and maternal cardiovascular and biochemical parameters. Pregnant ewes (110 to 120 days' gestation) were instrumented with catheters in the femoral artery, femoral vein, and uterine veins, and electromagnetic flow probes were placed on the middle uterine arteries. The fetal carotid artery and jugular vein were catheterized, and a catheter and balloon were placed in the amniotic fluid. Beta hydroxybutyrate (0.44 mmole/min) and antipyrine (0.03 mmole/min) were simultaneously infused directly into the fetal jugular vein for 90 minutes. The fetal beta hydroxybutyrate level increased from a baseline of 0.12 +/- 0.08 to 6.80 +/- 0.46 mmoles/L and was associated with a significant decrease in fetal PaO2 (23.7 +/- 2.4 to 16.0 +/- 0.4 mm Hg) and a large increase in the fetal lactate (1.85 +/- 0.27 to 5.43 +/- 0.92 mmoles/L) at 90 minutes. The present results suggest that during fetal hyperketonemia fetal oxygenation is significantly reduced and may contribute to the increased perinatal mortality in the pregnant diabetic patient.

The use of amniotic fluid 3-methyl histidine to creatinine molar ratio for the diagnosis of intrauterine growth retardation

To determine if the amniotic fluid 3-methyl histidine to creatinine molar ratio (3MH:CR) could prove useful for the antepartum detection of intrauterine growth retardation (IUGR), the 3MH:CR was determined retrospectively in 3 groups of human amniotic fluids. Group A consisted of amniotic fluids from pregnancies yielding IUGR fetuses whose birth weight was less than or equal to the tenth percentile for gestational age; group B consisted of amniotic fluid from pregnancies yielding infants whose birth weight was greater than the tenth but less than or equal to the 25th percentile for gestational age; group C consisted of amniotic fluids from pregnancies yielding infants whose birth weight was greater than the 25th but less than or equal to the 75th percentile for gestational age. The mean 3MH:CR x 10(-3) for groups A, B, and C were 15.9 +/- 1.9, 5.4 +/- 0.8, and 6.2 +/- 0.5, respectively. The mean 3MH:CR x 10(-3) was statistically different between groups A and B (P less than or equal to .001) and between groups A and C (P less than or equal to .001), but not statistically different between the 2 control groups. Employing an upper limit of normal of 8 for the 3MH:CR x 10(-3), 13 of 15 IUGR neonates were correctly identified as IUGR, and 23 of 27 neonates were correctly identified as being of normal birth weight for gestational age (sensitivity 86.7%, specificity 85.2%, incidence of correct diagnosis 85.7%). No consistent relationship was shown to exist between maternal serum and amniotic fluid 3-methyl histidine level. There was no statistically significant relationship between 3MH:CR x 10(-3) and gestational age. The comparison of the data generated in this study to that obtained with previously reported ultrasonic and biochemical techniques suggests that the amniotic fluid 3MH:CR ratio may prove helpful in establishing the antenatal diagnosis of IUGR, particularly in cases where the gestational age is uncertain.

Total parenteral nutrition in a pregnant insulin-requiring diabetic

A 28-year-old class F diabetic woman whose pregnancy was complicated by gastroparesis, hemorrhagic gastritis, narcotic addiction, intrauterine fetal growth retardation, and severe preeclampsia was supported with total parenteral nutrition (TPN) from the 27th to the 29th week or pregnancy. During this period there was adequate control of serum glucose, a positive nitrogen balance, and a normal amino acid profile. Unfortunately, a rapid deterioration in renal function and hypertensive disease occurred, requiring cesarean section at the 29th gestational week. TPN was continued for an additional 30 days postoperatively until the gastritis resolved and adequate oral nutrition could be reestablished. Wound healing was satisfactory.

The effects of epidural anesthesia on electronic fetal heart rate monitoring

A variety of changes of FHR monitoring parameters have been attributed to epidural anesthesia. Epidural anesthesia with lidocaine may cause tachycardia in a small percentage of patients and decreased FHR variability in other patients. No changes in baseline FHR have been observed after epidural anesthesia with bupivacaine or chloroprocaine. Chloroprocaine causes no significant change in FHR variability. Bupivacaine is associated with a statistically significant increase in FHR variability when group data are compared. However, this response does not occur in every patient, nor is it predictable in any given patient. Several studies have shown high incidences of pathologic periodic changes in FHR in women receiving epidural anesthesia with lidocaine. These changes appear to be strongly related to both maternal hypotension secondary to anesthesia-induced sympathetic blockade and to maternal uterine hypertonus. Studies in which bupivacaine or chloroprocaine were employed, and in which hypotension was avoided, indicate that observed pathologic periodic changes are not related to drug injection but rather to sporadic nonanesthesia-induced changes in uterine activity. Epidural anesthesia employing anesthetic solutions to which epinephrine has been added lead to decreased uterine activity. Epidural anesthesia without epinephrine appears to have no effect on uterine activity. In general, epidural anesthesia in the absence of maternal hypotension or uterine hypertonus causes minimal changes in the FHR parameters. Those changes that do occur are neither universal or predictable. Therefore, any alteration in FHR monitoring parameters occurring in a patient receiving epidural anesthesia should be evaluated and acted upon in the same fashion and by the same methods one would employ if the patient were not receiving epidural anesthesia.

Vaginal delivery in patients with a prior cesarean section

To assess the risks and benefits of vaginal delivery in patients with prior cesarean section, the English literature on this subject from 1950 to 1980 was reviewed. The following conclusions were reached: 1) Properly conducted vaginal delivery after cesarean section is relatively safe, with a 0.7% incidence of uterine rupture, 0.93 perinatal mortality, and no maternal deaths due to uterine rupture. 2) Of those patients allowed a trial of labor, 66.7% were successfully delivered vaginally. Successful vaginal delivery occurred in 74.2% of those patients with a nonrecurrent indication for their previous cesarean section and in 33.3% of those patients whose indication for previous cesarean section was cephalopelvic disproportion. Sixty-seven percent of those patients with a prior vaginal delivery versus 47.1% of those patients without a prior vaginal delivery subsequently delivered vaginally. 3) A classic uterine scar clearly increases the probability of uterine rupture. However, the precise magnitude of the increased risk cannot be accurately determined. 4) Certain basic safety requirements such as available operating room facilities and adequate personnel for careful observation are mandatory, but other management policies that remain controversial include use of regional anesthesia, oxytocin administration, timing of hospital admission, artificial rupture of membranes, mode of delivery, proper method to evaluate the uterine scar, and delivery of fetuses in breech presentation and twins. 5) A policy of selective vaginal deliveries among patients with prior cesarean sections will result in cost reductions due to decreased postpartum hospitalization.

The effects of bupivacaine and chloroprocaine as local anesthetics for epidural anesthesia of fetal heart rate monitoring parameters

The effects of saline-induced pressure-volume changes in the epidural space, and bupivacaine and chloroprocaine as local anesthetics for epidural anesthesia, on various fetal heart rate monitor parameters were investigated in 34 low-risk women. Epidural space pressure-volume changes, bupivacaine, and chloroprocaine had no effect on the incidence of pathologic periodic fetal heart rate changes, the level of the baseline fetal heart rate, or the level of uterine activity units. Epidural space pressure-volume changes and chloroprocaine did not affect fetal heart rate variability. The use of bupivacaine was associated with a significant increase in fetal heart rate variability

Clinical experience with a screening program for gestational diabetes

Screening for abnormal glucose metabolism was carried out in 2,077 pregnant women. Historical or clinical risk factors for gestational diabetes were present in 959 women (group 1). The remaining 1,118 patients composed group 2. A 50 gm oral glucose load and a 1-hour serum glucose determination with a threshold of 150 mg/dl were used as a glucose challenge screening test (GCT). Patients with an abnormal GCT underwent an oral glucose tolerance test (GTT). Group 1 patients underwent screening at the initial clinic visit or when the clinical risk factor was first recognized, with repeat screening at 28 to 32 weeks if the initial testing was normal. Group 2 patients were screened at 28 to 32 weeks. In group 1, 69 patients (7.2%) exhibited an abnormal GCT and 14 (1.5%) demonstrated an abnormal GTT. In group 2, 68 patients (6.1%) exhibited an abnormal GCT and 16 (1.4%) demonstrated an abnormal GTT. These incidences are not statistically different. The estimated costs per patient screened and per case of gestational diabetes detected were $4.75 and $328.96, respectively.

Pulmonary eosinophilic granuloma complicating pregnancy

The first known case of pregnancy complicated by pulmonary eosinophilic granuloma is reported. The patient developed dyspnea late in pregnancy, but there was no objective evidence of deterioration in arterial blood gases or pulmonary function tests. Cesarean section was required at 36 weeks' gestation because of falling estriol levels in the presence of a breech presentation and an inability to induce cervical dilation. Maternal, postoperative, and neonatal courses were normal. Recommendations are made concerning the treatment of similar patients with similar symptoms.