Delayed-interval delivery: extended series from a single maternal-fetal medicine practice

OBJECTIVE

Our purpose was to review the extended experience of a single maternal-fetal medicine practice with delayed-interval delivery.

STUDY DESIGN

We completed a retrospective review of our maternal-fetal medicine practice database from January 1991 through March 1999. Patients were derived from both primary and consultative practices. All patients were managed with tocolysis, antibiotics, and cerclage after delivery of the first fetus(es). Retained siblings were investigated by amniocentesis to exclude intra-amniotic infection.

RESULTS

Twenty-four consecutive patients had attempted delayed-interval delivery. Exclusion criteria for delayed-interval delivery included monochorionicity, abruptio placentae, severe preeclampsia, and the need for hysterotomy. The mean latency interval was 36 days, with a range of 3 to 123 days. Additionally, patients with previous cerclage(s) had significantly shorter mean latency intervals than patients without previous cerclage(s). Patients with long latency intervals (> or =49 days) had earlier births of the first fetus.

CONCLUSION

Selected multichorionic pregnancies may benefit from delayed-interval delivery. Patients with previous cervical cerclage(s) during the index pregnancy are less likely to achieve significant latency intervals. Even modest intervals between births of siblings at critical gestational ages can improve neonatal survival and decrease neonatal morbidity.

A multicenter controlled trial of fetal pulse oximetry in the intrapartum management of nonreassuring fetal heart rate patterns

OBJECTIVE

Recent developments permit the use of pulse oximetry to evaluate fetal oxygenation in labor. We tested the hypothesis that the addition of fetal pulse oximetry in the evaluation of abnormal fetal heart rate patterns in labor improves the accuracy of fetal assessment and allows safe reduction of cesarean deliveries performed because of nonreassuring fetal status.

STUDY DESIGN

A randomized, controlled trial was conducted concurrently in 9 centers. The patients had term pregnancies and were in active labor when abnormal fetal heart rate patterns developed. The patients were randomized to electronic fetal heart rate monitoring alone (control group) or to the combination of electronic fetal monitoring and continuous fetal pulse oximetry (study group). The primary outcome was a reduction in cesarean deliveries for nonreassuring fetal status as a measure of improved accuracy of assessment of fetal oxygenation.

RESULTS

A total of 1010 patients were randomized, 502 to the control group and 508 to the study group. There was a reduction of >50% in the number of cesarean deliveries performed because of nonreassuring fetal status in the study group (study, 4. 5%; vs. control, 10.2%; P =.007). However, there was no net difference in overall cesarean delivery rates (study, n = 147 [29%]; vs. control, 130 [26%]; P = .49) because of an increase in cesarean deliveries performed because of dystocia in the study group. In a blinded partogram analysis 89% of the study patients and 91% of the control patients who had a cesarean delivery because of dystocia met defined criteria for actual dystocia. There was no difference between the 2 groups in adverse maternal or neonatal outcomes. In terms of the operative intervention for nonreassuring fetal status, there was an improvement in both the sensitivity and the specificity for the study group compared with the control group for the end points of metabolic acidosis and need for resuscitation.

CONCLUSION

The study confirmed its primary hypothesis of a safe reduction in cesarean deliveries performed because of nonreassuring fetal status. However, the addition of fetal pulse oximetry did not result in an overall reduction in cesarean deliveries. The increase in cesarean deliveries because of dystocia in the study group did appear to result from a well-documented arrest of labor. Fetal pulse oximetry improved the obstetrician's ability to more appropriately intervene by cesarean or operative vaginal delivery for fetuses who were actually depressed and acidotic. The unexpected increase in operative delivery for dystocia in the study group is of concern and remains to be explained.

Selective delivery in a twin gestation

One or more infants of a multifetal pregnancy occasionally require delivery selectively because of in utero risk of fetal death in circumstances in which the sibling fetus appears well. At 26 weeks 5 days of gestation a small fundally placed twin in a dichorionic gestation had an estimated fetal weight of 650 g with decreased amniotic fluid and ominous Doppler velocity findings in his umbilical artery. A normally grown presenting sibling had reassuring fetal surveillance data. Over a 2-week interval the growth-restricted twin showed no growth, and his status deteriorated. He was selectively delivered by hysterotomy. Selective delivery may offer parents of multifetal gestations an additional option when 1 or more of their fetuses are at high risk for in utero death.

Delayed-interval delivery in multifetal pregnancy

OBJECTIVE

Our goal was to review a single subspecialty practice experience with a uniform approach to delayed-interval delivery.

STUDY DESIGN

A 66-month retrospective review of our maternal-fetal medicine practice database was completed. Fifty-nine sets of twins or triplets delivered at < 30 weeks' gestation were identified. No cases of twins or triplets who came to our care, either in consultation or as primary providers, were excluded.

RESULTS

Forty-three patients were excluded as candidates for delayed-interval delivery because of monochorionicity, abruptio placentae, severe preeclampsia, and the need for hysterotomy. Sixteen pregnancies were identified as candidates for delayed-interval delivery, and we actually attempted to delay delivery in 9 of them. The details of the interval deliveries are summarized; there was a mean latency interval of 34 days with a range of 3 to 76 days. Pregnancies in which delayed-interval deliveries wer attempted were significantly less mature at the time of presentation than those managed by delivery of all infants initially. Perinatal mortality was significantly lower in the retained fetuses.

CONCLUSIONS

This retrospective consecutive case review from a single maternal-fetal practice documents that selected multichorionic pregnancies may benefit from delayed-interval delivery. Modest intervals between siblings during critical gestational ages can improve newborn survival and decrease neonatal morbidity.

Pregnancy outcome following donor embryo replacement

OBJECTIVE

To investigate the occurrence of adverse perinatal outcome among donor embryo pregnancies.

STUDY DESIGN

Thirty-five pregnancies following donor embryo replacement were delivered between 1990 and 1994. Thirty-two pregnancies following standard in vitro fertilization (IVF) in women of 34 years of age or older were delivered during the same time period. All pregnancies meeting study criteria and who conceived through the same assisted reproductive technology program were included. Patients electing multifetal pregnancy reduction in either group were excluded.

RESULTS

The patients were similar with regard to age and parity. There was no difference in the mean number of embryos transferred between the groups or between those conceiving singleton or multiple gestations. The occurrence of spontaneous abortion was 34% in the donor embryo group and 25% in the control IVF group. Of the continuing pregnancies, there was a trend toward more cesarean births in the donor embryo group, but it was not statistically significant. Birthweights and gestational ages also were not different between the groups. Preterm birth occurred in approximately one-third of the pregnancies in each group owing largely to the number of multiple gestations. The incidence of preeclampsia was 26% among donor embryo pregnancies and 29% among control group pregnancies. Adverse outcome defined as preterm birth with or without preeclampsia occurred in over one-third of the pregnancies in each group.

CONCLUSION

There is no increase in adverse perinatal outcome among donor embryo pregnancies compared to age-like control IVF pregnancies. Modest increases in the occurrence of adverse outcome among such pregnancies cannot be excluded by the data in the current report.

Palliative fetal surgery for diaphragmatic hernia

Congenital diaphragmatic hernia is associated with a poor prognosis in spite of advances in antenatal detection and newborn care. Open fetal surgery has been suggested as a strategy for salvaging selected fetuses at high risk for pulmonary hypoplasia as a result of this lesion. We report a strategy for palliative fetal surgery with definitive repair postponed to the newborn period.

Rapid cytogenetic assessment of fetal blood samples

OBJECTIVE

To obtain a timely fetal karyotype in selected circumstances by investigating the usefulness of fetal blood samples.

METHODS

Forty-five patients had fetal blood sampling for a variety of abnormalities including hydrocephalus, oligohydramnios, fetal growth retardation, nonimmune hydrops, duodenal atresia, polyhydramnios, and multiple anomalies. Four cytogenetic techniques were attempted in determining fetal karyotype: a direct harvest of lymphocytes in the fetal blood sample, a 24-hour incubation of fetal lymphocytes without mitogen, and a 48- and 72-hour mitogen-stimulated incubation followed by harvest and analysis.

RESULTS

Ten of these 45 cases showed diagnostic cytogenetic abnormalities. Twenty-nine cases had results reported within 30 hours of obtaining the specimen following analysis of unstimulated cultures. One-half of the abnormal results were reported within 30 hours of receiving the specimen.

CONCLUSION

Unstimulated lymphocyte cultures from fetal blood samples may provide rapid cytogenetic diagnosis and alter obstetric management in selected circumstances.

Fixed mini-dose warfarin for prophylaxis of thromboembolic disease in pregnancy: a safe alternative for the fetus?

BACKGROUND

Fixed mini-dose warfarin has been used for thromboprophylaxis in high-risk nonpregnant patients with encouraging results. The usefulness of this strategy in pregnant women requires documentation of fetal safety.

CASE

A woman with antithrombin III deficiency suffered a venous thrombosis during early pregnancy and could not be successfully managed long term with heparin. One milligram of warfarin daily was used for prophylaxis, and serial fetal blood samples were used to monitor the fetal coagulation status. No apparent coagulation abnormalities were demonstrated in the fetus at 33, 36, and 38 weeks' gestation. The woman suffered no further thromboses throughout the remainder of her pregnancy and puerperium.

CONCLUSIONS

The efficacy of fixed mini-dose warfarin for prophylaxis in pregnancies at risk for thromboembolic disease will require further investigation. This fetus did not appear vulnerable to coagulation abnormalities as a consequence of the warfarin regimen.

Percutaneous, ultrasound-directed ablation of ectopic pregnancy with methotrexate. A report of three cases

The early diagnosis of unruptured ectopic pregnancy has been facilitated by the availability of high-resolution ultrasound and sensitive quantitative assays for beta-human chorionic gonadotropin. Nonsurgical treatment of selected patients has been advocated. Three patients with fairly advanced unruptured ectopic pregnancies were treated with ablation with methotrexate using an ultrasound-directed, percutaneous technique. That approach appears to be reasonable and safe in selected patients, though the subsequent reproductive performance is unknown.

Amniotic fluid glucose concentration as a marker for intra-amniotic infection

This study evaluated the use of amniotic fluid (AF) glucose concentration as a rapid indicator of intra-amniotic infection. Amniotic fluid glucose concentrations were measured in 86 pregnancies and compared with AF cultures. There were 14 positive cultures with a mean AF glucose of 7.1 mg/dL (range 1-24) and 72 negative cultures with a mean AF glucose of 30.4 mg/dL (range 5-66), a significant difference (P less than .001). An AF glucose of less than or equal to 5 mg/dL had a positive predictive value of 90%; an AF glucose of greater than 20 mg/dL had a 98% negative predictive value. Amniotic fluid glucose can be obtained rapidly and inexpensively, and may be of use in the diagnosis of intra-amniotic infection.

Multifetal reduction of triplets and pregnancy outcome

Multifetal pregnancy reduction has been suggested as a strategy to improve pregnancy outcome in grand multiple gestations of three or more fetuses. We prospectively investigated multifetal pregnancy reduction in 13 women with triplet pregnancies in the first trimester following ovulation induction, in vitro fertilization, or gamete intrafallopian transfer procedures. Eleven women whose triplet pregnancies followed similar reproductive technologies and who declined or were not offered the procedure were managed expectantly. Mean (+/- standard deviation) infant birth weight was 2227 +/- 478 g in the multifetal reduction group and 2239 +/- 399 g in the group managed expectantly. Gestational age was 35.5 +/- 2.3 weeks in the study group and 35.7 +/- 2.5 weeks in the triplets managed expectantly. Newborn hospital days as well as newborn and maternal complications were not statistically different between the management groups. Maternal interventions included tocolytic medication, home uterine activity monitoring, and extended hospitalization, and were more common in the triplets managed expectantly than in the study group of triplets reduced to twins. Multifetal pregnancy reduction for triplet pregnancies does not necessarily improve pregnancy outcome, though it may be offered on the basis of parental choice.

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.

Fetal blood sampling in the management of intrauterine thyrotoxicosis

Graves disease is an autoimmune disorder caused by thyroid-stimulating immunoglobulins (Igs) which result in an excess production of thyroid hormones. These Igs are passively transferred to the fetus and may produce intrauterine thyrotoxicosis. Thyrotoxic fetuses are at risk for preterm delivery, intrauterine growth retardation, and perinatal death. Our patient had markedly elevated thyroid-stimulating Igs and had given birth to a preterm thyrotoxic infant in a previous pregnancy. We managed her third pregnancy with serial assessment of fetal thyroid hormones by funipuncture to identify the hyperthyroid fetus and modulate propylthiouracil therapy. We believe that this approach in selected patients with Graves disease may improve the outcome of these pregnancies.

Selective embryocide in the nonsurgical management of combined intrauterine-extrauterine pregnancy

Early diagnosis of ectopic pregnancy has provided the opportunity for nonsurgical management in selected cases. We used selective embryocide to manage the ectopic embryo in a patient with a combined intrauterine-extrauterine gestation following in vitro fertilization. The intrauterine pregnancy continued to term without incident.

Prolongation of premature gestation in women with hemolysis, elevated liver enzymes and low platelets. A report of five cases

Severe pregnancy-induced hypertension complicated by hemolysis, elevated liver enzymes and low platelets (HELLP) is considered an indication for immediate delivery, often resulting in premature or even previable infants. In five cases, temporary reversal of the HELLP syndrome was achieved using low-dose aspirin and corticosteroids. Pregnancy was prolonged an average of 4 weeks; three pregnancies were prolonged, beginning at less than or equal to 25 weeks, for an average of 5.5 weeks. Two of seven infants died, one from pulmonary hypoplasia due to oligohydramnios and the other from complications of prematurity. No long-term maternal morbidity was encountered, though one patient had peripartum disseminated intravascular coagulation and a seizure. A review of the literature supports the usefulness of low-dose aspirin in this setting; the impact of corticosteroids as part of the reversal strategy has not been discussed previously.

Meeting the challenge of the rising cesarean birth rate

The rising cesarean birth rate is a matter of national concern, and the goal of clinical obstetricians is to contain this trend while maintaining good maternal and perinatal outcome. Despite published reports suggesting that excellent perinatal outcome can be achieved with modest cesarean birth rates, the general increase of abdominal delivery in the United States appears to continue unabated. An educational approach to modify the community cesarean rate was directed at physicians, nurses, and interested lay groups via presentations in the Denver metropolitan community over a 5-year period. The content of these presentations included management of patients with previous cesarean births, diagnosis and management of fetal distress, the approach to patients with apparent failed progress in labor, indications and strategies for the indicated induction of labor, alternatives in the management of breech presentations and twin deliveries, and identification of patients at risk for genital herpes. The total cesarean birth rate increased to a level of 19.3% in this community in 1986, largely accounted for by the increase in the primary rate to 13.7%. Repeat cesarean birth rates remained relatively stable at 5.6% over the 2-year survey. Hospitals in which resident house officers either managed the entire service or participated in patient care achieved some of the lowest rates of both primary and repeat cesarean birth. Although intellectual arguments for decreasing cesarean births are acknowledged by physicians and nurses alike, translating them into practice on a daily basis is tempered by the constraints of time and the burden of medicolegal concerns. Educational efforts alone, therefore, are likely to produce change only slowly.

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.

Cesarean birth for failed progress in labor

"Failure to progress" is the leading indication for primary cesarean section and has a major impact on the escalating cesarean birth rate in the United States. We investigated the labor and delivery records of nulliparous women at term with vertex presentations admitted to the clinic and private services of our hospital to determine the importance of different management strategies associated with operative deliveries. Birth weights and immediate neonatal outcome were identical between the clinic and private services. The cesarean birth rate on the clinic service was 5.2%, compared with 17.1% on the private service; 80% of the abdominal deliveries on the private service were for "failure to progress." Epidural use rates were similar on both services and were associated with a 70% incidence of oxytocin augmentation. Once oxytocin augmentation became part of labor management, a 14-fold increase in cesarean sections was observed for the private service, but oxytocin had no impact on the cesarean birth rate in the clinic service. The placement of an intrauterine pressure catheter and an approach to the use of oxytocin that might be characterized as "selective active management" were necessary to achieve efficient uterine action in a timely fashion, permitting a high likelihood of vaginal birth on the clinic service.

The safety of inhaled beta-agonist bronchodilators during pregnancy

To assess the safety of inhaled beta-agonist bronchodilators during pregnancy, perinatal outcomes in 259 prospectively managed women with asthma using these medications during pregnancy were compared to perinatal outcomes in 101 concurrently followed pregnant subjects with asthma not using inhaled bronchodilators and to perinatal outcomes in 295 concurrently followed pregnant control subjects without asthma. No significant differences between women with asthma using inhaled bronchodilators and subjects not receiving inhaled bronchodilators were found in the following parameters: perinatal mortality, congenital malformations, preterm births, low birth weight infants, mean birth weight, small for gestational age or low ponderal index infants, Apgar scores, labor/delivery complications, or postpartum bleeding. Increased incidences of maternal chronic and pregnancy-induced hypertension and transient tachypnea of the neonate were observed in the pregnancies of subjects with asthma using regular inhaled bronchodilators compared to control subjects, but a logistic regression analysis within the sample of subjects with asthma did not significantly associate the use of inhaled bronchodilators with these outcomes. In the light of the known substantial perinatal risks of severe, uncontrolled asthma and the relatively sparse evidence of human gestational safety for alternative asthma medications, these data support the use of inhaled beta-agonist bronchodilators as part of the management of asthma during pregnancy.

Neonatal aortic thrombosis associated with the lupus anticoagulant

The lupus anticoagulant has been associated with clinical thrombosis and poor pregnancy outcome. There are no published reports of its detection in neonates born to affected mothers. We report such a case associated with neonatal aortic thrombosis.

Prostaglandin E2 in tylose gel for cervical ripening before induction of labor

Two hundred seventeen women who received 3 mg of prostaglandin E2 (PGE2) gel applied to the cervix followed by adjunctive oxytocin were compared to 94 patients whose labor was induced with oxytocin alone (OA). Postdatism, pregnancy-induced hypertension and rupture of the membranes were the major indications for induction of labor, accounting for 70% of the PGE2 group and 88% of the OA group. Mean initial cervical scores were found to be significantly less favorable among PGE2 patients as compared with OA patients. Though PGE2 was associated with a significant improvement in mean cervical scores, responsiveness of the cervix to PGE2, as determined by clinical examination, was not necessary for a successful induction. Failed inductions were infrequent in both groups. Nulliparous PGE2 patients with unfavorable cervical scores had fewer cesarean sections (CSs) and shorter labors than did their OA counterparts. Complications were uncommon but largely due to the subsequent use of oxytocin. Patients with prior CSs were safely induced following PGE2 cervical ripening.

Use of amniotic fluid analysis in the management of preterm rupture of the membranes

The management of preterm rupture of the membranes (PROM) must weigh the risks of respiratory distress from immediate delivery against those of expectant management. We divided 115 patients with PROM between 24 and 36 weeks of gestation into interventionist and expectant management groups on the basis of the amniotic fluid maturity. There was no difference between these groups with respect to gestational age and birth weight. Mature amniotic fluid was demonstrated in 41% of the patients. Interventionist management of infants with mature amniotic fluid irrespective of gestational age was associated with an improved outcome when compared to expectant management. Infants with PROM who can be shown to have mature amniotic fluid should be delivered promptly to avoid the small but real risks of expectant management.

High cesarean section rate: a new perspective

Cesarean section rates in the United States have increased dramatically in recent years, whereas perinatal mortality rates have fallen. To investigate the hypothesis that these two events are not necessarily causally related, a prospective attempt to modify obstetric management directed at minimizing the rate of abdominal delivery while preserving excellent perinatal survival was done at a university-affiliated hospital in the Denver metropolitan area. Unselected patients who were admitted to separate services at the hospital were used for comparison, with one group subject to the specific management criteria. Corrected mortality rates and low five-minute Apgar scores on the two services were not significantly different after two years. The total cesarean section rate on the first service was 5.7%, and the total cesarean section rate on the comparison service was 17.6%. Analysis of the data showed major differences in indications for cesarean section in the areas of repeat cesarean section, cephalopelvic disproportion, breech presentation, fetal distress, and genital herpes. These data support the contention that excellent perinatal outcome can be achieved with modest abdominal delivery rates.

Role of myoinositol in regulation of surfactant phospholipids in the newborn

According to animal studies myoinositol decreases surfactant phosphatidylglycerol and increases phosphatidylinositol. In the present study lung effluent phospholipids and serum myoinositol were analyzed in respiratory distress syndrome (RDS, 19 cases), in other lung disease (6 cases) and in 22 newborn with no lung disease. In addition, myoinositol was studied in amniotic fluid and in serum from umbilical vessels and from maternal vein (15 healthy newborn). There was a significant correlation between the fetal and amniotic fluid levels of myoinositol, but no detectable correlation between fetal and maternal myoinositol. Serum myoinositol was higher in preterm than in term newborns. In healthy newborns there was a negative correlation between lung effluent phosphatidylglycerol (expressed as percent of the phospholipids) and serum myoinositol (r = -0.968), and a positive linear correlation between myoinositol and lung effluent phosphatidylinositol (r = 0.849). In RDS at birth, undetectable phosphatidylglycerol corresponded with high serum myoinositol. During the first 5 neonatal days serum myoinositol either (1) decreased and phosphatidylglycerol appeared, (2) remained high and phosphatidylglycerol correspondingly low in some small preterm infants, or (3) decreased but phosphatidylglycerol did not expectedly increase and disaturated lecithin/sphingomyelin ratio remained low in other small preterm babies. We propose that a premature decrease in serum myoinositol among small preterm infants with RDS is not beneficial, since myoinositol may promote hormone-induced lung maturation and healing of lung damage.

Trial of labor in patients with multiple previous cesarean sections

Trial of labor (TOL) in patients with multiple previous low transverse cesarean sections has not been investigated extensively, and information regarding the risks and benefits of this kind of management is largely unavailable. A combined series of patients experienced a TOL after two or more previous cesarean deliveries; the rate of vaginal delivery was 66%, and there was virtually no morbidity. Though a larger number of patients is necessary to document the desirability of a TOL in these circumstances, the evidence available now suggests that this management approach is both reasonable and safe.

Trial of labor following cesarean section: a two-year experience

Elective repeat cesarean section is one of the major factors responsible for the increase in the total cesarean section rate observed since 1970. Beginning in January, 1980, a voluntary program encouraging a trial of labor for patients with a documented previous low-transverse cesarean section and no apparent recurring indication was instituted. Two hundred seven patients were managed with an adequate trial of labor, and 84.5% were delivered vaginally over a 2-year period. There were no deaths associated with a trial of labor, and maternal and fetal morbidity was negligible. This voluntary program resulted in a 27.9% decrease in the repeat cesarean section rate over the 2 years reported. Patient and physician acceptance of such a program was evaluated by follow-up questionnaires. Current recommendations include a mandatory trial of labor in patients with only one previous low-transverse cesarean section and no current indication for cesarean delivery. A more liberal management policy regarding patients with two or more previous low-transverse cesarean sections also seems warranted.

Enhancement of human amniotic cell growth by Ficoll-Paque gradient fractionation

Ficoll-Paque isopycnic centrifugation was used as a preparative procedure for amniotic fluid (AF) cells prior to tissue culture. This technique serves to reduce contaminating erythrocytes and also enhances cell growth or mitotic indices. The technique described in this report yields three subfractions designated as a turbid interphase layer (F-2), a middle cell layer (F-3), and a bottom pellet (F-4). The middle cell layer (F-3) demonstrated better cell growth and higher mitotic index than any of the other fractions or control unfractionated amniotic fluid cells. The use of Ficoll-Paque isopycnic preparative centrifugation of amniotic fluid cells is a valuable adjunct in cell culture for cytogenetic analysis. This may be especially true when amniotic fluid contains large numbers of erythrocytes.

Diagnosis of a triploid fetus at genetic amniocentesis

Nearly 20% of spontaneously aborted fetuses with chromosomal errors have been shown to have a triploid karyotype. Such a fetus is rarely encountered during the course of an amniocentesis at midtrimester. Because amniotic fluid cell polyploidy is an occasional finding among normal fetuses at midtrimester, the following report illustrates the importance of gathering corroborative evidence of an affected fetus before arriving at a prenatal diagnosis.

Effect of prolactin on phospholipid biosynthesis by alveolar cell carcinoma (A549) in monolayer tissue culture

By means of an alveolar cell carcinoma (A549) model, the effect of prolactin on pulmonary surfactant phospholipid biosynthesis was investigated. Preliminary results suggest that phosphatidylcholine synthesis via the phosphatidic acid phosphohydrolase pathway in addition to phosphatidylglycerol may be stimulated by the presence of prolactin.

Enhanced Growth of amniotic fluid cells in presence of fibroblast growth factor

A shorter period of time between amniocentesis and cytogenetic diagnosis is of considerable clinical usefulness. Fibroblast growth factor (FGF), a potent mitogen for cells of mesodermal origin, was used to enhance the growth rate of primary cultures of amniotic fluid-derived cells. At the initial harvest and at 5 scored metaphases, culture dishes incubated with FGF showed a 9-day advantage as a group when compared with their untreated, paired controls. In addition, less variability was encountered in the growth time of the FGF-treated dishes; 97% of these treated dishes were harvested initially between 10 and 20 days, while only 48% of the control dishes were harvested initially during this time period. Success was also noted in the recovery of failing cultures. The addition of FGF to the standard enriched medium used in amniotic fluid cell cultures has shortened the processing time and provided a more uniform growth rate in the majority of cultures studied.

Neural origin of cells in amniotic fluid

Cells from the amniotic fluid of fetuses with open neural tube defects (NTDs) have several abnormal characteristics of potential diagnostic value. The cell number in a unit volume of fluid is 10 to 100 times the normal range of cell count. The majority of cells adhere to tissue culture dishes within 24 hours of inoculation, instead of the 4 or 5 days required by normal amniotic fluid cells. The rapidly adhering cells morphologically resemble glial cells. Their Coulter volume is about twice the average seen in normal amniotic fluid--derived cells. This larger number of oversized, rapidly adhering cells is likely due to the continuous accumulation of neural cells in the amniotic fluid. We have detected the presence of the glial protein S-100 and the absence of the neuronal protein 14-3-2 by using a specific immunofluorescence assay. We conclude that fetuses with NTDs shed large numbers of glialike cells into the amniotic fluid where their detection may have diagnostic importance.

The management of elective, repeat cesarean section

The perinatal outcome of 252 consecutive, elective, repeat cesarean section was studied retrospectively. One hundred fifty patients (60%) were scheduled for delivery within approximately seven days of their expected delivery, cesarean (EDC), designated on the basis of rigorous clinical criteria and corroborative sonographic biparietal diameters. One hundred two patients (40%) did not meet these criteria and required analysis of amniotic fluid for L/S ratio and creatinine prior to their operations. Forty-three patients (17%) labored prior to their scheduled procedure or amniocentesis and underwent cesarean section shortly after admission. No cases of the respiratory distress syndrome were noted in the electively delivered patients. The authors conclude that careful clinical assessment of gestational age will prevent the occurrence of iatrogenic hyaline membrane disease in infants born to mothers by elective, repeat cesarean section. When the EDC is in question, however, amniotic fluid phospholipid analysis is clearly advisable.

The use of continuous insulin infusion for the peripartum management of pregnant diabetic women

Sixteen pregnant diabetic patients near term were maintained on a regimen of continuous insulin infusion during the peripartum period. Blood glucose remained in the range of 75 to 150 mg. per deciliter, with insulin infusion rates between 0.25 and 2.00 U. per hour. Following delivery the infusion was continued through the first postpartum day or until oral intake was tolerated and subcutaneous long-acting insulin could be given. Sliding scale regimens were unnecessary; insulin dosage for discharge was easily determined; and the metabolic care of these patients was greatly simplified. Neonatal hypoglycemia in the 17 infants delivered of these diabetic patients was not entirely eliminated despite euglycemia in the mothers.