Thromboelastography versus Standard Coagulation Assays in Patients with Postpartum Hemorrhage

OBJECTIVE

 Thromboelastography (TEG), a point-of-care test that measures blood's dynamic viscoelastic properties, is routinely used to guide resuscitation in surgical specialties with high hemorrhage risk. Patients with ongoing postpartum hemorrhage (PPH) often develop coagulopathy and hypofibrinogenemia. Timely assessment of fibrinogen is crucial because cryoprecipitate for repletion requires thawing time prior to administration. TEG may provide rapid assessment of coagulopathy in ongoing hemorrhage but this has not been thoroughly studied. Our objective was to determine if TEG accurately reflects coagulopathy in ongoing PPH when compared with standard assays.

STUDY DESIGN

 This was a retrospective cohort study of people with ongoing PPH (quantified blood loss >1,000 mL), from January 1, 2016, to December 31, 2019. TEG variables and standard coagulation parameters were compared in patients who had both assays drawn simultaneously. As a secondary analysis, patients who had TEG were compared with those who did not. The Mann-Whitney, Fisher's exact, Kruskal-Wallis, Spearman's rho, and logistic regression tests were used for analysis. Significance was set at p < 0.05.

RESULTS

 A total of 680 patients were included, 69 of whom had TEG and coagulation parameters drawn simultaneously and were included in the primary analysis. The remainder were included in the secondary analysis. TEG variables and coagulation assays correlated significantly-prolonged R with increased PTT (rho 0.25, p = 0.04), prolonged K and decreased α angle with decreased fibrinogen (rho -0.61, p < 0.001; rho 0.24, p < 0.001), and decreased maximum amplitude with decreased platelets (rho 0.62, p < 0.001). Those who had thromboelastographic assays had higher blood loss and need for interventions to manage hemorrhage than those who did not.

CONCLUSION

 TEG correlated significantly with standard laboratory assays in ongoing PPH, including for patients with hypofibrinogenemia. Given the point-of-care nature and rapid turnaround time, TEG should be considered for timely hemorrhage evaluation and directed resuscitation of coagulopathy.

KEY POINTS

· TEG significantly correlates with standard laboratory measures of coagulopathy in postpartum hemorrhage, including in patients with hybofibrinogemia (fibrinogen <200).. · TEG is routinely used in nonobstetric hemorrhage, and should be considered in PPH.. · Due to the point-of-care nature, TEG may allow for rapid guided resuscitation, including fibrinogen..

Serum Lactate Level as a Predictor for Blood Transfusion in Postpartum Hemorrhage

OBJECTIVE

Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. At present, there are no reliable clinical or laboratory indicators to identify which patients might require blood transfusions during a PPH. Serum lactate has long been used as an early biomarker of tissue hypoperfusion in trauma settings. The aim of this study is to understand serum lactate's role in the management of obstetric hemorrhage.

STUDY DESIGN

A retrospective chart review was performed of women who delivered between 2016 and 2019 at our institution and experienced a PPH. The patients were divided into two groups: those with a normal serum lactate level, defined as ≤2 mmol/L, and those with an abnormal serum lactate level, defined as >2 mmol/L. Need for packed red blood cell transfusion, as part of the resuscitation, was assessed for both groups.

RESULTS

During the study period, 938 women experienced PPH. Of these, 108 (11.5%) had a normal serum lactate, ≤2 mmol/L, and 830 (88.5%) had an abnormal lactate, >2 mmol/L. Women with elevated lactate levels were more likely to receive a blood transfusion versus those with a normal lactate level (57.0 vs. 46.3%, p = 0.035, respectively). Additionally, the average number of blood transfusions administered was significantly higher in the abnormal lactate group versus in the normal lactate group (1.34 vs. 0.97, respectively, p = 0.004). In a multivariable linear regression model, increasing serum lactate levels were found to be predictive of requiring more than 1 unit of blood (p < 0.001).

CONCLUSION

Women with elevated serum lactate levels were more likely to require blood transfusions during a PPH versus those with a normal serum lactate level. Thus, serum lactate levels are useful as an early indicator of requirement for blood transfusion in the management of obstetric hemorrhage.

KEY POINTS

· Lactate is a biomarker for blood transfusion in trauma.. · Lactate's role in PPH is unknown.. · Elevated lactate predicts receiving more blood transfusions..

Patient Experience with Telehealth Medicine During the Ongoing COVID-19 Pandemic in New York City

Background: The COVID-19 pandemic accelerated integration of telehealth services into OBGYN practices in New York City. Since then, studies have shown high patient satisfaction with OBGYN telehealth services. However, few studies have compared satisfaction between obstetric and gynecologic patients. The primary objective of this study was to compare satisfaction with telehealth services between obstetric and gynecologic patients. Methods: This was an institutional review board-approved cross-sectional survey study among patients who had a telehealth visit at NYU OBGYN Faculty Group Practice from March 2020 to March 2021. Results: Gynecologic patients had higher rates of being "completely satisfied" compared with obstetric patients (40% vs. 24%, p < 0.001). Gynecologic patients were more likely to opt for telehealth services than obstetric patients both during a pandemic (70% vs. 59%, p < 0.001) and in the absence of a pandemic (53% vs. 37%, p < 0.001). Discussion: Prior studies have demonstrated high satisfaction with OBGYN telehealth. However, obstetric patients were less likely than gynecologic patients to feel satisfied with and opt for telehealth services.

Postpartum Readmissions for Hypertensive Disorders in Pregnancy During the COVID-19 Pandemic

BACKGROUND

Hypertensive disorders in pregnancy are one of the most common causes of readmission in the postpartum period. Because of the COVID-19 pandemic, early hospital discharge was encouraged for patients who were medically stable, because hospitalization rates among SARS-CoV-2–infected patients steadily increased in 2020. The impact of an early discharge policy on postpartum readmission rates among patients with hypertensive disorders in pregnancy is unknown.

OBJECTIVE

This study aimed to compare the postpartum readmission rates of patients with hypertensive disorders in pregnancy before and after implementation of an early discharge policy owing to the COVID-19 pandemic.

STUDY DESIGN

This was a quality improvement, retrospective cohort study of postpartum patients with antenatal hypertensive disorders in pregnancy who delivered and were readmitted because of hypertensive disorders in pregnancy at the New York University Langone Health medical center from March 1, 2019 to February 29, 2020 (control cohort) and from April 1, 2020 to March 31, 2021 (COVID-19 cohort). During the pandemic, our institution introduced an early discharge policy for all postpartum patients to be discharged no later than 2 days postpartum during the delivery admission if deemed medically appropriate. The reduction in postpartum length of stay was accompanied by the continuation of patient education, home blood pressure monitoring, and outpatient follow-up. The primary outcome was the comparison of the readmission rates for patients with postpartum hypertensive disorders in pregnancy. Data were analyzed using Fisher's Exact tests, chi-square tests, and Wilcoxon rank-sum tests with significance defined as P<.05.

RESULTS

There was no statistical difference in the readmission rates for patients with postpartum hypertensive disorders in pregnancy before vs after implementation of an early discharge policy (1.08% for the control cohort vs 0.59% for the COVID-19 cohort). The demographics in each group were similar, as were the median times to readmission (5.0 days; interquartile range, 4.0–6.0 days vs 6.0 days; interquartile range, 5.0–6.0 days; P=.13) and the median readmission length of stay (3.0 days; interquartile range, 2.0–4.0 days vs 3.0 days; interquartile range, 2.0–4.0 days; P=.45). There was 1 intensive care unit readmission in the COVID-19 cohort and none in the control cohort (P=.35). There were no severe maternal morbidities or maternal deaths.

CONCLUSION

These findings suggest that policies calling for a reduced postpartum length of stay, which includes patients with hypertensive disorders in pregnancy, can be implemented without impacting the hospital readmission rate for patients with hypertensive disorders in pregnancy. Continuation of patient education and outpatient surveillance during the pandemic was instrumental for the outpatient postpartum management of the study cohort. Further investigation into best practices to support early discharges is warranted.

Maternal-neonatal outcome with Staphylococcus aureus rectovaginal colonization

OBJECTIVE

To estimate prevalence of rectovaginal colonization by Staphylococcus aureus among pregnant women with group B streptococcus (GBS) screening results and its association with maternal and infant outcomes.

STUDY DESIGN

Cultures that detected both group B streptococcus (GBS) and S. aureus were obtained at > or = 35 weeks of gestation. Computerized database search and chart review determined invasive neonatal infection and maternal outcomes at the time of delivery through 6 months postpartum.

RESULTS

A total of 6,626 GBS screening cultures met study criteria, and 769 (11.6%) GBS isolates and 67 (1.0%) S. aureus were identified. No maternal S. aureus-related outcomes were found. The rate of maternal methicillin-resistant S. aureus colonization was 0.1% (7 in 6,626). GBS-positive patients were twice as likely to be colonized with methicillin-susceptible S. aureus than GBS-negative patients. GBS-positive culture rates differed significantly by primary language: Spanish 10.0%, English 13.7%, Russian 26.9%, Cantonese 13.2%, Mandarin 11.5%, Arabic 15.9%, and other 17.8%.

CONCLUSION

In our population, S. aureus colonization percentage (1.0%) was lower than the 7.5-8.2% reported by other medical centers, as was overall GBS carriage rate. S. aureus did not predispose to maternal or infant morbidity or mortality up to 6 months postpartum.

Vaginal radical trachelectomy: A valuable fertility-preserving option in the management of early-stage cervical cancer. A series of 50 pregnancies and review of the literature

OBJECTIVE

To report the obstetrical results following vaginal radical trachelectomy (VRT), a fertility-preserving surgery in the treatment of early-stage cervical cancer.

METHODS

Retrospective review of our first 72 patients treated by a laparoscopic pelvic lymphadenectomy followed by a VRT from October 1991 to October 2003 with regards to their reproductive function.

RESULTS

Patients' median age was 32 years old (21-42) and 53 (74%) were nulligravida. A total of 50 pregnancies occurred in 31 women. The majority (66%) had only one pregnancy, 19% had 2 pregnancies and 16% had 3 pregnancies or more. The rate of first trimester miscarriage was 16%, the rate of second trimester miscarriage was (4%) and 2 women (4%) elected to have pregnancy termination. A total of 36 pregnancies (72%) reached the third trimester. Of those, 3 (8%) ended prematurely at <32 weeks gestation, 5 (14%) delivered between 32 and 36 weeks and 28 (78%) delivered at term (>37 weeks). One newborn died of neonatal sepsis from E. coli infection and one died from cardiac malformation (trisomy-18). Seven patients (10%) had infertility problems: 3 from ovulatory causes of which 2 successfully conceived with IVF, one from endometriosis and low sperm count and 3 from probable cervical cause of which one conceived with IUI. One patient had a twin pregnancy following IVF and elected to have embryo reduction and subsequently delivered at 37 weeks.

CONCLUSION

Based on our experience, the obstetrical results following VRT for early-stage cervical cancer are very encouraging. The majority of women can anticipate to conceive spontaneously and deliver near term.

Use of abnormalities in the Friedman curve as a predictor of operative delivery in macrosomic babies

OBJECTIVE

To assess the use of the Friedman labor curve as a predictor of operative delivery in macrosomic pregnancies.

STUDY DESIGN

Medical records of 1141 patients who had delivered babies > or =4000 gm (group 1) were reviewed and were compared with the results of the next mother who delivered a neonate with birth weight <4000 gm (group 2). The variables studied were progress of labor as denoted on the Friedman curve, oxytocin use, and need for operative delivery.

RESULTS

In the 1141 patients with neonatal birth weights > or =4000 gm, there was a trend toward a longer second stage, arrest disorder, and operative delivery but this did not reach statistical significance.

CONCLUSION

Abnormalities in the Friedman curve were not useful as a predictor for operative delivery in pregnancies complicated by fetal macrosomia. There were no statistically significant differences between the two groups in terms of the variables studied.

Amniotic fluid granulocyte colony stimulating factor levels in chorioamnionitis do not predict neonatal sepsis

PROBLEM

To assess the usefulness of amniotic fluid (AF) granulocyte colony-stimulating factor levels (G-CSF) in chorioamnionitis (CAM) to predict neonatal sepsis.

METHOD OF STUDY

AF samples were obtained from term and preterm patients with (Group I) and without (Group II) CAM and were assayed for G-CSF levels. Patients with other infections were excluded. All AF samples were also tested for gram stain and cultures. The sensitivity, specificity, and predictive values of these parameters for diagnosing neonatal sepsis were assessed.

RESULTS

Positive AF cultures were the best predictors of neonatal sepsis in CAM, with a sensitivity of 67% and a positive predictive value (PPV) of 80%. Elevated AF G-CSF levels (> 1,000 pg/ml) were poor predictors of neonatal sepsis with a sensitivity of 29% and PPV of 39%.

CONCLUSION

Even though AF G-CSF levels were markedly elevated in patients with CAM, they were poor predictors of subsequent neonatal sepsis.

Amniotic fluid granulocyte colony stimulating factor levels: a rapid marker for diagnosing chorioamnionitis

PROBLEM

To assess the usefulness of amniotic fluid (AF) granulocyte colony stimulating factor (G-CSF) levels as a rapid marker for diagnosing chorioamnionitis.

METHOD OF STUDY

AF levels were obtained from term and preterm patients with and without chorioamnionitis (CAM). Patients with urinary tract, respiratory tract, and other infections were excluded. Results obtained from the AF G-CSF assays were compared with those from other parameters used for diagnosing CAM: maternal fever, leukocytosis, tachycardia, fetal tachycardia, AF glucose levels, white blood cell count, Gram stain, and aerobic and anaerobic cultures. The sensitivity, specificity, and predictive values were calculated.

RESULTS

In the uninfected AF samples, G-CSF levels were present but low, ranging from 400 to 1600 pg/ml. Levels in the infected samples, however, were markedly increased, ranging from 1600 to 14,000 pg/ml; P < 0.05. When a cutoff of 2000 pg/ml was used as a clear marker for CAM, the sensitivity was 67%, the specificity was 100%, and the positive and negative predictive values were 100% and 86%, respectively. The comparison of the other AF G-CSF laboratory parameters also revealed high sensitivity, specificity, and predictive values for detecting CAM.

CONCLUSION

(i) AF G-CSF levels are elevated in CAM. (ii) An AF G-CSF level > 2000 pg/ ml is a strong positive predictor of CAM. (iii) Elevated AF G-CSF levels appear to be more reliable in predicting CAM than any other single test currently used in clinical practice.

Correlation between maximum cervical dilatation at cesarean delivery and subsequent vaginal birth after cesarean delivery

OBJECTIVE

To determine whether the extent of cervical dilatation at cesarean delivery affects the subsequent vaginal birth after cesarean (VBAC) rate.

METHODS

Relevant records of the index pregnancy (group I) were reviewed for cervical dilatation at cesarean delivery, oxytocin use, indication, neonatal weight, and epidural use. The records of the subsequent pregnancy (group II) were reviewed for successful VBAC rates, neonatal weight, oxytocin, and epidural use.

RESULTS

There were 1917 patients in the study. The indications for cesarean in group I were malpresentation (5.1%), fetal distress (14.9%), and arrest disorders (80%). In group II, the VBAC success rates were 73% for previous malpresentation and 68% for previous fetal distress. In those with previous cesarean deliveries for arrest disorders with cervical dilatation at 5 cm or less, the VBAC success rate was 67%. It was 73% for 6-9 cm dilatation and 13% for the fully dilated group (P < .05).

CONCLUSIONS

Patients who attempt a VBAC may be counseled that a cesarean delivery at full dilatation is associated with a reduced chance of a subsequent successful VBAC.

Fetal cardiac effects of oral ritodrine tocolysis

The beta-sympathomimetic oral tocolytic ritodrine can cause maternal tachycardia and hypotension, and may cross the placenta. A new echocardiographic technique has been developed to explore fetal and placental ritodrine effects. Values in 76 healthy historic controls were compared to 18 studies in 16 patients performed while receiving stable oral ritodrine therapy, measured both at baseline and 30 minutes after a dose. Data collected included maternal pulse and blood pressure (BP), fetal cerebral and umbilical Doppler waveforms, and fetal heart rate. A new index of fetal myocardial contractility, combined ventricular shortening fraction, was derived from two-dimensionally directed M-mode. Maternal pulse and BP, fetal heart rate and heart size, and all Doppler indices were normal, without demonstrable dose-response effects. In the control subjects, combined ventricular shortening fraction fell with increasing gestational age (combined ventricular shortening fraction = -0.27 estimated gestational age + 49; r = 0.27; P < or = 0.02; standard error of the estimate, 11%). However, combined ventricular shortening fraction in ritodrine patients was abnormally decreased in 72% of cases. The mean index in normal subjects was 43 +/- 5%, but in ritodrine patients it was only 31%. We conclude that a history of premature labor or oral ritodrine, or both, is associated with reduced shortening fraction. Since there was no change in placental resistance, cerebral hypoxia, fetal heart rate, or heart size (preload), then low shortening fraction may be due to increased fetal systemic vascular resistance (BP) or decreased myocardial contractility.

First trimester disulfiram exposure: report of two cases

Disulfiram has been used effectively to deter alcohol consumption in patients with a history of alcohol abuse. Its use in reproductive age women has become increasingly common in recent years, intensifying the risk of fetal exposure. Nonspecific but significant abnormalities have been described in the infants of women treated with disulfiram in the first trimester of their pregnancies. Based on these data, authors have previously exposure is confirmed despite a lack of any pattern to the defects reported. We report the outcomes of two pregnancies with first trimester disulfiram exposure. In both cases, the timing and dose of disulfiram was known. In one case, disulfiram was the only potential teratogen exposed to the fetus. Both neonates were normal at birth and have shown subsequent normal development. This report suggests that the poor prognosis previously given to fetuses exposed to disulfiram in the first trimester may not be warranted.

Use of esterase inhibitors and zone electrophoresis to define bacterial esterases in amniotic fluid

OBJECTIVE

The purpose of our study was to define further the role of bacterial esterases in amniotic fluid obtained from women with chorioamnionitis.

STUDY DESIGN

Amniotic fluid samples from 39 patients with chorioamnionitis were submitted for bacterial cultures and in vitro assay. Esterase inhibitors diisopropyl fluorophosphate and iodoacetic acid were added and the degree of inhibition calculated. These results were compared with the amniotic fluid culture results. Chi square analysis was performed to compare the results of the esterase assay and the inhibition assay between the uninfected and infected amniotic fluid samples.

RESULTS

Thirty-one patients had positive bacterial cultures, with 21 being infected with gram-negative organisms. All samples showed significant inhibition (range 55% to 82%) with diisopropyl fluorophosphate. There was partial inhibition with iodoacetic acid (range 10% to 30%) in the gram-negative samples but no inhibition in the gram-positive and uninfected samples. Six infected and two uninfected samples were analyzed by using zone electrophoresis with human plasma as a control. Minimal esterase motility was noted in the amniotic fluid samples as compared with that in plasma.

CONCLUSION

The esterases in amniotic fluid appeared to be of bacterial, not human, origin. Furthermore, different groups of bacteria appeared to produce different esterases in infected amniotic fluid.

Amniotic fluid index: correlation with amniotic fluid volume

We calculated the amniotic fluid indexes (AFIs) of 310 women on 459 occasions. Normative data were analyzed and compared with data in several high-risk groups. In the normal gestations there was a progressive increase in AFI with advancing gestation until 32 weeks, after which there was a decline. The mean AFIs in abnormal gestations varied with the clinical diagnoses. These values were compared to those obtained by assessing amniotic fluid volume (AFV), that is a pocket more than 2 cm. There were 51 patients with abnormal AFVs. Forty-two had decreased fluid, six also had decreased AFIs; nine had increased AFVs and five (all with diabetes) also had increased AFIs. Thus, AFIs in normal pregnancies showed an orderly pattern of change with gestational age, and there was no accurate correlation between AFI and AFV. Thus, using AFV alone may lead to false interpretations of amniotic fluid status.

Surgical treatment of incompetent cervix

A comparison of multiple factors in the surgical management of cervical incompetence was carried out in 114 procedures. Factors examined included training level of the operator, gestational age, cervical effacement and dilation at the time of operation, diagnostic evaluation, Shirodkar or McDonald procedure, year of the procedure, and tocolytic therapy. The endpoint for successful outcome was defined as 37 weeks or newborn weighing over 2500 gm rather than neonatal survival, thus differing from previous studies. All patients were delivered vaginally unless there was an obstetric indication for cesarean delivery. The most important determinants of a term birth in patients with incompetent cervix were operator experience and the use of a Shirodkar procedure.

Variable decelerations in reactive nonstress tests with decreased amniotic fluid index predict fetal compromise

A total of 3158 patients at greater than or equal to 34 weeks' gestation undergoing nonstress tests and amniotic fluid index determinations were divided into six groups according to the amniotic fluid index and the nature of the decelerations. Fetuses with antepartum decelerations had statistically significantly increased incidences of intrapartum decelerations and operative deliveries because of intrapartum "distress," regardless of the amniotic fluid index. They also had significantly increased rates of neonatal acidosis and low Apgar scores when there were "severe" decelerations and an amniotic fluid index less than 5 in the antepartum period. Thus spontaneous decelerations in reactive nonstress tests with an amniotic fluid index less than 5 may predict fetal compromise.

Acid-base differences in preterm and term twin pregnancy

A prospective study was undertaken which examined 179 sets of twins, 68 premature (less than 36 weeks of gestation) and 111 term. The purpose of this study was to assess differences in the acid-base status between twins related to gestational age, birth order and the time interval between twin births. Although the twin blood-gas data is within the range considered normal, statistically significant differences favoring the first-born were noted for both preterm and term twins. These differences do not depend on gestational age, route of delivery or presentation, and become evident when the interval between twin births exceeds one minute. We postulate that after delivery of the first twin, the reduced uterine size causes a decrease in the intervillous blood flow and consequently a reduction in the respiratory exchange between the second fetus, still in utero, and its placenta.

Relationship between antepartum cocaine abuse, abnormal umbilical artery Doppler velocimetry, and placental abruption

We performed serial umbilical artery Doppler flow velocimetry studies on 314 women and grouped them according to history of antepartum cocaine abuse, placental abruption with antepartum cocaine abuse, preterm labor with antepartum cocaine abuse, preterm labor without antepartum cocaine abuse, and controls without preterm labor or antepartum cocaine abuse. Analyses excluded twin gestation, diabetes, and hypertension. The overall incidence of deliveries at or before 36 weeks was 28% (31 of 112). Thirteen (12%) of the infants were small for gestational age (SGA) and 33 (29%) were low birth weight (LBW). Almost all subjects with a history of cocaine abuse had normal systolic-diastolic ratios (S/Ds). All patients with abruption had abnormal S/Ds, as did 14 of 64 subjects who had preterm labor and a history of cocaine abuse. No abnormal S/Ds were found in the women with preterm labor or in controls. Among cocaine-abusing women, there was a significant correlation between placental abruption and abnormal S/Ds (P less than .05) and between abnormal S/Ds and the incidence of preterm birth and SGA and LBW infants.

Pancreatic enzyme activity in pregnancy

Serum amylase activity and the amylase:creatinine clearance ratio (Cam:Ccr%) are two of the most commonly used indicators for the diagnosis of pancreatitis. However, published data on the effect of pregnancy on these indicators are conflicting. Furthermore, there are no published data on the effect of pregnancy on serum lipase activity, which is considered one of the most sensitive and specific indicators of pancreatitis. A study was undertaken to determine the effect of pregnancy and gestational age on serum amylase, serum lipase and Cam:Ccr% levels and to establish a baseline of normal values for use in the diagnosis of pancreatitis in pregnant women. Serum amylase, serum lipase and Cam:Ccr% levels were determined on a sample population consisting of 175 pregnant women with gestational ages ranging from 5 to 40 weeks and on a control group of 44 reproductive-age, nonpregnant women. The study results indicated that there is no significant difference in serum amylase, serum lipase and Cam:Ccr% levels between pregnant and nonpregnant women. Cam:Ccr% showed a small but statistically significant increase in the third trimester of pregnancy.

Cordocentesis in isoimmunization and fetal physiologic measurement, infection, and karyotyping

Diagnostic cordocentesis is indicated in situations that require fetal vascular access. These include detection of intrauterine TORCH infections, estimation of the extent of fetal anemia before initiating therapy for isoimmunization and determination of fetal hematocrit for appropriate timing of subsequent transfusions. It may also be applied to evaluate fetal acid-base status and rapid karyotyping in fetuses with structural anomalies, intrauterine growth retardation, or oligohydramnios. More recently, it has been used to assist in the diagnosis of intrauterine starvation. Therapeutic applications of cordocentesis include intrauterine transfusion and the administration of medications directly to the fetus. Complications inherent to this procedure include cord hematoma and placental abruption.

Performance of cesarean section using absorbable staples

Although stapling techniques have gained wide acceptance in general surgery, they are still not commonly used in obstetrics. U.S. Surgical Corporation has introduced a stapling device suitable for use in cesarean sections. The copolymer staples (a blend of polylactic and polyglycolic acids) maintain their tensile strength until healing occurs and absorb without producing granulation tissue. The benefits include minimal trauma to tissue and reduced operating time, blood loss and postoperative morbidity. From July 1988 to February 1989, all patients undergoing low transverse cervical cesarean sections were randomized to either group 1 with the uterine incision performed in a routine manner or group 2 with the uterine incision cut and stapled using the Stapler. The preoperative management, intraoperative technique and postoperative surveillance were similar for both groups. The uterine incision was assessed by pelvic sonography during the postpartum period. Statistical analysis was performed using Fisher's exact test and chi-square analysis. Both groups were comparable for age, race, parity, gestational age and primary diagnosis. The length of the operative procedure was significantly shorter (p less than 0.05) in the stapled group. These patients also had a statistically significantly decreased incidence of uterine incisions and lacerations. All other parameters were not significantly different in the two groups. The stapled uterine incisions were visible by ultrasonography in more patients in the stapled group throughout the postpartum period than in the sutured group. Thus, stapling of the uterine incision was an acceptable alternative to traditional suturing techniques and it was possible to visualize clearly these incisions during the postpartum period.

In vitro inhibition of esterase activity in amniotic fluid: comparison with bacterial cultures

Assessment of leukocyte esterase activity in amniotic fluid for the rapid and reliable diagnosis of chorioamnionitis has been demonstrated previously. We compared in vitro inhibition of esterase activity in amniotic fluid with bacterial cultures to identify the origins of the specific esterases released by the infecting organisms. One hundred forty-one samples were tested (90 uninfected, 51 infected). Each sample was evaluated for Gram stain, cultures, and an in vitro esterase assay followed by ebelactone inhibition. Forty-two patients had positive amniotic fluid cultures. Ebelactone produced varying degrees of inhibition of esterase activity (range, 20% to 60%) in the uninfected samples and in those infected with gram-negative organisms. There was no inhibition in the samples infected with gram-positive organisms. Thus different groups of bacteria may elicit the production of different and specific esterases in infected amniotic fluid, as shown by the differences in in vitro inhibition.

The Shirodkar operation: a reappraisal

Sixty-six cerclages were performed by one surgeon in 46 patients with documented cervical incompetence. The mean operative blood loss was 25 ml, and the mean operating time was 18 minutes with no postoperative morbidity. Fifty-five of the pregnancies were carried for at least 37 weeks, eight were delivered before 37 weeks, and three are continuing. Six of the eight preterm deliveries were a result of factors unrelated to cervical incompetence. The two remaining preterm births were probably also unrelated because one occurred 8 days after emergent cerclage placement and the other occurred 12 weeks after the procedure, both as a result of premature rupture of membranes. There were no cesarean deliveries related to the Shirodkar suture. The efficacy of the procedure was demonstrated by a corrected perinatal survival rate of 100% and term delivery of 88%. (Since this article was written all three of the undelivered patients were delivered of infants after 37 weeks' gestation for a term delivery rate of 88% with 100% neonatal survival.

The role of transvaginal ultrasound in a referral military hospital

In an attempt to overcome some of the difficulties encountered with transabdominal ultrasonography we report on 55 patients who underwent 88 transvaginally directed sonograms. In 24 patients in whom a diagnosis of an early intrauterine pregnancy was made, the mean crow-rump length (CRL) was 10.7 mm (range, 3 to 27). In six patients (25%) the CRL was 5 mm or less. These data suggest that the use of transvaginally directed sonography may permit an earlier diagnosis of pregnancy than the abdominal approach does. This earlier diagnosis should allow the exclusion of ectopic pregnancy in many of the patients at risk for this disorder.

Aneurysm of the vein of Galen: a new cause for Ballantyne syndrome

Ballantyne syndrome is a condition of multiple causes and is characterized by maternal, placental, and fetal edema. We describe the first case of Ballantyne syndrome in a patient whose fetus had ultrasonographic demonstration of an aneurysm of Galen's vein.

Leukocyte esterase activity in amniotic fluid: normal values during pregnancy

Chorioamnionitis during pregnancy is a common diagnostic dilemma for the obstetrician. Fast and accurate diagnosis poses the most significant problem. Since leukocytes are known to be released in response to infections, examination of amniotic fluid for their presence is an important part of the evaluation for chorioamnionitis. These neutrophils contain several esterases that are not present in serum, urine, or vaginal secretions. The esterases are not influenced by bacteria or by commonly used drugs. We have previously described the reliability of leukocyte esterase (LE) activity for the detection of chorioamnionitis in term pregnancies uncomplicated by other diseases. A prospective study was performed to assess the presence or absence of LE activity to establish normal values in amniotic fluid at various gestational ages prior to term before its use as a possible predictor for chorioamnionitis. Sterile amniotic fluid specimens were obtained from 13 patients undergoing second trimester genetic amniocentesis (with gestational ages varying from 15 to 19 weeks) and from 11 patients with a wide variety of medical problems, undergoing amniocentesis for Rh sensitization or lung maturation studies (with gestational ages ranging from 25 to 27 weeks). All patients with ruptured membranes or preterm labor were excluded. Each amniotic fluid sample was divided into two parts, one of which was transported to the laboratory for aerobic and anaerobic cultures and the other used for LE activity detection as measured by dipstick. The LE results were retrospectively compared with the results of the cultures. LE activity was always found to be negative when the culture results were negative. negative.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful pregnancy with isolated herpes simplex virus encephalitis: case report and review of the literature

Isolated herpes simplex virus encephalitis in pregnancy is a rare illness with an elusive diagnosis. We describe the second patient to survive this disease and the first to have no sequelae, because of prompt diagnosis and treatment with acyclovir.

Esterase activity in second- and third-trimester amniotic fluid: an indicator of chorioamnionitis

Accurate and rapid diagnosis of chorioamnionitis poses a major diagnostic dilemma. We previously reported that leukocyte esterase activity in amniotic fluid, as measured by dipstick assay, could be used as an aid in the diagnosis of chorioamnionitis. This study examines the effectiveness of an in vitro spectrophotometric assay of esterase activity in amniotic fluid. We define baseline levels of esterase activity in uninfected amniotic fluid and demonstrate a quantitative increase when infection is present. Fifty-seven amniotic fluid samples obtained at second- and third-trimester amniocenteses were divided into three parts, one for culture and two for a comparison of esterase activities by the dipstick and spectrophotometric methods. In this study, the spectrophotometric assay, because of its higher specificity and sensitivity in the determination of elevated esterase activity, was shown to be more reliable for predicting chorioamnionitis than either the dipstick or culture method.

Multiple pregnancy with late death of one fetus

Twenty cases of fetal death complicating a multiple pregnancy after 20 weeks' gestation are reviewed. We evaluated gestational age at diagnosis and delivery (29.3 +/- 0.7 and 31.8 +/- 0.9 weeks, respectively), interval from diagnosis to delivery (2.6 +/- 0.6 weeks), and cause of fetal death as a group and by type of placentation (76.5% monochorionic). Eighty-five percent of the surviving fetuses were delivered preterm, and the four neonatal deaths were all due to extreme prematurity, with a mean (+/- SEM) birth weight of 794 +/- 237 g. Perinatal mortality was 585 per 1000, 450 for twin A and 750 for twin B. The causes of fetal death varied. Maternal disseminated intravascular coagulation was not diagnosed in any pregnancy in the present series. The high risk of complications related to preterm birth, compared with the low risk of problems related to continuation of a multiple pregnancy after diagnosis of a fetal death, argues in favor of conservative management in this setting.

Genetic counseling for cancer patients and their families

Cancer survivors who have undergone chemotherapy, radiotherapy, or surgery worry about the impact of treatment on their future health as well as on their reproductive ability. Genetic counseling--focusing on the probability of later cancers, possible infertility, and the chance of having children who are affected--is vital for cured cancer patients. Since each type of cancer and each type of treatment has unique sequelae, genetic counselors must make a thorough review of the patient's environmental and family history. They must also be alert for cancer family syndromes, including cancers of the breast, ovary, and colon.

Placental transfer of thiamine in the human subject: in vitro perfusion studies and maternal-cord plasma concentrations

The transfer of thiamine across human placenta has been studied in an in vitro perfusion system. With the maternal and fetal perfusates not recirculated, the transfer index (ratio of clearance of thiamine to that of L-glucose) toward the fetus was 2.09 +/- 0.36, suggesting a mediated transport system. In the reverse direction, the transfer rate approximates that expected from simple diffusion (transfer index 0.78 +/- 0.25). Stepwise increases in thiamine concentration in the maternal perfusate were associated with parallel increases in transfer rates up to 500 nmol/L. Above that concentration, the rate of increase declined and the transfer index fell. When the maternal perfusate was recirculated and the fetal circulation was kept open, the thiamine concentration rapidly decreased, reaching a plateau in 30 to 40 minutes at a level about 0.1 to 0.2 of the fetal perfusate. In contrast, the concentration within the placenta greatly exceeded those in the perfusates. The observations indicate an effective transport system directed toward the fetus, saturable at low concentrations and capable of establishing a transplacental gradient. Measurement of thiamine concentrations in 20 paired samples of plasma obtained at term demonstrated a mean (+/- SD) cord:maternal ratio of 2.5 +/- 1.4. Differential protein binding was excluded as a cause of the gradient. The in vivo gradient is probably attributable to placental transport.

Effects of alterations of zinc-to-phosphorus ratios and meconium content on group B Streptococcus growth in human amniotic fluid in vitro

Several authors have described the bacterial growth-altering properties of amniotic fluid. We examined Group B Streptococcus growth in aseptically obtained amniotic fluid in vitro after altering its zinc, phosphorus, and meconium contents. Zinc and phosphorus levels were calculated in amniotic fluid and in meconium. Separate solutions of zinc and phosphorus were added to yield concentrations of 0.7, 7.0, 70, and 700 mumol. The solutions were incubated with Group B Streptococcus III 893 and Escherichia coli C5 strains, and 24-hour growth curves were plotted. Meconium, 0.5 mg/ml, was added to each amniotic fluid + zinc and amniotic fluid + phosphorus solution, and growth curves were plotted. The rate of proliferation of Group B Streptococcus varied directly with the zinc concentration (700 = 70 greater than 7 greater than 0.7 mumol) and inversely with the phosphorus content (700 less than 70 less than 7 = 0.7 mumol). Meconium enhanced the proliferative effect of zinc and hindered the inhibitory effect of phosphorus. Thus one possible mechanism whereby meconium enhances bacterial growth in amniotic fluid may be by alteration of zinc-to-phosphorus ratios.

Leukocyte esterase activity in human amniotic fluid for the rapid detection of chorioamnionitis

Chorioamnionitis plays an important role in perinatal morbidity and mortality. Fast and accurate diagnosis poses a major problem. A prospective study was performed to assess the value of positive leukocyte esterase test (Chemstrip 9) for the diagnosis of chorioamnionitis during labor. We evaluated 21 patients with chorioamnionitis in labor at term and used 21 matched control subjects. The sensitivity and specificity of leukocyte esterase activity were compared with those of amniotic fluid cultures, Gram stains, maternal pyrexia and leukocytosis, and fetal tachycardia. The sensitivity in diagnosing chorioamnionitis was 91% and the specificity was 95%. The use of this test strip could provide a rapid, inexpensive screening test for chorioamnionitis.